AAMC Reporter: January 2007

Medical Schools Without Borders

American medical schools today are in the midst of an international movement—literally. Partnerships with foreign governments from India to Ireland are increasingly commonplace, and the reasons for going global are as complex as the challenges.

Several medical schools around the United States are establishing various facilities and services under their institutional brand in countries across the globe. For example, the University of Pittsburgh Medical Center (UPMC) has opened a cancer center in Ireland and a transplant center in Italy, among other projects.

West Virginia University School of Medicine (WVUSOM) recently opened a medical and pharmacy school in Oman, a country of 2.6 million with a severe shortage of doctors and pharmacists. WVUSOM and the Oman government collaborated to help build a three-story, $8 million medical school with 400 students. The school, which combines pre-med and medical training into a seven-year program, opened in 2001.

But these international efforts often transcend bricks and mortar; they can sometimes be as much about marketing as X-ray machines or classrooms. According to Claudia Costabile, international communications specialist for Johns Hopkins Medicine International (JHI), which has several overseas academic and clinical partnerships, health care institutions once responded to growing care costs by bringing patients to America, which became more difficult after the 9/11 terrorist attacks. So institutions have expanded their presence overseas to tap the international market of patients, in order to boost revenues. And with the facilities so far away from headquarters and often created in concert with governments or other entities, the importance of maintaining the institutional brand—not only for public relations but also to establish expectations for a standard of care that patients will recognize and trust—is half the battle.

"We have had to diversify overseas. It's a general marketing trend among American universities," said Costabile. JHI partnerships include hospitals in Panama, Dublin, Beirut, and Abu Dhabi.

A patient receives treatment at a Botswana outpatient clinic

Humanitarian needs also drive the overseas migration. The University of Pennsylvania School of Medicine has assumed a massive role in the fight against AIDS in Africa, recently sending faculty, residents, and medical students to Botswana to treat patients and study the AIDS epidemic.

"With nearly a third of adults in Botswana infected with HIV, the country is considered a test-tube case in Africa regarding AIDS, and our program is one of the frontiers in HIV care," said Harvey Friedman, M.D., director of the Penn-Botswana Program and chief of infectious diseases at the school.

The partnership began when pharmaceutical company Merck contacted Friedman about five years ago; it was soon joined by the Botswana government and the Bill and Melinda Gates Foundation. Today, more than 40 Penn residents and medical students treat approximately 7,500 patients in the country. And the results are promising, with HIV seropresence in Botswana declining from 38 percent to 34 percent of the population over the past four years, according to Friedman. Penn is now helping to open a medical school in Botswana to increase the number of sorely needed physicians, explained Stephen J. Gluckman, M.D., professor of medicine at Penn and clinical director of the Botswana-U Penn partnership. Penn is helping to develop accreditation programs for residencies in Botswana for specialties such as pediatrics, surgery, and obstetrics, and for board certification procedures, all of which the country does not currently have. The school will open in 2009.

Friedman said coordinating the efforts of such a diverse group of stakeholders—and overcoming bureaucracy—was the primary challenge.

"Things move a little slower, and there are more decision- makers involved, but the government is very dedicated to this cause," Friedman said.

In fact, physicians and coordinators may even find the cultural needs more bewildering than medical ones.

"The greatest challenge we faced initially is that everyone was used to doing things their own way," said Patrick Casey, Ph.D., senior vice dean of research for Duke-National University of Singapore Graduate Medical School Singapore, which was established last year. "This effort included three Singapore government ministries and the national university, which already had a medical school of its own. Everyone had a different idea of what the school policies should be."

The solution was to make the new school semi-independent under the National University of Singapore. The curriculum is based on Duke's, but was tailored for the region, to fit the post-graduation curriculum.

"The first two years are compressed into one, and the fourth year is an elective medical rotation," Casey said. "This additional year gives students the specific training they need for this society." The students are expected to practice in Singapore once they graduate.

"As we build these relationships, the efforts should above all be driven by the needs of the country," said Carol A. Aschenbrener, M.D., senior vice president of medical education for the AAMC.

This leaves a fine line for schools to tread, however. American schools want to preserve the prestige associated with their names, while still being sensitive to cultural differences.

"We learned it is not considered proper to discuss prostate cancer publicly in Turkey," said JHI's Costabile. "Our doctors and medical students are given cultural competency training, to teach them local customs, such as how to greet people properly. It's cultural, not personal."

JHI works closely with local public relations companies to learn these sensitive issues, Costabile said. To help maintain the JHI brand, Costabile said they "Hopkinize" every facility with the appropriate logos and marks, and establish specific vetting processes for all news releases and other publicity materials to ensure consistency, integrity, quality, and sensitivity.

"We ask them to sign a contract agreeing to follow our guidelines and standards," Costabile said.

In return, JHI helps overseas facilities acquire accreditation by the Joint Commission Institute, and a Hopkins medical director visits the sites quarterly for quality checks and to move along accreditation efforts. Physicians from the overseas hospitals also visit the U.S. for continuing medical education and observerships, and vice versa.

Maintaining the level of quality associated with Duke University School of Medicine is a top priority in Duke's Singapore partnership, Casey said.

"That priority is the reason it took three years of negotiations before we signed, then another two years to develop the first class," Casey said. Duke holds only two of the 16 Singapore-Duke medical school board seats but maintains full veto power over academic decisions.

"We also had a high level of trust for the stakeholders in terms of our operational flexibility. We wouldn't be here otherwise. We make sure the Duke seal is on everything," Casey said.

Singapore wanted to replicate Duke's medical curriculum in order to attract talented students and drive the Singapore economy, explained Khee Chee Soo, M.D., vice dean of clinical and faculty affairs for the Duke-NUS school. Another goal of the school is to help maintain the number of people who come to Singapore from other countries for medical care. Aside from providing Singapore with much-needed physicians, Duke University also benefits from the partnership.

"We wanted to become a larger global presence and chose Singapore because of the developing technology here," Casey said. Singapore has developed sophisticated electronic patient medical records systems and is known for its high level of patient care, he explained.

"With Duke, we formed a school that offers innovation and a higher level of academic medicine to Singapore," Soo said. The school will open in 2007 with 25 students, then increase by 50 new students each year.

—By Deborah Epstein, special to the Reporter

Contact Us    © 1995-2008 AAMC    Terms and Conditions    Privacy Statement