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Special
Editorial: Honour
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Lesley Pocock
Publisher and Ethics Editor
MEJFM, ME-JN, ME-JIM, ME-JPA, ME-JAA, MEJB,
World Family Medicine
medi+WORLD International AUSTRALIA
Email: lesleypocock@mediworld.com.au
The late Dr Noori Abdulla Khider, Erbil,
Kurdistan, Iraq. MEJFM Doctor of the Year for
2014
As the publisher of MEJFM for quite some time
now and with a background as a postgraduate
medical educator I have been in a position to
observe changes in, particularly, primary care
medicine in the region. Generally not only have
standards greatly improved in that time the
Middle East may be leading the world in some
endeavours. This comes down to the skills, dedication,
endeavour and honour of Middle East doctors,
academics and medical students.
As well as the plight of the ordinary people
of the Middle East who reside in conflict zones
there are still some obvious concerns regarding
medical education and the practice of medicine;
most of this, I observe, is out of the scope
of those groups mentioned above.
Rarely, as it is not my position or right, I
have been moved to make comment on some of the
extreme difficulties faced by some of the most
honourable people in the Middle East. I count
many such people, certainly as colleagues, but
many as personal friends.
The first aspect is wages and (ongoing) tertiary
funding. While conflict and economic sanctions
can make these aspects of tertiary education
beyond the control of some governments and funding
organisations there are some difficulties which
can be removed, given proper focus. The first
aspect is adequate funding of the tertiary education
sector, and maybe even prior to that, recognition
of the value of tertiary educated populations.
Of course for this aspect to provide proper
value to the country and students alike, the
curricula must match and meet world standards.
There is also argument for creating higher than
current standards and the Middle East leading
the world in some endeavours.
The second aspect is equal funding for quality
educational institutions in all regions, within
a country. I have come across such anomalies.
An example is Hawler University, Erbil, Iraq.
I am well acquainted with the University mainly
as one of our MEJFM Middle East Doctors of the
Year, the late Dr Noori Abdulla Khider, an exemplary
man who unfortunately died in 2014, was an academic
there. He has two daughters still studying at
the University.
The academic staff through a variety of measures
over a period of time, including no wages paid,
only 25% of wages paid, no payment for postgraduate
supervisions, extra lectures, MSc and PhD discussions,
article evaluation and other issues, since 2013,
has resulted in a situation where they have
not been paid their due salaries for the equivalent
of the past 10 months. During one year they
received only 25% of wages paid for six months,
the equivalent o having received just one and
half salary out of 12. I believe other Universities
in Kurdistan are in the same position. I draw
this to the attention of the Kurdistan Ministry
of Health who can hopefully remedy this situation.
The most important aspect of this is that all
such non paid academics at Hawler University
turn up to work every day to allow their students
to complete their degrees, which are the medical
student’s own investment in time and money
to serve their country and the Iraqi population
as future doctors. We honour those committed
academics at Hawler and hope this can be swiftly
remedied
Syrian ‘war’ child victim, (Omran,
taken August 19, 2016)
The third aspect is obvious to those who watch
the news – conflict and war. This editorial
is not to judge who is right or who is wrong
in any conflict – most people on all sides
of wars are usually fighting for their own convictions.
What is a concern however is the doctors in
warzones who not only face constant danger caring
for the injured or those suffering from resulting
extreme conditions such as malnutrition –
and who so often are children and babies. There
is a horrific tendency of late for doctors and
hospitals to be deliberately targeted. Presumably
this is a new strategy, implemented to demoralise
populations and further weaken those already
weakened. While Syria is only one such horror
story for such doctors and innocent populations,
I will use this situation as my example.
As of April 2016, there have been 365 attacks
on medical facilities in Syria and 738 healthcare
workers have been killed, according to data
from the global non-profit Physicians for Human
Rights (PHR).
Roughly 95 percent of the once-thriving city’s
doctors have fled, been killed or detained.
This has led to an extreme shortage of staff
– particularly specialized physicians.
General surgeons, are said to be forced to do
the work of neurosurgeons, oncologists, endocrinologists
and vascular surgeons.
A known physician (whose name is withheld for
security reasons) working in Eastern Aleppo,
said his facility receives between 15 and 20
war injuries a day, mostly civilians, and often
children. But without a paediatrician on staff,
children have to be treated by non-specialized
physicians.
In April, an airstrike on the eastern al-Quds
hospital killed one of the rebel-held Aleppo’s
last pediatricians, Dr. Muhammad Waseem Maaz.
The hospital was supported by Medecins Sans
Frontieres (MSF) and was one of the few left
in Syria with a functioning emergency room,
intensive care unit and operating room.
A report by Amnesty International called out
against the systematic targeting of hospitals
and medical facilities in Aleppo, a violation
of international humanitarian law.
An additional example of national devastation
is in places where no official war has been
declared, but civilians and doctors face the
same circumstances as those in war. Medical
friends and colleagues in Libya for example,
where there is no acknowledged war occurring,
but due to factional fighting and insurrection,
work without power, water, access to their bank
accounts, rubbish piling up uncollected and
even blockage of roads making it difficult to
even get to work to save lives – and the
hospitals are without basic necessities.
Middle East Primary Care Quality Improvement
program
The fourth aspect is those graduating from many
of the medical schools in the Middle East are
finding it difficult to obtain employment in
the region. It seems ‘overseas educated’
doctors are being preferentially employed. The
reasons for this may or may not be valid and
as with all things in life it should really
come down to the qualities and qualifications
of each individual. I did some research on hiring
organisations and while there seems to be no
overt policy among such, there are some requirements
listed such as candidates for the positions
must be undertaking annual CME. The academics
and administrators of regional universities
will need to address any deficiencies in their
curricula and postgraduate institutions but
one thing I can personally help those in the
region without a CME/CPD program is to provide
one via the MEJFM which we will start to do
as from the November issue.
As a postgraduate medical educator I have provided
QA&CPD programs to Australian family/primary
care doctors and some Australian specialist
colleges. Having spoken at international conferences
and venues on this topic I find Australia is
a leading purveyor of Quality Assurance (QA)
/Quality Improvement (QI), and CME/CPD.
Additional to providing strategic programs for
Australian Doctors I have provided global medical
education strategies sponsored by major NGOs
including those that are available to every
country, with a view to provide parity of medical
education resources for all countries of the
world. This opened my eyes to the major deficiencies
in some countries and the major needs of many,
mostly developing countries. I therefore started
to make it available to individual doctors and
students globally but also developing countries
as national CME programs (including Indonesia
and Nepal).
These same programs have been modified and added
to for use in a range of countries where we
have made it available.
Australia has a mix of urban based doctors
as well as doctors in rural and remote areas
so the original QA/QI&CME/CPD already addresses
issues of remoteness and lack of nearby facilities,
however working in developing and low income
nations has shown there is up to 30% missing
medical education if medical education is to
suit the needs of ALL doctors and patient populations
in the world. These issues include socioeconomic
issues (where doctors and hospitals may not
be able to afford modern diagnostic equipment
– therefore other means of diagnosis have
to be found, and issues of poverty such as malnutrition,
Vitamin D deficiency and old diseases such as
leprosy that have not been eliminated. It also
includes issues of lack of vaccination and screening
facilities.) Another problem is longterm sequelae
of untreated chronic diseases that almost become
unrecognisable, as well as climatological issues,
and prevalence of rare and tropical diseases.
The inability of a patient to afford the therapeutics
or tests prescribed adds another level of complexity.
Our education has grown to cover many of these
additional attributes as well and is perhaps
the only body of postgraduate medical education
that does attempt to cover ‘all presentations
anywhere in the world’. Of course with
increased global tourism, travel and migratory
workforces, all doctors, everywhere need to
know everything. This is just as relevant to
first world doctors as third world doctors.
For easier dissemination and better educational
quality, an interactive ICT platform is used.
The Interactive Case based modules cover all
presentations on all topics (e.g. renal disease)
and interactive questions with answers and feedback
(on correct and incorrect selections) cover
diagnosis, tests as required, and patient management
and ongoing patient care. The doctor/ user tests
themselves /their answers interactively against
the author’s answer – university based
experts in each topic. Videos, animations, test
results, X-rays, scans, ECGs charts, lists of
Normal Values etc are supplied surrounding each
topic.
The QA and QI aspects require the education
providers to show that the doctors have learned
from the programs (Quality Assurance/QA) and
that they have implemented what they have learned
(Quality Improvement/QI) into their practice.
Each program we will supply has an assessment
sheet to be filled in by the users to ensure
the programs meet their needs. A pre and post
test in each program shows both doctor and education
provider if knowledge has increased. Education
also covers psycho-social issues of both doctors
and patients as well as Behaviours, Attitudes,
Skills and Knowledge (BASK questions).
The CME/CPD will be presented as a full national
program covering full population health over
a three - five year period. This way it also
serves as strategic CME to bring doctors prior
trained in all places and all periods of time,
up to date. The ICT based, interactive (the
doctor- student pits themselves against the
author/educator as does all professional education)
will be provided online within each issue of
the MEJFM. The education is free to air, but
we ask all users to register with us so that
we can log your participation.
For those individuals or countries wishing to
use this as a formal CME/CPD program there is
an examination module available on completion
each of the nine educational programs (see list
following), on DVD, which we will need to cover
costs of posting and reporting (the module itself
awards the Certificate of Successful Completion,
which can be printed out, once all required
work is completed). A copy can be emailed to
any governing body.
The exam requires a pass mark of 80% but users
can attempt it as many times as they wish until
they have achieved that pass mark. All questions
are based on the free education modules which
will be archived online on MEJFM for access
at any time. Universities are not only welcome
to use the education for undergraduates and
postgraduates, (some universities in Australia
use the cases for final year medical students)
they are also welcome to comment on or submit
case presentations for sharing with the region.
The Middle East Quality Improvement Program
(CME and CPD) Outline:
Modules
Emergency Medicine
Child Health Emergencies
Obstetrics and Gynaecology
Chronic Medical Disease
Mental Health
Dermatology
Infectious Disease
Geriatrics
Surgery
Diagnostic Process
The program will be provided within the MEJFM
commencing with the November 2016 issue.
CPD for each of the above topic areas will
be provided over a 6 month period. The exam
for the above modules will be taken from all
education provided within those 6 months, and
will be available at the end of each 6 months.
Free online resources, e.g. educational videos
connected to each topic area will also be provided
online.
For more details contact me on: lesleypocock@mediworld.com.au
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