Correspondence:
lesleypocock@mediworld.com.au

With the inevitable international financial crisis and the debasement of global standards, the era of 'new (ethical and sustainable) business' is surely overdue. Even wealthy countries are finding healthcare delivery increasingly unaffordable and unviable and doctor shortages are increasing everywhere.

A pragmatic approach to quality medical education is an urgent requirement. In the new era, we finally have the opportunity to do things better and to rethink the way we do things on a global scale and with community needs in mind.

In the current world, a few people have many opportunities to advance themselves, and most people have none. This situation affects education and training and consequently the delivery of vital community services, such as healthcare.

Under these circumstances education must meet community requirements and expectations. Lack of affordability must not prevent countries from having properly trained doctors. It is a universal human right for all populations, and if education of doctors is limited due to commercial costs of education, then a new way must be found.

The question then is, how to improve parity of opportunity, parity of access to education, affordability of medical education, the building up of national professional classes, and stop the brain drain of health professionals from low income to high income nations, given the inbuilt inequity of the world.

A further aspect is the inherent unaffordability of the system yet we still follow the old failed approaches to medical education and require 'financial profit margins'. This also needs to be re-appraised to keep the system affordable and of highest quality as currently the quality deteriorates with decreased money in the education system and makes the quality products even more elitist.

Should vital areas of education, such as medical education, rely on outdated unethical systems? The system currently caters to a protocol, of privilege and power, not need and equity.

Every country, including wealthy western countries do not have enough doctors, and healthcare is barely affordable to most. Increased stress on doctors, due to patient numbers/ratios and continuing educational and other requirements are putting increasing stressors on medical professionals. The current system is failing most people of the world.

How do we approach these problems when postgraduate training and medical education processes are either non-existent or not meeting the health needs of the world's people - rather they are becoming more scarce and unavailable.

Lack of access
This involves the financial ability to pay for that education, and physical /geographical access (e.g. distance to facilities, possibly requiring accommodation, and the requirement therefore for even more financial outlay).

Lack of access can also include issues of lack of access to quality education where the local product may be inferior due to less money in the system, and less ability to pay for top educators, thereby putting higher quality educational products out of geographical and financial reach

Affordability
This is really one of the two most important points as it encompasses the main problems and the ethical concerns. Should not all countries have well-qualified and competent doctors. If the country is poor and has limited facilities - both educational and in professional classes - is it right that students cannot afford to attend university locally even with its limited facilities, due to economic constraints, or to be able to afford to travel overseas to gain better education.

Universal healthcare is surely everyone's right and if the current system is not meeting the government and population needs of countries we need a new global approach that allows for a viable system. This must also focus on the current 'brain drain' when practitioners in poor countries find work in wealthier countries that also have shortages of medical personnel. So the strategy also has to include ways to prevent this brain drain, and solutions for both the wealthy and unwealthy countries, as well as their populations. Some form of national incentive may be required, as you cannot blame doctors from looking for a better life for themselves and their families.

Relevance to global practice (medical education currently stops at national borders)
In the author's experience in providing national CME to various low income nations we have identified that up to 30% of educational topics are missing from global medical curricula.

This includes specific disease more prevalent in low income nations that does not make it into the general educational literature e.g. leprosy, TB, Ebola. It also includes disease that is normally prevented by public health programs in wealthier countries, and the relevance of 'western' medical education when doctors have no access to modern diagnostic equipment and when patients cannot afford the treatment prescribed.

It is vital in a world of global warming and climate change, of increased travel, tourism and migratory workforces, that all primary care doctors of the world have a complete knowledge of international medical education. It is also vital in terms of parity and equity of medical education resources.

The launch of the Nepal CME program, by World CME and the Nick Simons Institute has both identified some of the missing 30% and gone some way toward filling that void. Lessons learned will be included in MMU - a new postgraduate multimedia medical university, which attempts to address these issues, particularly the issues of affordability and access to quality medical education.

MMU will provide skills training (short courses), as well as International Diplomata in International medicine across four departments: General Practice/Family medicine; Surgery - for both GPs/FPs and Surgeons, Geriatrics and Integral medicine.

All educational programs are written by top global medical academics and are delivered in a Quality Assurance framework which allows the doctor/student to self evaluate the worth of the educational programs.

Level of content (ESL), local terminology, local facilities, local drugs/prescribing practices, and government policy are all additional aspects that have been addressed.

Geographical, climatological (outbreaks are moving into different latitudes due to global warming), socio-economic, cultural, psychosocial issues (motivation to improve
standards, to retain doctors where they are needed etc) are further issues that need to be addressed both nationally and internationally.

Emergence of resistant strains of TB, outbreaks such as SARS and avian flu, and antibiotic resistant organisms also show the need for a global approach to human health and continuing medical education.

Where does evidence base and best practice fit, if the primary care doctor cannot afford diagnostic equipment and the patient cannot afford prescribed treatment? How does a doctor who earns less than $US 200 a year, afford 'international medical education'?

Under the current system doctors in both developed nations and developing nations have inadequate CME due to these inequities.

Professional/Adult learning techniques
It must be recognised that the practising doctor has a different set of skills to the student and a wider appreciation of healthcare. There are also many cases in medical topics where there is no defined pathway for a particular patient's set of health problems. A systems approach is encouraged and diagnostic decisions must be made relevant to each particular patient. Professional learning whereby the participant assesses him/herself against the author or provider of education is a better approach as is patient focused medical education.

The use of ICT is now a recognised strategy to cut costs of delivery of medical education but the technology itself should always be used to provide better ways of teaching than done originally on paper. With education delivered by electronic media, medical education topics can be improved, especially where the data shows that students and doctors have specific problems. The variety of media in multimedia provides enhanced learning platforms as well as interactivity and immediate feedback. Video and animation allows you to 'get under the skin' as does simulation.

World data for example, shows that less than 5% of GPs/FPs worldwide can perform spirometry well so the MMU course on the same provides time/space animations of 'real patient lungs' and the student can compare them against normal lung patterns for a range of (real) patients.

All education therefore will be delivered in multimedia format on CD and DVD, for both strategic reasons of affordability, but also because multimedia provides more enhanced learning methods and process.

CD or DVD, provides better platforms than the internet and quicker response times for interactive components. It also requires no further outlay of money, given that the doctor has a PC in the first place.

The quality Board of MMU has been drawn from around the world and includes committed people who have devoted their life to medicine and who have a genuine interest in seeing equity and parity of quality medical education for all countries.

Board members include Dr. Tawfik A M Khoja; Director General Executive Board, Health Ministers' Council for Corporation Council States, Kingdom of Saudi Arabia; Professor Nabil Kurashi; Professor of Family Medicine, College of Medicine, King Faisal University, Pro tem Regional President, WONCA EMRO, Vice-Chairman, Arab Development Institute, Vice-President, Arab Development University of Bahrain,
Dr Abdulrazak Abyad' Chief Editor of MEJFM. ME-JIM,. MEJN and MER-JAA MEAMA - Middle East Academy for Medicine of Ageing, as well as MENAR, MEPCRN, MEAAA; Lebanon; Professor John Murtagh, Author of world best selling reference book General Practice, and medical educator at Monash University, The University of Melbourne, University of Notre Dame and the Royal Australian College of General Practitioners (RACGP) Australia. John brings a lifetime's quality teaching experience to the project. Mr Brygel a General Surgeon and surgical educator is the author of the original 'Video Book of Surgery' and works with organisations such as the Royal College of Surgeons (RACS) and medi+WORLD International (mWI) and World CME (WCME) to provide surgical education for Surgical trainees and family doctors/GPs. Mr Brygel lectures at Monash University, The University of Melbourne, Royal Australian College of Surgeions (RACS) and runs various surgical clinics; Professor Craig Adams, Chair, Clinical Skills Domain, Head of Anatomy. Deputy Chair, BCS Committee, The University of Notre Dame & St. Vincent's Hospital Sydney, Australia; Prof. Abdulbari Bener, Advisor to World Health Organization, Head & Consultant, Dept. of Medical Statistics & Epidemiology, Hamad General Hospital & Hamad Medical Corporation, Weill Cornell Medical College, Qatar; Dr. Mohamed Sayed Hussein, Head of Studies and Research Division, Health Ministers' Council for GCC, Riyadh, Kingdom of Saudi Arabia; Prof. Jean-Pierre Michel; Head of The Geriatric Ward, Department of Rehabilitation & Geriatrics Geneva; University Hospital and Medical School, President of the European Academy for Medicine of Ageing Academic, Director of the European Union Geriatric Medicine Society, WHO expert Health and Age Program, and many others.

MMU is a genuine attempt to provide parity of medical education resources and is launching all Departments in February 2009. Further detail is available at:
www.multimediamedicaluniversity.com.