School of Medicine Department of Family Medicine What Has Worked & What Hasn’t in Residency Development: University vs Rural-based Training Jeff Markuns, MD, EdM

Objectives On completion of this program, you should be able to: Outline universal issues in developing new residency training programs in developing countries Describe the issues for consideration in choosing a site for beginning post-graduate Family Medicine training Compare and contrast residency program development in university and rural settings

Background Family Medicine is a key component of building improved primary care in developing countries There is often a shortage of physicians with specialty training in primary care, necessitating (more) post-graduate training in Family Medicine In these countries, a core group of academic physicians in specialties other than Family Medicine itself are necessary to develop curriculum and train an initial cohort of Family Medicine physicians

The Case of Vietnam

Current situation of the community health services Most General Physicians work there just after Medical School It’s difficult to update their professional capabilities They can practice all their life without any retraining, exams… The working conditions in community health centers are very poor. Budget for CHC is very restricted

Montegut AJ et al Fam Med 2007 Family Medicine in Vietnam

We recommend the creation of educational programs that will lead to a specialty that will be the cornerstone for the delivery of primary health care to the people of Vietnam: FAMILY MEDICINE

March 2000

To improve health care delivery to the people of the Socialist Republic of Vietnam by reforming the training of primary health care physicians Develop, implement and evaluate a national family medicine training program National Goals

Establish and maintain departments of Family Medicine Complete a post-graduate and medical school curriculum in Family Medicine Upgrade community training sites Conduct faculty development in Family Medicine GHPCI Recommendations:

Active member of coalition Approved by all coalition members China Medical Board of New York, Inc. Needs Assessment visit with CMB President, January 2001 $1.8 Million Grant approved June 2001

Six year project Model based on a three-site educational network

Family Medicine in Vietnam

A Tale of Two Cities Residency programs begun in the two largest cities in Vietnam Hanoi Medical University Ho Chi Minh School of Medicine & Pharmacology Aim to develop Family Medicine training programs in the two largest universities in Vietnam

A Tale of Two Cities Benefits of working in Hanoi & HCMC: Substantial academic resources already in place Desirable location for many doctors Large populations means tremendous need Both well-respected by government Both eager to begin academic departments of Family Medicine

A Tale of Two Cities Ho Chi Minh City Founded by dynamic and strongly committed former Pedi ER doc Strong background in medical education Applied innovative approaches Not constrained by “traditional” approach to primary care Ends justifies the means Continual eye to the future Engaged in continual faculty development

A Tale of Two Cities Hanoi Medical University Developed initial site within the university Staffed up with full time faculty relatively quickly Strongly committed to core ideals of Family Medicine Prefer to see whole families Committed to continuity Took on effort to develop Master’s level training early on Built close relationship with U.S. partners

Tale of Two Cities Urban challenges Fewer graduates returned to practice in rural or government clinic settings Many found promotions in hospitals or other institutions Bureaucratic constraints generally greater Greater competition with private clinics Misses a substantial portion of the population Strong government priority for Family Medicine is rural care

Heading out of town Smaller urban area of Thai Nguyen Benefits: Committed local leadership Less local bureacracy Attracted more local rural docs Kept docs closer to home Challenges: Lack of substantial support infrastructure Suffered from lack of sustainable funding Program closed (temporarily?) after two years

Heading out of town Expansion to city of Can Tho in Mekong Delta Similar benefits and challenges as Thai Nguyen Local leaders continue forward, although a struggle Likely some benefit from self-starting group

A new approach Funding to attempt a new model of training Paired a training program in an urban academic center with a truly rural training location Hue College of Medicine & Pharmacy and Ninh Hoa District Hospital Substantial physical infrastructure developed in province Now needed human resources to match

A collaborative approach Hue College of Medicine & Pharmacy known for distance approach to training Committed to training their faculty to be able teach in local training program as well as rural Specific expectations of faculty to participate Institution with strong support from both government and funder Forward-thinking rural province seeking to address local needs

A collaborative approach Benefits Recruitment in local province has been strong Local government provides policy support Rural trainees benefit from well-trained academicians Physicians closer to home have opportunity to train part-time Graduates more likely to remain in commune

A collaborative approach Challenges Communication between academic and local faculty minimal Great need for additional faculty development for local faculty Oversight of program less than optimal Absence of on-the-ground leadership Still in need of training resources Still no outpatient clinic or training! Unclear sustainability when program funding ends Graduates consistently seeking more system supports

Consistent tension Despite program successes, policy supports remain challenging Graduates need to see opportunity for advancement to attract new trainees to the specialty Tremendous need remains, however, in rural areas Innovative partnerships may hold the key to Family Medicine’s future

Other Experiences Share your own experiences Are you involved in residency training? Urban or rural? What challenges have you faced? What successes have you had?

A challenging decision You are contacted by a local mission group interested in developing a residency program. They operate a hospital in the rural western portion of the country. The only medical school is in the country’s bustling capital in the east. The local missions are eager to see the first program open in the west. The only approved post-graduate training programs in the country are all at the medical school.

A challenging decision Where would you advocate for a training program to be? What challenges and opportunities do you see in each location? What could help you decide?

Context Analysis Two aspects: Performance context Learning context Adapted from The Systemic Design of Instruction by Dick, Carey, & Carey

Context Analysis Performance context The performance site – the place where they will use their new skills Will the learner be supervised? What are the physical aspects of the site? What are the social aspects of the site? Are the skills relevant to the performance site? Adapted from The Systemic Design of Instruction by Dick, Carey, & Carey

Context Analysis Learning context The learning site - the place where students will learn the skills Is the site compatible with your requirements? Does the site simulate the workplace or performance site? What facilities, equipment, and resources are needed? What limitations may impact the training? Adapted from The Systemic Design of Instruction by Dick, Carey, & Carey

Context Analysis Learning context What is the political and leadership environment surrounding the site? Is there financial support? Other local external factors

Collecting Information about Context Observation is critical! Plan site visits well in advance. Interview: Learners Managers Instructors Adapted from The Systemic Design of Instruction by Dick, Carey, & Carey

Collecting Information about Context Two goals for the performance context: 1. A description of the physical and organizational environment where the skills will be used 2. A list of any special factors that may facilitate or interfere with the learners’ use of the new skills Adapted from The Systemic Design of Instruction by Dick, Carey, & Carey

Collecting Information about Context Two goals for the learning context: 1. A description of the extent to which the site can be used to deliver training on skills that will be required for transfer to the workplace 2. A list of any limitations that may have serious implications for the project Adapted from The Systemic Design of Instruction by Dick, Carey, & Carey

Choosing a training site Consider the following: Commitment of local leadership Support (or oversight) of local government Local financial support and options for sustainability Physical infrastructure Local future job opportunities for graduates Presence and interest of local partners for collaboration Human resource issues