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Exporting Education

The New Physician October 2001
U.S. medical schools find prestige, funding by taking their products abroad in a changing global climate.

Dr. Daniel Alonso is doing what many said couldn’t be done. Some in medicine still consider it Cornell’s folly: Why build a medical school in the middle of the Persian Gulf? New York City is where the Weill Cornell Medical College belongs, not halfway around the world in Doha, Qatar.

But as Alonso drives past the buildings rising in the middle of Qatar’s ambitious educational campus, he can’t help but think the proof is all there. The school is being built so fast it almost makes your head spin. Qatari construction crews work through the night on the modern white edifices, and the first 30 premed students would arrive in a month. Looking at the progress, no one can deny Alonso and his staff are doing what many said couldn’t be done.

Cornell’s Qatar venture is the latest in a string of medical schools’ global initiatives—a new trend in exporting medical education. Their intentions are as varied as the countries they deal with, but no matter if the programs are savvy business deals or humanitarian adventures, U.S. medical students often become a prime beneficiary of the international outstretching of arms.


There’s no doubt that medical students are a well-traveled bunch. According to the Association of American Medical Colleges’ (AAMC) annual Medical School Graduation Questionnaire, about 20 percent of students graduate with an international health experience—and that figure rose as high as 38 percent in 2000.

But this is nothing new. “Students have chosen to study overseas for decades,” says Dr. David Stevens, the AAMC’s vice president for medical school standards and assessments. “The classic story is the medical missionary, but there are secular examples of that as well. [Students] want to see how it is somewhere else.”

To aid them, many medical schools have established some sort of exchange program, in which students can apply to a school-sponsored, fourth-year clinical elective in a foreign country. These rotations can be Third World or first, rural or urban; it’s really up to what the student wants and the school arranges.

An elective at the University of North Dakota School of Medicine (UND)—in which UND medical students train at hospitals in Norway in exchange for Norwegian future physicians putting in time at UND—was born out of a strong cultural link the school has with Scandinavia. “One-third of Norway’s population left [in the 1870s and ’80s], and most came to this area,” says Dr. George Magnus Johnson, a former chairman of the UND pediatrics department. The Red River Valley, where UND is located, is still home to many of these immigrants’ descendents; they make the food of their ancestors, hold similar values, and Norwegian is still spoken in some circles. As a result, Norwegian students are attracted to this little slice of home in the upper Midwest. In fact, Johnson claims the school already hosts the highest number of Norwegians compared to other U.S. universities. And the fledgling program has sent two UND future physicians abroad.

Dr. Rachel Hoffart was one of the first two UND students to make the transatlantic trip. She and a classmate spent three months last year taking electives in Ob-Gyn, epidemiology and general Norwegian medicine. The two were also scheduled for a month in internal medicine, but they left the country in the wake of Sept. 11.

Now an internal medicine resident at Gundersen Lutheran Medical Center in La Crosse, Wisconsin, Hoffart says her experience made her a better physician. “It really helped me learn how to communicate with patients,” she says. “I had to use a lot of nonverbal communication. Now, when patients talk to me, I find myself listening to how they’re saying something.”

In exchange for paying the UND students’ round-trip airfare, the school gets a little something in return. Linda Olson, Ed.D., UND’s director of medical education, says the genetic and cultural similarities between Norwegians and North Dakotans offer opportunities for epidemiological research. Hoffart and her classmate worked on a study comparing the two populations’ occurrence of type 2 diabetes.

And Hoffart says the school probably also gains a selling point for potential UND students who might be interested in travel opportunities, although the program was a tough sell to this year’s fourth-years. Olson points a finger at money, saying it can be too costly for some students to spend four months abroad while maintaining a home in the United States. The program offers a stipend covering the plane ticket but not much else. So while the school was expecting its second Norwegian visitor this fall, representatives of UND would not be passing him in the skies over the Atlantic. “What we’re really hoping to do is find some supplemental funding,” Olson says.


Ah, money. As Olson suggests, travel-
ing is expensive, and putting a medical school—or any part of one—on a boat bound for faraway places takes a lot of money. That’s especially true for schools that travel for humanitarian reasons. Loma Linda University (LLU) School of Medicine has had a relationship with the medical school in Kabul, Afghanistan, since the 1960s—a partnership that even the Taliban government embraced. And it all came about through a chance meeting in India.

Dr. Gordon Hadley, a professor at LLU since 1946, was serving as a visiting professor at a Christian missionary school in India in the 1950s. When the dean of the Kabul Medical Institute paid a visit to the Indian school, he mentioned he could use a few professors like Hadley. The adventuresome pathologist took the dean seriously, and in 1960, he packed his bags for a yearlong teaching stint in Kabul.

LLU was happy to send him. The university is part of the Seventh-day Adventist Church, and the school’s mission statement calls for globally focused, philanthropic health-care initiatives. The work is funded by LLU, private donations, grants and help from the U.S. Afghan medical society.

Hadley continued to teach in Afghanistan throughout the ’60s and ’70s—even helping to establish another medical school in Jalalabad in 1974. “This…in some respects is the most exciting thing I’ve done,” he says. “As a result of [my work], I’ve taught a lot of the doctors in Afghanistan. The current minister of health is a former student.”

Politics can interfere with international partnerships, however. In 1978, the Soviet Union invasion halted Hadley’s business in the country. “That’s when the real trouble started,” says Dr. Joan Coggin, one of Hadley’s colleagues who has been making the trek to Afghanistan for the past five years. Then in 1996, the Northern Alliance government issued an invitation to LLU, asking that Hadley and his colleagues return. “The government wanted to really improve the medical school,” she says. “We thought we could do something to help them.”

So they did. LLU began work on the Loma Linda University Center, a four-room complex within the Kabul Medical Institute. Outfitted with laboratories, a library and a computer room, the center was dedicated on July 4, 2001—that’s right, just last year. In fact, Hadley and Coggin continued to be two of the few Americans welcomed by the Taliban government when it seized control from the Northern Alliance. “They knew we were a Christian school, but they also knew we were willing to help them, and that’s all they cared about,” Coggin says.

It was actually LLU’s conservatism that helped create the ties, Hadley says. “I think [the Adventists’] prohibition of liquor and tobacco made [the Taliban] feel more comfortable,” he says.

“They also knew there would be no proselytizing,” Coggin adds.

Hadley says he’s held up his end of the bargain, which conflicts with part of LLU’s mission statement directing the school to share “the good news of a loving God” through international service. “It seems to be my mission to be perfectly open while I’m there and to practice medicine and to help,” he says. “[The students] will ask you little questions, but if you concentrate on human need, the rest takes care of itself.”

In exchange for the LLU officials putting their missionary hats aside, the Taliban agreed to let female LLU professors conduct their classes as they would in America: sans burqua. The women were also allowed to drive, and all LLU classes were conducted in English, at Hadley’s insistence.

Coggin says she was a little surprised by the freedoms she was permitted, as she was aware of how the Taliban treated other women.

So when plans for a trip to begin working in the new LLU center were halted last September, their fear for friends half a world away was natural. “We were just so concerned for the people we knew,” Coggin says. “It’s so confusing because the Taliban that we knew were just superb people—not savages at all. They were scholars…and as soon as they had peace, they were going to go back to their books.”

But peace came another way. Hadley says the decades of war have robbed the medical school of plumbing, electricity, windows, supplies, furniture and even a roof. Vandals ransacked the buildings, but left LLU’s contribution largely untouched. He says U.S. bombs came close to this American-style educational center but didn’t hit, so he’s in good shape to begin classes again. “I’m in basic science,” he says. “I’ve got a few microscopes and a video projector, and I can teach.”

And the need is greater than ever, he says, noting that LLU’s biggest obstacle now is money. “What’s happened [is] they’ve had a war for 20 years. The birthrate shot up, and the country is filled with people from zero to 20 years of age. It’s in our self-interest to get these kids educated.”

“If you can educate a doctor, then you can provide health care for the future,” Coggin says. “Instead of sending physicians over there, we’re educating their own physicians.”

Like LLU, the University of Pittsburgh Medical Center (UPMC) entered into its foreign relationship for humanitarian reasons.

In some ways still a second-world country, southern Italy is defined by poverty and fewer services than those available north of Rome. Sicily—about as far south as you can get—is no exception, and at the end of the 1990s, its hospitals were feeling the pinch, particularly in organ transplantation. An island of 5.1 million people, Sicily lacked a hospital equipped to perform transplants beyond kidneys, and the Italian government was spending thousands of dollars on each southern Italian patient sent abroad to receive a new liver, heart or lung. And because of deep-seated north-south Italian animosity, “you could not get an organ if you were Sicilian,” says Dr. Tracy Davido, a surgical intern at the Ohio State University Medical Center who did a fourth-year clinical elective in Sicily. “To think that this entire island couldn’t get organs—it’s really very sad.”

In an effort to curb costs, the Italian government approached UPMC with a proposition: It would build an American-style transplant hospital in Sicily and pay UPMC to manage it. UPMC officials liked the idea, and in 1999 they opened the Instituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione (ISMETT) within a Palermo, Sicily, hospital. The center conducts both traditional and living-donor liver and kidney transplants, heart transplants and cancer resections, and will open its services to lung and pancreas transplants when a 90-bed, free-standing hospital is finished early next year.

“The goal is to bring advanced techniques to Sicily. We’re not there to compete with anything,” says Dr. Anthony Harrison, a UPMC surgery professor who divides his time between Pittsburgh and Palermo. “There’s no question that this project has had enormous benefit to Sicily.” ISMETT celebrated its 100th liver transplant earlier this year.

The hospital offers Sicilian patients state-of-the-art care—even using some technology that isn’t yet widely available in the United States. “Patients and their families—when they crossed that threshold—they could just tell. It was almost like walking into a Star Trek health-care system because it was so modern,” Davido says. “This is a UPMC hospital.”

And like the UPMC in Pittsburgh, medical students rotate through on fourth-year clinical surgery electives. In addition to University of Pittsburgh students, ISMETT has seen future physicians from at least eight countries. “It’s unbelievable the way these kids travel. They are all fluent in English. Rounds are in English. Records are bilingual,” Harrison says. “I’m struggling to learn Italian.”

Records are bilingual because the medical staff at ISMETT is too. Italian physicians work with colleagues from Pittsburgh, and much of the Italian nursing staff trained at UPMC. UPMC also sends some of its nursing staff to Palermo, sometimes for years at a time, with their Pennsylvania jobs secure for their return.

Harrison says the travel is good for all parties involved. “These things are two-way streets. There are some superb physicians in Italy. There’s a cross-pollination, learning a different way of looking at problems.”

Davido agrees. “The experience of seeing a health-care delivery system in another country is incomparable,” she says, adding that she thinks every medical student should be required to spend time in another country, or at least in a rural or underserved area. In addition to the lessons in cultural competency, Davido was able to test her surgical skills in ways she never could have in the United States because of liability issues. “The first day I was in the OR, I was allowed to do all the knot tying on a procedure. You couldn’t tell, because I had a mask on, but my jaw dropped. In 90 percent of teaching hospitals in the U.S., you’d never be allowed to do that. As a student, you stand there practicing your knots, knowing you need to practice them in the operating room.”

Her Italian experience impressed residency directors during the Match, she says. Few of her peers have experienced holding a needle driver or taking a stitch in the OR. “You’re treated more like a colleague,” she says.

In addition to the student benefit, ISMETT generates what Harrison calls “good exposure” for UPMC. “In one area, I think it increases our reputation to foreign nationals who come to Pitt for heath care,” he says.

Harrison looks at the ISMETT relationship as a management project; there’s a contract between the Italian government and UPMC officials. And while the government pays the medical center a fee for its role at ISMETT, “this isn’t a money-maker,” Harrison says. On the other hand, “we don’t lose money on it” either, he adds.


The UPMC arrangement is an example of the creative ways medical schools are finding to generate funds. The AAMC’s Stevens says schools have always had several options for generating income, including research grants, philanthropic donations and tuition dollars. The offshore venture is “probably a category on its own: strategic partnering, if you will,” he says. And the most creative partnership to date is the one between Weill Cornell Medical College and the quasi-governmental Qatar Foundation.

The arrangement is part of the foundation’s effort to beef up educational opportunities for Qatari students, who previously had no medical school in their country and usually chose to go to other schools in the Persian Gulf. Virginia Commonwealth University already has a presence in Doha, and the foundation is negotiating with other U.S. universities as well.

Cornell, which had been looking for an international project in which to get involved, found a sweet offer. The foundation put up $750 million to build and maintain the school for the first 11 years. Out of that sum, Cornell gets an undisclosed management fee and a donation to its institution, but Alonso insists the Qatari school will maintain Cornell’s not-for-profit designation. “We couldn’t do this for profit.”

In return, Cornell gets to manage the school independently. Alonso reports to no one in Doha, and professors will be selected largely from Cornell’s Ithaca and New York City campuses. “The resources and the autonomy—that is the powerful thing,” he says.

Nonetheless, Cornell has waded into uncharted territory. “It’s certainly a creative approach, isn’t it?” Stevens says.

Alonso places the endeavor somewhere between a business deal and a humanitarian gesture. “This is not the Peace Corps,” he says. Instead, it’s a top U.S. medical school’s and an oil- and gas-rich nation’s effort to bring medical education closer to its students. “We have 125 [allopathic] medical schools here. In Qatar there are no medical schools—so there was clearly a need.”

There’s also great difficulty in opening a new U.S. medical school, as Ross University—a Caribbean medical institution—discovered when it tried to open a branch campus in Wyoming in 1998. The state’s medical society opposed the move, saying Ross would take state funding from two established residency programs.

The need for a new Middle East school appears greatest among Qatar’s women. Living in a family-oriented society, women have found it more difficult to leave the country for medical training, despite Qatar’s tradition of female physicians. Sixty-five percent of the first premed class are women, and among the Qatari students, women make up 70 percent to 80 percent of the class. “I’m guessing human nature now, but…in Qatar, this is a way to get ahead,” Alonso says.

The school opened its doors this year to a premed class of about 30 students. They entered directly from high school and will spend two years there before applying to the four-year medical school, which reviews potential students using the same standards as Cornell’s New York campus. Graduates will earn a Cornell degree. Entrance to the premed program doesn’t guarantee acceptance to the medical school, however, and Alonso hopes to have 50 students per class when the medical school is up and running in 2004. Anyone can apply—Israeli students were specifically negotiated—and the incoming class has four U.S. citizens, while up to 70 percent of the class is reserved for Qataris.

The plan makes for some confusion within the Liaison Committee on Medical Education (LCME), which will be charged with accrediting the new institution. Other overseas programs have not had to worry about separate LCME accreditation, as rotations generally fall under the parent school’s accreditation. Still, Alonso says he sees no roadblocks to having the Doha campus qualify with the LCME.

But Stevens, who is also spending this year as the LCME secretary, says the Cornell situation has caused the committee to rethink its jurisdiction, which has traditionally been within the United States and Canada. “The LCME is still exploring its policy in that context,” he says. “If you ask me to predict the outcome, I’d say it’s likely the LCME will continue its historic policy of only accrediting programs conducted in the U.S. and Canada.” Without LCME accreditation, Cornell’s Qatar graduates might be classified as foreign medical graduates.

The matter needs a decision, for at the end of six years, Alonso anticipates that the best students will seek U.S. residencies. But he expects students will have residency options in Qatar as well. Long-range plans include a Cornell-affiliated, American-style medical center in Doha, he says.

No matter where students will complete their training, Alonso says he has no concerns that the newly minted physicians won’t return to their own country to practice. “These Qatari people don’t stay abroad,” he says. “They go back to their families.”

He says those same Qatari people have made him feel at home, despite the turmoil in the region. “We feel very safe,” he says, adding that something terrible could happen, but contingency plans allow Cornell to leave in the event of war or other threat.

One initiative suffering from the region’s distress is Columbia University’s (CU) collaborative program with Ben Gurion University of the Negev (BGU) in Beer Sheva, Israel. The M.D. program in international health loses at least one applicant each time a bomb goes off in Israel, despite Beer Sheva’s relative seclusion from the problem areas, says Dr. Richard Deckelbaum, the BGU-CU program director at Columbia. Now in its fifth year, the program’s administrators had hoped to have class sizes at about 50 students, but fear of the region’s violence has kept that number closer to 30.

No one could say the program hasn’t met with success, however. The initiative is the result of CU’s interest in creating an M.D. program with a focus on international health, which administrators knew wouldn’t fly in New York City. “We never even thought of doing an additional medical school at Columbia,” Deckelbaum says. “If you want to do something radical in a 250-year-old institution—it’s very difficult.” So CU administrators turned to their ties in the Middle East.

BGU-CU students have been the subjects of radical change in medical education. “There’s a great gap in doctors who thought about economies, education [and] population,” Deckelbaum says of the world’s physicians. To combat this, BGU-CU students learn about cross-cultural medicine, health-care economics, epidemiology, biostatistics, nutrition and environmental health in addition to traditional basic sciences and clinical rotations. They’re also required to spend at least one rotation working and researching in a developing country. Columbia considers some aspects of the curriculum so innovative that it’s contemplating integrating them into its M.D. program, while other Israeli medical schools have adopted Columbia’s American-influenced, systems-based educational style.

BGU-CU graduates receive a BGU degree—which, unlike Cornell, allows Columbia to bypass the LCME—but because of the program’s connection to Columbia, they may rotate through CU’s hospitals and benefit from the Columbia name on reference letters during the residency application process, which can be troublesome for foreign medical graduates.

Largely U.S. citizens, the program’s students undergo a rigorous application process directed by CU administrators. And beyond steering the process, Columbia has involved more than 100 faculty and staff members in the program. CU absorbs the costs of those who travel and does not receive a fee from BGU, which picks up all the administrative costs.


What Columbia—and all schools with international projects—does get out of its overseas venture is an opportunity to expand its brand. Stevens says that’s perhaps why elite U.S. schools lead many of the prominent programs. “It’s kind of like a brand to negotiate from,” he says.

Steve Thompson, Johns Hopkins University’s (JHU) director of international projects, says that’s one of the reasons JHU entered into an agreement to provide research, clinical services and a joint M.D.–Ph.D. program in Singapore. “This is a unique opportunity to extend the pre-eminence of Johns Hopkins medicine throughout the region and the world,” he says.

Alonso thinks this trend is a positive step. “The perception is that this is a good thing for American medical education in general,” he says. “People in [the Middle East] are not coming here like they once were, so maybe there’s a trend for us to go there. Exporting education may be a way of improving other countries’ opinion of us.”

Alonso says there’s no question that other schools are paying attention as Cornell and others wade into untested waters. “I think the model of what we’ve done has been watched closely. Make no mistake: This is clearly an experimental project.”

And it’s probably not the last. As U.S. medical education pays increasing attention to cultural competency issues, schools are realizing that international experiences can help students become better physicians, Stevens says. “This is the medical education piece of the increasing globalization of everything in our lives. The world is shrinking.”

Dr. Dan Hunt would agree. As the associate dean of student affairs at the University of Washington School of Medicine, he helps students find ways to gain overseas experiences. “I think we’re going to see a lot more schools with a specific mission because students have come in with better ideas about global roles,” he says, adding that after Sept. 11, many believe that experiencing the world can help medical schools and students better understand their patients.
Jennifer Zeigler is a senior writer with The New Physician.