|PRACTICAL ADVICE PAPER
|Year : 2014 | Volume
| Issue : 2 | Page : 158-162
Sherbrooke - Montevideo: A socially responsible international collaboration to foster family medicine
Martine Morin1, Paul Grand'Maison2, Eduardo Henderson3, Julio Vignolo4
1 Department of Family Medicine, Université de Sherbrooke, Quebec, Canada
2 Faculty of Medicine and Health Sciences, Université de Sherbrooke, Quebec, Canada
3 Department of Surgery, Universidad de la Republica, Montevideo, Uruguay
4 Department of Family and Community Medicine, Universidad de la Republica, Montevideo, Uruguay
|Date of Web Publication||31-Oct-2014|
Dr. Martine Morin
Department of Family Medicine, Faculté de Médecine et des Sciences de la Santé, Centre Hospitalier Universitaire de Sherbrooke, 3001, 12ème Avenue Nord, Fleurimont (Québec) J1H 5N4
Source of Support: None, Conflict of Interest: None
Background : The World Health Organization advocates for faculties of medicine to orient health professional education toward the needs of the populations graduates are to serve and to include a greater emphasis on primary health care. It was in this framework that in 2007, the Faculty of Medicine and Health Sciences at the Université de Sherbrooke (FMHS-UdeS) in Canada and the Facultad de Medicina de la Universidad de la Republica (FMUdelaR) in Montevideo, Uruguay developed a comprehensive collaboration to sustain the development of family medicine in both universities through education, practice and research. Activities and Outcomes : In addition to information sharing through email and teleconferencing, this five year collaboration has included 28 bilateral visits by the two institutions' teachers and leaders. During these visits, Uruguayan members participated in workshops and benefited from exchanges during educational and clinical activities. Interactions led to the improvement of their skills as teachers of family medicine with an emphasis on clinical teaching, supervision, feedback to learners in clinical evaluations, use of various educational methods, use of standardized patients for teaching and evaluation, and research. FMHS-UdeS members learned about the community aspects of family medicine in Uruguay and reflected on how these could be implemented to the benefit of Canadians. Conclusions : The international collaboration forged between the FMHS-UdeS and the FMUdelaR represents a socially responsible endeavor that has been highly rewarding for all involved. It represents a significant learning opportunity for each group aiming to better prepare physicians to serve as primary health care providers in their communities.
Keywords: Canada, family medicine, health professional education, International education exchange, International collaboration, primary health care, social responsibility, Uruguay
|How to cite this article:|
Morin M, Grand'Maison P, Henderson E, Vignolo J. Sherbrooke - Montevideo: A socially responsible international collaboration to foster family medicine. Educ Health 2014;27:158-62
The activities carried out in this collaboration were financed by both Faculties of Medicine, funds from the Pan-American Health Organization (Program of Technical Cooperation among Countries), and Health Canada (Programme de subventions internationales à la santé),
| Background|| |
In 1978, the Alma-Ata Declaration was adopted at the International Conference on Primary Health Care. This declaration emphasized the right to health for all and highlighted primary health care as key in meeting the needs of populations. It called for national and international action to achieve implementation.  In spite of a worldwide movement of health care reform and despite major improvements in health indicators in many countries, differences persist among and within countries on important health issues such as access to services, maternal mortality rate and life expectancy.  To address these issues, since 2007 the World Health Organization's (WHO) American arm, the Pan-American Health Organization (PAHO), has promoted the concept of "renewed primary health care".  This renewal aims to incorporate the following principles: Responsiveness to people's health needs, orientation to quality, accountability, social justice, sustainability, integration, participation and collaboration with other sectors such as education, municipal government and community interest groups.
Implementing renewed primary health care requires taking into account the quality, equity, relevance and effectiveness of health services, as well as individual and population health needs. It requires creative partnerships among stakeholders, including decision makers, health administrators, professionals, academics and the public, and it calls for the reorientation of health professional education.  The Global Consensus for Social Accountability of Medical Schools has established a set of strategic directions that faculties should adhere to and actions they should implement to become socially accountable.  To achieve the Alma-Ata objectives, faculties of medicine should orient health professional education toward the needs of populations, including placing stronger emphasis on primary health care.  Among other approaches, this includes the development of family medicine as an academic discipline and clinical practice.
Faculties of medicine around the world should strive to participate in this endeavor.  Furthermore, in this era of globalization, engaging in partnerships at an international level is a viable way to affect change in the participating institutions. It is in this framework that over the past 6 years the Faculty of Medicine and Health Sciences at the Université de Sherbrooke (FMHS-UdeS) in Canada and the Facultad de Medicina de la Universidad de la Republica (FMUdelaR) in Uruguay have developed a comprehensive collaboration to foster the development of family medicine to improve primary health care.
Canada, a high-income country of 33 million people in North America, has a universal health care system that ensures accessibility and insurance coverage to all Canadians. The system gives a significant role to primary health care and public health at the level of communities. Family medicine residencies have been implemented progressively over the past 40 years, and residency completion has been required to practice family medicine since the early 1990's.
Uruguay, a high middle-income country of 3.3 million people in South America, implemented an integrated national health system in 2007. This system emphasizes primary health care and integration of public and private sectors with a focus on accessibility, equity, quality and cost effectiveness. Each Uruguayan receives health services through either the public or private system. Uruguayan medical students must complete seven years of undergraduate medical education to obtain a license for general practice. Among the students who graduate, 50% will pursue a career as a general practitioner, among which 10% will elect to complete a three-year residency program in family medicine. This program has been offered for the last 15 years by the university's Department of Family and Community Medicine.
The FMHS-UdeS, situated in Sherbrooke, Canada matriculated its first MD student in 1966. It is recognized nationally and internationally as a leader in medical education in areas including problem-based learning, community-oriented medical education, distributed medical education and social responsibility. Committed since its inauguration to preparing generalist physicians to work outside of metropolitan areas, it is also a national leader for the development of family medicine and other broad-based specialties-internal medicine, general pediatrics, obstetrics and gynecology, general surgery and general psychiatry. This emphasis on primary health care has been effective; in recent years, more than 45% of FMHS-UdeS graduates have gone on to complete residencies in family medicine, and another 25% have chosen other broad-based specialties. Among the students who asked for a residency match in family medicine, 75% had identified this specialty as their first choice of residency program. Since 2001, the FMHS-UdeS has been a WHO/PAHO Collaborating Center on the development of health human resources responsive to the needs of communities and populations.
The FMUdelaR, situated in Montevideo, Uruguay, implemented a new curriculum in 2009 following a thoughtful and extensive review process. The renewed curriculum is student-centered and emphasizes active educational methods, community-based activities, and a vision of medicine through the lens of primary health care. This approach is intended to emphasize primary health care within medical education and strengthen the role of the Department of Family and Community Medicine. [Table 1] provides a brief comparison of the principal characteristics of the two institutions.
|Table 1: Comparison of the general characteristics of the faculty of medicine and health science of the Université de Sherbrooke and the Facultad de Medicina de la Universidad de la Republica|
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In 2007, the two faculties of medicine signed an official agreement of collaboration that includes exchanges of expertise, students and teachers. Based on our shared experience, we consider this type of international collaboration between institutions as highly beneficial for the advancement of primary health care and we wish to share our experience and its benefits, obstacles and overall usefulness with the international community and to encourage others to establish similar collaborations.
The overall aim of the collaboration is to promote the development of health care practitioners who can meet the needs of the populations served by the partner institutions. More specifically, the collaboration's objectives are to: (1) Support the implementation of the renewed curriculum at FMUdelaR, (2) support the development of the FMUdelaR's Family and Community Medicine Department through faculty development and strengthening its clinical teaching, (3) promote and further develop the community-oriented approach at the FMHS-UdeS and (4) support a culture of scholarship and research at both institutions.
In 2005, one of the Uruguayan authors of the present paper (EH) began a one-year preceptorship in medical education at the FMHS-UdeS. In 2006, he was hired as a faculty member of the FMHS-UdeS and simultaneously completed a graduate certificate in higher education teaching. He developed strong relationships with several leaders in medical education and gained an appreciation for their expertise in medical education. Seeing an opportunity for collaboration, an open dialogue began wherein the basic aspects of the partnership were identified. The project started small and progressively grew into a win-win partnership based on shared vision, trust and respect between the parties. Although not intended initially, the collaboration has developed into a partnership that encompasses many of the features described in the 'twinning' literature, notably its emphasis on ensuring a long-term and sustainable two-way collaboration [Figure 1]. 
|Figure 1: Map of the Americas showing the locations of the two collaborating institutions (map designed by the Université de Sherbrooke's Faculty of Medicine and Health Sciences' Communications Office, 2013)|
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Activities and outcomes
In addition to numerous exchanges of documents and information through emails, teleconferences and video-conferences, the most significant exchanges within the collaboration have occurred through 28 bilateral visits since 2007. During these visits, one to six leaders and educators from one partner institution were invited to visit and exchange ideas and experiences with their counterparts at the other institution. [[Figure 2] presents the chronology of these trips. Worth noting are the three visits from the FMHS-UdeS dean to Montevideo and the two visits of the FMUdelaR dean to Sherbrooke. As described in the following paragraphs, these visits provided unique opportunities for discussion, observation and learning that were instrumental in moving toward meeting the collaboration's objectives.
|Figure 2: Chronology and specific details of the 28 bilateral visits (1-6 participants per visit) between Sherbrooke, Canada and Montevideo, Uruguay since 2007|
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Supporting the implementation of the renewed curriculum at FMUdelaR
The implementation of the new curriculum was facilitated through document-sharing, meetings between educators, and workshops on teaching methods. Uruguayan teachers and leaders became more proficient in the use of problem-based learning, small group educational methods and evaluation tools to assess clinical competencies, including the use of the Objective Structured Clinical Examination, standardized patients and simulation. Increasing the role of family medicine in undergraduate medical education was not as successful as expected due to a change of focus in the curriculum in favor of public health and a decision of department leaders to prioritize the development of the family medicine residency program.
Supporting the development of the FMUdelaR's Family and Community Medicine Department through faculty development and strengthening its clinical teaching
The collaboration has focused principally on strengthening education. To that end, 11 Uruguayan professors from the Department of Family and Community Medicine have traveled to Sherbrooke for a week or longer, while 6 professors from the FMHS-UdeS have spent a week or more in Montevideo. Exchanges have resulted in a better shared understanding of the major issues in family medicine education and in its clinical practice, including its place in the health care system of each country. Uruguayan teachers participated in various workshops and benefited from exchanges during educational and clinical activities. These interactions led to the improvement of these educators' abilities as medical educators generally, and in family medicine particularly. Interactions emphasized clinical teaching, learner supervision, feedback and clinical evaluation, use of a variety of educational methods and use of standardized patients for teaching or evaluation. This has resulted in a greater commitment of the Uruguayan faculty to their roles as teachers, educators and leaders in family medicine, and in turn to demonstrable improvement in clinical education at the residency level.
Promoting and further developing the community-oriented approach at the FMHS-UdeS
FMHS-UdeS professors learned firsthand about the community aspects of family medicine as emphasized in Uruguay, and they reflected on how these could be similarly implemented in Canada. In fact, the significant community involvement of the Uruguayan medical students during their undergraduate education inspired the recent introduction of comprehensive community service-learning activities for FMHS-UdeS medical students. Faculty from the FMHS-UdeS wanted to further the collaboration by developing a resident exchange program between the two universities; this was unfortunately never implemented due to legal constraints. The partners hope that this obstacle can be overcome in the near future as an exchange of residents will benefit both schools.
Supporting a culture of scholarship and research at both institutions
To promote scholarship and research, a FMHS-UdeS family medicine researcher spent a week in Uruguay in both 2011 and 2012 to explore the possibilities of developing research capacity and collaborating. A joint Sherbrooke and Montevideo research project on the "vision of health" was planned in the fall of 2011 and completed in 2012. This project measured how medical students, practicing physicians and faculty conceived health and the physician's role. Data are currently being analyzed with comparisons being made among groups and between countries. These data will also be used to investigate the effect of the new MD curriculum in Uruguay by comparing the responses of students who were admitted to the MD program before and after the implementation of the new curriculum in 2009.
Challenges and Factors for Success
International partnerships are complex. Challenges can occur at any stage of the effort, including implementation, operation and evaluation, and occur with various aspects of the collaboration, for example, communication, funding, legal constraints and motivation. In our collaboration, one of the first obstacles faced was the language barrier: FMHS-UdeS is a French-language institution and FMUdelaR is Spanish. Fortunately, there were some bilingual participants. Other challenges included (1) seasonal difference in academic calendars, (2) differences in the health care systems and in the role of family physicians, (3) differences between the two schools in the educational programs at the student and resident levels, (4) availability of human resources, (5) how impact is measured and (6) securing funds.
Despite these challenges, the partnership has been and continues to be a success in the eyes of the participants. As likely pertinent to the success of many partnerships, the partners of our collaboration agree that the following factors have contributed to its success: (1) Common vision of the collaboration and its objectives, (2) strong leadership and commitment by the local actors in both countries, (3) commitment of both deans, (4) initial availability of internal financial support, (5) ability to secure external funds, (6) recognition of each group's expertise and (7) sharing successes and dissemination activities.
The partners have learned other lessons over the course of this collaboration. Even though official agreements signed between institutions are needed to confirm leaders' support, it is the people involved who make a difference and ensure that the collaboration works. Their commitment, contribution and willingness to share, learn and work with others is of utmost importance. While detailed planning and efficient coordination are needed, such collaboration must also leave space to pursue unexpected opportunities and spontaneous activities. These may yield significant benefits, keep people engaged and help sustain the collaboration. Further, when a project that initially involves a relatively small group of people is successful, it encourages others to want to contribute. This increases the richness of the collaboration and promotes sustainability.
The present FMHS-UdeS/FMUdelaR international collaboration to foster the development of family medicine will continue to build on its successes. Going forward, the partnership will focus on several things. First, it will reinforce the use of simulation in medical education and of clinical simulation laboratories for students, residents and practicing physicians at FMUdelaR. Second, it will work to improve the clinical skills education at the level of the postgraduate program within the Department of Family and Community Medicine in Montevideo and improve the teaching of community aspects of family medicine in Sherbrooke. Third, it will reinforce scholarship and research at both institutions by developing new joint research projects in primary health care.
| Conclusions|| |
The international collaboration forged between the FMHS-UdeS and the FMUdelaR over the past 6 years represents a "socially responsible" endeavor.  Its aims are to improve the competence of future physicians who will be better prepared to act as primary health care providers in their communities. A rewarding experience for all involved, it represents a significant opportunity for learning and improving skills for each group. As a win-win project that will make a difference in future practice of primary health care in both countries, the partners encourage other institutions to create similar international partnerships. The benefits far outweigh the challenges.
| Acknowledgments|| |
The authors wish to thank all the educators, leaders and their respective faculty deans for making this collaboration possible, as well as the administrative personnel at both institutions and all those that have taken part in this collaboration's activities. We also express gratitude to Jennifer Chambers, M.Sc., for critical revision of the manuscript.
| References|| |
Macinko J, Montenegro H, Nebot C. Renewing primary health care in the Americas: A Position Paper of the Pan American Health Organization/World Health Organization (PAHO/WHO). Washington, D.C.: PAHO; 2007. p. 33.
Boelen C. Towards Unity for Health: Challenges and opportunities for partnerships in health development-A working paper. Geneva: World Health Organization; 2000. p. 84.
Borrell RM, Godue C, García Dieguez M (Organización Mundial de la Salud/Organización Panamericana de la Salud). Serie: La renovación de la Atención Primaria de Salud en las Américas -No. 2 La Formación en Medicina Orientada hacia la Atención Primaria de Salud. Washington, D.C: PAHO; 2008. p. 71.
Macdonagh R, Jiddawi M, Parry V. Twinning: The future for sustainable collaboration. BJU Int 2002;89 Suppl 1:13-7.
Boelen C, Dharamsi S, Gibbs T. The social accountability of medical schools and its indicators. Educ Health (Abingdon) 2012;25:180-94.
[Figure 1], [Figure 2]