Friday, December 07, 2012

Locally relevant medical education: stopping the brain drain or stunting brains?

The concept of locally-relevant medical training was first introduced by Eyal and Hurst as a way to combat “brain drain,” the exodus of trained professionals from poor sending countries to the richer countries of the West. Brain drain can have devastating consequences for the already fragile health systems of underdeveloped sending countries, and it represents a massive loss of investment for sending countries who have subsidized their graduates’ medical training only to see them leave to provide their services abroad. The WHO has since endorsed the locally-relevant training model as a way in which to address the disproportionate shortage of health professionals in poor and remote regions of the world. So, how does it work? Locally-relevant medical training is designed to make foreign medical graduates, 1) less desirable to Western hirers and, 2) better equipped to practice medicine in the scarcity conditions of their home countries. What this means is that medical students in sending countries would no longer be trained to score well on US board examinations or how to read MRI scans, but rather how to manage local endemic disease and succeed with the diagnostic equipment and supplies available in their localities.

The idea of locally-relevant training sounds practical, and it may indeed be an effective way to avoid the pitfalls of brain drain if correctly instituted. Indeed, if the paramount goal is to increase and/or introduce healthcare services into underserved regions of the world, locally-relevant training appears to be a commonsense solution. But, some may argue that it is not necessarily the answer.  First, is the locally-relevant model fair to its students? They are taught “second-rate” medicine as compared to the Western gold standard. As a result, their freedom of movement is restricted as they are no longer qualified to practice medicine in the West. Is it okay to deny these individuals the opportunity to study the latest and greatest advances in medicine simply because of where they live? Second, it can also be argued that sending countries should provide more incentive for their graduates to remain at home. This may entail increasing wages, improving practice conditions, and expanding research opportunities.

Does a focus on locally-relevant medical training unfairly place the impetus on sending countries to change the status quo? After all, blame for the phenomenon of brain drain does not fall squarely on the sending countries; it is in large part driven by a shortage of medical professionals in the West, the “pull” factors attracting foreign graduates to the West, and, surely, “push” factors that drive foreign graduates from practicing at home. Some may argue that the richer countries should implement policies on their end to protect sending countries from the harmful effects of brain drain. The West, however, is the beneficiary of the status quo; why would it “shoot itself in the foot” and preempt a scheme that is an easy fix for its own physician shortage problems? To be fair, there are initiatives like PEPFAR’s Medical Education Partnership Initiative that work to increase the local retention of health care professionals in sub-Saharan Africa and other regions of the world. But this initiative and many others do not address the real problem: there are too few medical professionals graduating each year from Western institutions to provide adequate care for its population. Countries in the West should train more homegrown medical professionals to cover their own deficits if they are serious about mitigating the deleterious effects of brain drain on sending countries. 

Guest post by David Kennedy, Medical Student
University of North Carolina at Chapel Hill

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Anonymous Anonymous said...

Very nice discussion. I find 'locally relevant' as a means to prevent brain drain to be extremely patronizing and reminiscent of colonial domination.
Another potential issue with 'locally relevant' training is that eventually regions / countries / institutions do gain access to those 'gold standard' interventions about which the trainees were never taught. Do the practitioners then have to go back to school?

In our education group we have always taught what our colleagues in LMICs wanted. That is, what they should be doing in an ideal world. We then have the discussion about what they can actually do.

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