Training specialists in developing countries: A new model

Specialist training is vitally important in any health-care system. While primary care forms the basic building blocks of the health-care system, once the foundation is built, the need for advanced knowledge and expertise in subspecialties becomes apparent. Therefore, a robust specialist training apparatus is indispensable in the evolution of an independent, equitable, and sustainable system aimed at taking advanced health care to the populace.^[1]

There is a huge unmet need for specialist training in developing countries. For example, many African countries lack the ability to train physicians with the highest competencies and skills needed to deliver specialized services to the population simply due to the lack of local expertise.^[2] To date, the path to advanced medical training, particularly in specialties with procedural skills (bronchoscopy, cardiac catheterization, etc.), has required the trainee to relocate and be “resident” with the trainer for a meaningful training to occur. The account of a foreign physician providing a dedicated mentorship and supervision of a young resident physician undergoing specialized training in his home country, Ethiopia, is a novel, and remarkable departure from the “normal” model.^[3] This is a new approach to exchange of knowledge and skills with its own advantages and challenges:

First, it focuses on establishing the trainee in his/her own natural environment and makes the training process more adaptable, locally relevant, and culturally appropriate.

It creates a platform for the trainee to succeed by channeling funds which would otherwise have been spent on travel and other logistics, into the establishment of an equipped and locally sustainable center with facilities required to provide the improved level of services. Lodging and resultant logistical fees are generally less expensive in the developing world than in highly industrialized countries. Thus, funds are saved and can be recouped into building other necessary systems such as equipment (e.g., bronchoscopes, spirometers, mechanical ventilators, oxygen delivery systems, etc.) that are required for the specialist to practice at the highest level.

Medical training has long been founded on strong trainer-trainee relationships. This model builds confidence in the trainee by creating a long-term mentee and mentorship relationship, usually evolving into a collegial partnership.

It helps in mobilizing local support for the trainee. The local institution does not worry about whether the trainee will return after the training process. In addition, by showcasing the improved services that are now possible during the training period, the local institution is able to “see” the value added.

Several trainees can be trained at the same time, shortening the time period to ramp up local capacity and to establish a community of learning within the specialty locally.

Licensure issues for providing direct care (and thus “hand on” experience) are often easier to solve when the specialist trains in-country rather than when the trainee is seeking training elsewhere. Many countries seeking this training to be built within country are more willing to provide licensure for the trainer to come and teach locally. Thus, licensure issues are more easily solved.

Trainees can transition into specialist training quicker and at a younger age at a stage in which they are more energetic and ready for a rigorous specialist training process. Most specialty training is sought after the trainee has already received at least their medical degree. Many countries with very well-developed health systems with specialty training already integrated into the system require foreign graduates to train fully within the countries system – often adding years onto the time spent away.

It has the potential to create synergistic effects in the development of other interdependent specialties training locally. Specialized services often do not stand alone in the provision of quality patient care. In other words, in-country training of specialists can evolve into a local center of excellence in certain key branches of medicine if there is a sustained and concerted effort including the much needed “political will.”

It widens the breadth of experience for the trainer as he/she works with the trainees to adapt and apply clinical guidelines in a sound and thoughtful process for the local population without compromising the quality of care.

Finally, it is an altruistic experience for many trainers who have long sought to provide relevant services and training in underserved populations or help their home country from diaspora. The success of the program depends on developing a smart, realistic curriculum and clear goals of training. It requires local support to succeed and it also requires financial investment from the local institutions. This local support initially may involve facilitating the local logistics of a visiting trainer but long term must include assisting the development of the environment and career pathway in which the newly minted specialist can thrive; no one wants to spend years gaining a skill to not be able to practice it.

Overall, the goal should be to build confidence in local specialists and to establish a mentorship relationship for the long haul. The training must embrace a non-inferiority standard and assure that graduates of the training program are trained to a global standard.

Institutions in developing countries need to explore and refine this opportunity to hook up with established “northern” partners and develop collaborative training systems that are internationally sound, locally relevant, economically sustainable, fulfilling to trainees, and meaningful to the local population.