Shortcomings of Medical Education in Developing Countries

Oleg Kucheryavenko is one of the founders and CEO of the International Working Group for the Advancement of Evidence-based Health Care. His expertise runs across evidence-based policy making with a special focus on teaching EBM to medical students and recent graduates. Completed ICH Good Clinical Practice training (UK National Health Service) and "Health Care Quality Assurance" program (USAID). Admitted to the Summer School in International Health at the University of Copenhagen (2012).

Being ignorant is not so much a shame, as being unwilling to learn.”
-Benjamin Franklin

Although the formal assessment of medical interventions using controlled clinical trials was established in the early 1940s, it was not until 1972 that Professor Archie Cochrane presented what would later become acknowledged as Evidence-based Medicine (EBM).

One of the basic tenets of EBM is that one should only treat a patient when there is evidence that the procedure would be of benefit, never intervening when such evidence is scarce or, worse yet, when medical intervention could cause harm. Following these tenets, physicians and medical students alike would tailor treatment options to match each patient’s risk-benefit profile and after careful analysis of available evidence.

Failure to understand the basic principles of EBM constitutes a major shortcoming for those involved in the clinical decision-making process. Given the importance of EBM as a means of addressing current issues of medical practice, institutions of higher education should adjust their curricula to put more focus on the evidence-based approach.

Basing clinical decisions on evidence allows practitioners to determine effectively which treatment options are most suitable in a given case, drawing on expert opinions while still maintaining an individualistic approach. EBM can be applied to any aspect of clinical care: from ordering diagnostic and screening tests to providing treatment tailored to a patient’s needs and defining the way in which it should be performed.

Increased recognition of the failure to translate research findings into practice has led to greater awareness of the importance of using active implementation strategies. Although there is a growing body of research evidence which demonstrates the effectiveness of EBM strategies, this information has not been made readily accessible to policymakers and professionals. Studies have shown that few efforts to change educational policies have achieved more than fleeting success in many countries—and Russia is no exception. Unfortunately, evidence-based procedures have not been successfully integrated into the medical repertoire of nurses and allied health professionals. Diffidence and fierce resistance to innovations lead to a precipice and impose a major obstacle in the way to the health care modernization.

The purpose of this article is threefold. Firstly, in an effort to constantly stimulate interest in effective clinical thought, the complex problems of providing EBM education at institutions of higher education and of pressuring experts to adopt EBM ideology are discussed. Secondly, using the situation of the Russian health care system as a case study, the causal link between the limited success of EBM training and the traditional perspective of the professional clinician as the sole decision-maker is assessed. Finally, I will highlight a promising approach to raising awareness of the dangers caused by the inconsistent instruction of EBM in higher education.

The implementation of evidence-based medicine is closely associated with special skills that have not been taught traditionally within the colleges and universities. Effective teaching of EBM requires that its incorporation into the medical curriculum as well as revision to the faculty organization need to be made. Although the drive for evidence-based medicine has gained momentum, it still depends on the extent to which both the health care system and health workers are matured. Several shortcomings and barriers hampering the progress of EBM adoption are described below.

Language vs. Computer Ignorance

Although there are no available data to confirm or contradict an assumption, the simple surveys reveal that majority of physicians and, probably to a lesser extent, medical students, have a mediocre to very poor command of English. It is absolutely in the country’s best interest that academics as well as clinicians, now and in the future, should be competent in any of the leading foreign languages, and English is clearly preferable. In many countries the value of learning languages is still debated. Fortunately, quite a few people admit that in a globalized world characterized by abundance of international networking, professional connections and medical literature is mainly published in English, so sufficient skills in English are crucial for professional growth and career. English in addition to the first language is vital and it leaves no doubt that it opens up a new dimension for the specialist. It instantly grants access to credible evidence published by the Cochrane Collaboration, OVID, and PubMed etc. The same can be said of the computer skills that improve productivity, overall quality of clinical performance and adequate continuing medical education manyfold. Computers have made a well-rounded and diverse education available to those in remote areas with networking software and programs. It is of great concern in this regard that many hospitals and health care facilities in remote regions of Russia do not have very good computer support.

Teaching in retirement

Professional development involves teachers seeking and communicating the rationale underpinning their practice. It is noteworthy that teacher development is a longitudinal process of behavioral change focused on practical application of innovations such as evidence-based approach to clinical practice. Teacher development in medicine should be considered constantly ongoing and never a “once occurred and completed” situation. We face the conditions when many teachers are near retirement, and educational modalities they use are outdated and hardly something to boast about. The first step is to make the teaching aspect of medicine more attractive to college graduates and well-established physicians. In real terms, teachers make 100 percent less than clinical professionals in other occupations that require no less levels of education with starting salaries, on average, of $200. Compelling teachers to grow professionally and personally, prompting them to follow the trends and renew the educational curriculum comprise the second step of the process. Teacher should always stay ahead of the current trends of the time and allow the student to entirely trust the knowledge he shares; teachers must be the people within medicine who are most-aware of the latest advances and research.

Wages are the barrier to teaching

Surveys revealed that more professors would stay at universities if they were given more opportunities to develop their careers and could expect proper remuneration. We often encounter the best educators leaving the profession, which they had a calling for, simply for a better way of life elsewhere. They are mowed down by the red tape, low salaries, the lack of support from the government and respect from “consumers of higher education”. We have to face up to the fact that at times professors make their living with multiple part-time jobs often plunging into the work in pharmaceutical sales. If medical education itself is not providing high enough salaries, we cannot sustain the best people in this career track. How do we keep the best minds in the profession and make them teach EBM by vocation? This takes a lot of doing.

A conflict of visions: traditional educational views are in jeopardy

For over a long period of time, there has been conflict among educators and students over whether traditional or progressive ways of teaching science and allied disciplines are the best. Such debates have concealed the unvarnished truth that there is more than one kind of right answer and progressive paradigm of teaching has more positives to be adopted in higher education. It includes the concept that students should create, shape, and discover their own expertise and knowledge, whereas the traditional paradigm is formed by the concept that subject-specific knowledge and skills should be handed down from the more-wise professor to less-wise student.

Picture this. Once after a lecture one of the students approaches and catches you napping with an innocuous question: “Doctor, you have mentioned an antibiotic-induced complication which you called dysbacteriosis. But the Cochrane systematic reviews assert the opposite…” Curtains descend, buzzing crowd of students rush to the next class, but the Doctor and his “revolutionary” student are already involved in an argument about the current best evidence and non-existing dysbacteriosis. In a few moments, the student would yield to the shocking evidence of a lifelong experience his teacher has had. “Another expert opinion that I have to put up with,” the student disappointedly is told by his professor.

What would happen if this is presented as some kind of radical, disruptive change to the system, where the student is encouraged to use valid outside research to question teachings from his lectures? What would happen if the professor did not feel irritated by such questions? The upshot of all this is that those in the progressive medical community generally favor reform in both training and practice while those among old-fashioned educators who still work as they did under the Soviet system generally favor traditional approaches and resist what they consider the heresy of challenges?

Educators’ expertise is treated as absolute truth and not to be cast doubt on

At present, the science has developed quite an understandable state of affairs when eminent scientists keep on holding conservative views. Frequent updates of the current evidence as well as renewal of old paradigms interrupt the continuity of knowledge, they believe. Emerging new theories presupposes a foundation of a new methodology and rearrange the way of thinking. That is why conservatism cannot always be considered a positive phenomenon. Not all of the goals of EBM are totally rejected by the medical community. In fact, many younger physicians  and a fair number of more-established ones endorse the EBM core tenets.

No incentives to implement anything - EBMs no exception

There are no incentives to improve both students’ and physicians’ achievements beyond the bare minimum. If educators want their students to learn the EBM course material, do they have a strong incentive to establish a close relationship between performance and a learning outcome? Incentive measures, such as salaries, secondary benefits, and intangible rewards, and various forms of recognition have traditionally been used to motivate employees to increase performance. Whether based on perception or reality, organizational incentive systems do have a significant influence on the performance of individuals and thus the health service system overall. If an individual is motivated primarily by the desire to make money, will he or she have an incentive to change the habit of mind? Will the professional have an incentive to develop skills that others value highly? That is the question. A sensible starting point is to understand and address first and foremost the demotivating factors.

Apathy and lack of readiness to adopt new strategies in clinical practice have arisen in circumstances when doctors are forced to struggle to make ends meet. This is a plight when the teacher’s own finances motivate him to retain his old, systemic, ways of pedagogy instead of exploring newer, evidence-based, mechanisms.

The Mountain Is Not So Insurmountable

The practice of evidence-based medicine requires skills that are not taught within traditional medical course-work. Needless to say, EBM is not an educational priority and cannot be found in the curriculum at all in many countries. Since EBM has become increasingly acknowledged as important by the medical community and consumer groups, the medical curriculum, together with staff training, are subject to revision. For a policy to be implemented, it generally must have the support of many people. When such changes are being considered, governmental support for the undertakings must also be enlisted, so the efforts will not be prematurely prejudiced. So how do we surmount these obstacles and finally become keen supporters—then advocates—of the adoption of evidence-based medicine?

Decent learning resources to facilitate educational process, the use of information technologies, and sufficient English-language skills are prerequisite before proceeding to the core changes of pedagogy required. The EBM practice is essentially pedagogic by its very nature, requiring that the student/physician is an adherent keen on lifelong learning, increasing knowledge and is prepared to adjust to freshly-investigated evidence. First and foremost, rebuilding the incentive system should be acted upon, so that physicians are properly rewarded for following and passing on the methodology of evidence-based medicine. That means not just promising a wages increase, but designing stimulating programs that inspire reform and changing one’s views where it is most needed.

Adoption of EBM is challenging under the best of conditions. The effort to reform strong but outdated conventions in medical education is a battle, but one that can lead to a rewarding triumph.