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JULY/AUGUST 2004

BULLETIN

In this issue:

: First graduates of emergency medicine program in Italy now ready to teach others
: Enhancing knowledge to support the system: Practi-Med goes to Shanghai
: HMI confers third Klaus Peter International Teaching Award
: Research and education to be focus of collaboration with XMU
: Distance learning: Exchange programs let students build knowledge, perspective

The first graduates of the training program gathered for commencement.

First graduates of emergency medicine program in Italy now ready to teach others
Twenty-four physicians were recognized in April after completing a nine-month training program in emergency medicine. Now these doctors—18 from the University of Florence’s major teaching hospital, Careggi Medical Center, and six from other hospitals in the Florence area—will comprise the first faculty of emergency medicine in Tuscany and pass on that learning to others.

The Tuscany Emergency Medicine Initiative, the first program of its kind in Italy, began in July 2003. The program consisted of clinical rotations, as well as a lecture series led by faculty from both Careggi Medical Center and the Harvard-affiliated Beth Israel Deaconess Medical Center (BIDMC). Dr. Sharon Kleefield, director of health care quality at HMI, assisted with the implementation of testing methodologies for measuring and evaluating training courses for the physicians, and helped to define the standards and measures associated with quality emergency care. Kleefield served as a member of the examination oversight faculty, and was pleased to participate in the graduation ceremonies.

BIDMC enlisted Dr. Peter Rosen to lead an independent group of examiners that administered the examinations at the completion of the program. Rosen, a leading authority in the field of emergency medicine, assembled a distinguished group of experts that included former presidents of the American Board of Emergency Medicine. All 24 participants succeeded in passing, and this group is now serving as clinical instructors for the next phase of the program, begun in June. A group of 51 physicians have started a year-long course with the goal of being certified in emergency medicine. A rotating team of faculty from BIDMC will again deliver lectures and provide clinical teaching as the program goes forward.

Dr. Kevin Ban, an attending physician at BIDMC who is directing this initiative, said that the interactions between mentors and program participants have been illuminating, but not simply in terms of the learning that is taking place. “It’s very interesting to see the differences in approach to care between someone who is trained in emergency medicine and a physician who comes from internal medicine or some other discipline,” he said.

BIDMC and HMI are now set to repeat the success of this program by replicating the model for major hospitals in Pisa and Siena, with the train-the-trainer programs set to begin in September. Dr. Scott Weiner and Dr. Leon Sanchez, both members of the BIDMC faculty, will coordinate these initiatives regionally. Also in September, BIDMC will begin administering a master’s program in emergency medicine at the University of Florence. “The reasoning behind the development of the master’s program is that when the government of Italy formally requires that a residency program for emergency medicine be put in place, we will have already created the infrastructure for it,” said Ban.

One of the challenges this program is seeking to address is changing the local perception of emergency medicine—to make it a recognized specialty area, rather than one of the many tools of a doctor’s trade. Ban says that this will take time. “In the United States, if you ask an emergency physician what he does for a living, he will tell you that he’s an emergency physician. But in Italy, a person who performs the same function will respond that he is a doctor who works in an emergency department. We’re looking for people who don’t think that way to step up as leaders in this program.”

Enhancing knowledge to support the system:
Practi-Med goes to Shanghai
More than 400 health care professionals gathered in May for Practi-Med Shanghai, the latest in a series of continuing medical education programs aimed at enriching the knowledge of primary care practitioners, and the first organized by HMI with its partner Hua Shan Hospital (HSH).

HMI and HSH are currently working to develop a center for excellence in oncology in Pudong, and have also agreed to collaborate on a network of new facilities, including a flagship hospital in Nanhui and a general medical surgical hospital in Nanchung. “Practi-Med Shanghai is part of our overall effort to create a comprehensive health care delivery system serving the broader Shanghai region of China,” said Dr. Feng Xiao-Yuan, vice president of Hua Shan Hospital.

From left to right: Dr. Beverly Woo, Dr. Raymond Powrie, Dr. Soheyla Gharib, Margaret Regan (HMI program manager), Dr. Thomas Lee, Dr. Jeffrey Drazen, and Dr. Harvey Makadon.

Although the majority of the three-day program focused on common medical conditions encountered in outpatient practice, including cardiac disease, depression, asthma, pregnancy, and infectious disease, Practi-Med Shanghai also explored what makes a health care system successful. Dr. Harvey Makadon, HMI vice president of health systems development, explained that with the Chinese health care community continuing to move towards privatization, the leadership are eager to find ways to strike a balance between high-quality health care delivery and cost-efficiency. “Ensuring patient safety and satisfaction, reducing risk, and controlling costs will all factor in to the ability of providers to compete in this emerging marketplace,” he said.

Individual professional development is the guiding principle behind Practi-Med, but as with previous programs, the dynamics of primary care and the challenges facing those physicians are closely intertwined with concerns affecting the public at large. “Successful disease prevention requires the involvement of the public health system, neighborhoods, and the medical community,” said Dr. Lui Jun, director general of the Shanghai Municipal Health Bureau.

Dr. Harvey Makadon and Dr. Feng Xiao-Yuan

Makadon added, “Through educational programs like Practi-Med, we hope that by building the capacity of individual practitioners, we are helping to inspire incremental progress within entire health care organizations, and ultimately the system in which they operate.”

Among the Harvard Medical School faculty who lectured were Dr. Jeffrey Drazen, editor-in-chief of the New England Journal of Medicine; Dr. Thomas Lee, associate editor of the New England Journal of Medicine; Dr. Soheyla Gharib of Brigham and Women’s Hospital; and Dr. David Rattner of Massachusetts General Hospital.

Practi-Med Shanghai was held in conjunction with the New England Journal of Medicine and the China Medical Tribune.

HMI confers third Klaus Peter International Teaching Award
Andrew Colin, MD was awarded the Klaus Peter International Teaching Award by HMI in recognition of the central role he has played in the clinical training of overseas fellows. Colin, an associate professor of pediatrics at Harvard Medical School, works with the Department of Pediatrics at Ramathibodi Hospital, Mahidol University Medical School in Bangkok; and Kwong Wah Hospital in Hong Kong. The clinical training is provided through a formal fellowship in the pulmonary division at Children’s Hospital.

“The arrival of fellows from Thailand, Taiwan, and Hong Kong—all well-trained in the subspecialty of pediatric pulmonology—is always exciting for me because I encounter individuals who are on the front lines of serving their communities. Their challenges are real and immediate,” said Colin. “During their time in the Harvard community, they have the opportunity to witness the team-oriented thinking that goes along with patient-centered care in the U.S., and develop tools to apply those principles to their home institutions. Through these experiences, and by encouraging their active participation in discussions on controversial practices, we emphasize critical thinking and help these physicians along the path to discovering the next innovation that impacts their own environments through their practice as individuals.”

The $1,000 award, established in honor of Prof. Dr. Klaus Peter, dean of the Medical Faculty at Ludwig Maximilians University (LMU) in Munich, Germany, is given annually to an HMS faculty member who has contributed significantly to the field of international medical education, international exchanges, and mentoring of international students, residents, and fellows at HMS. Dean Peter was instrumental in the establishment and in the continuing success of the seven-year alliance between LMU and HMS.

Research and education to be focus of collaboration with XMU
A delegation from Xinjiang Medical University (XMU), a not-for-profit school with affiliated hospitals in Urumqi, China, visited HMI in June to formalize a collaboration that will focus on developing innovative research and education programs, and supporting the growth of XMU’s cardiovascular research center. XMU and its four affiliated teaching hospitals provide medical education and clinical care to the people of the Xinjiang Uygur Autonomous Region, an area in northwest China that is the country’s largest province.

Dr. Tom Aretz of HMI led the XMU contingent on a tour of Harvard Medical School.

The delegation was led by Mr. Li Bin, the university’s chief executive. He was joined by a distinguished group including Prof. Mao Xinmin, director of the scientific and research center at XMU; Prof. Wen Hao, president of the First Teaching Hospital of XMU; Prof. Yuemei Hou, vice-director of the cardiovascular department at the hospital; and Prof. Henry Ma, a senior advisor at XMU.

During a series of planning sessions, the XMU group and members of HMI’s education team took the first steps toward developing the structure for annual strategic and faculty development workshops at XMU. The first workshop is planned for October, when a team from HMI will lead a workshop on conducting scientific research.

The XMU group’s visit also included fact-finding trips to several departments of Massachusetts General Hospital, including the Transplantation Biology Research Center.

Distance learning: Exchange programs let students build knowledge, perspective

Four students from National Taiwan University College of Medicine (NTUCM) participated in clerkships at Harvard-affiliated hospitals, focusing on specialties ranging from clinical cardiology and neurology to ambulatory pediatrics. One student, Kuan Yin Liu, completed clerkships in multidisciplinary pain medicine and pediatric neurology at Massachusetts General Hospital (MGH). Like many of the students who participate in these exchanges, she was enthusiastic about the role that medical students play in American hospitals. “At NTUCM, I don’t do the primary care of patients in pediatrics, but at MGH, I had two patients every week, and by doing history-taking, physical examination, and follow-up on patients, I improved my thinking process and became more independent.”

The four students from Tokyo Medical and Dental University (TMDU) who spent part of their sixth year in the Harvard teaching hospitals felt the same way. Takaaki Hattori, who completed clerkships in rheumatology, neurology, and cardiology, said, “In the U.S., students have responsibility and play a role in the medical team. We want to do the same thing.” TMDU, with help from HMI, is in the midst of sweeping changes in its curriculum, including implementing problem-based learning (PBL). Ren Liu, who studied neurology and nephrology at Brigham and Women’s Hospital (BWH), said that PBL is already being integrated into the early years of the TMDU medical school curriculum.

Florian Baeres, of the University of Copenhagen in Denmark, was the most recent participant in the United States-European Union Medical Education Exchange (US-EU-MEE), a program involving six schools in the U.S. and Europe, including HMS. The program permits students to view another country’s health care from a systems perspective. By focusing on a single disease and patient, a student observes how their patient’s experience reflects the health care system of a particular country. Under the tutelage of Dr. Leonard Lilly, Florian observed patient care at BWH, with a focus on hypertension. “I followed a patient both prior to and after the stenting of both his renal arteries, which resulted in a significant improvement of his blood pressure,” he said. After the completion of the US-EU-MEE program, Florian took advantage of the opportunity to observe residents in the BWH cardiology department, as well as emergency physicians at Beth Israel Deaconess Medical Center.

Students from longtime HMI partners Ludwig Maximilians University (LMU) in Munich and Carl Gustav Carus Technical University Dresden (TUD) performed clinical rotations at Harvard-affiliated hospitals. These annual exchange programs are interesting because the students have the opportunity to experience firsthand the clinical teaching strategies that German schools are adopting. Five Dresden students arrived in November and spent four months at HMS. Their clerkship experiences included pediatrics, gastroenterology, hematology/oncology, cardiology, infectious disease, respiratory disease, and endocrinology. Ten students from Munich are currently in the midst of a four-month round of clerkships, including a popular course in advanced medicine at Mount Auburn Hospital. They are also completing a longitudinal curriculum course. A regular component of the Harvard-Munich alliance, this course challenges the students to work as a team on an element of curricular reform that can be implemented at their home institution.

HMI and Sri Ramachandra Medical College & Research Institute (SRMC-RI) have once again coordinated an enriching student experience. Larissa Lee, a third-year student at HMS, spent a month in Chennai focusing on tropical medicine. Under the mentorship of Dr. Krishna Seshadri, the coordinator of the HMI-SRMC-RI partnership, Larissa studied dermatology, pediatrics, internal medicine, and chest medicine, and saw patients in an outpatient clinic and hospital. “I was able to appreciate a wide spectrum of tropical diseases that are exceedingly rare in the U.S.,” she said. “Malaria is endemic in the region around Chennai, and tuberculosis and enteric fever are commonly seen at the hospital. I learned to expand my differential diagnosis for fever and shaking chills to include malaria, filaria and enteric fever, from my previous framework that included pneumonia and pyelonephritis.”

Another goal of Larissa’s rotation was to improve her physical exam skills. “I was able to focus on the importance of physical exam in a setting where laboratory and radiographic studies are not always an option,” she said.

In addition to advancing her clinical knowledge, the India experience gave Larissa a glimpse of the intersection between medicine and culture. “This rotation was invaluable for me to learn about health care delivery in a resource-poor setting, as well as the success of community-based medicine programs and the role of the private health care sector in an extremely populous country still plagued by poverty,” she said. “I gained an appreciation for the diverse cultures and religions in south India, and their impact on the practice of medicine.”