Partnership with Rochester medical school alters medical education in Ukraine (12/05/04)

Partnership with Rochester medical school alters medical education in Ukraine

by Roman Tratch

ROCHESTER, N.Y. - A groundbreaking program of change in medical education is happening in Ukraine, thanks to cooperation between the University of Rochester School of Medicine and Dentistry and the Rochester's Ukrainian community. What started as an attempt to help medical education in the USSR ended up with Ukraine being the sole beneficiary of an effort on the part of an American physician, Daphne Hare, M.D. (1937-1995), to remold the study of medicine in the USSR.

It began almost accidentally. Dr. Hare's husband, a philosopher, was teaching as an exchange professor at the university in the Russian city of Yekaterinburg in 1990. His wife accompanied him on his tour and, being a physician, was interested in Russian medical education. She made contact with the local medical school.

What she discovered was an educational system that was bogged down in hierarchy, students who could not afford to buy textbooks, textbooks with outdated science, oral exams which could be abused as there was no record left. Being an activist at heart, Dr. Daphne Hare decided to organize a program to help Russian medical education by bringing selected sixth-year medical students for a three-month study tour, called a "clerkship," at an American medical school. While applying for grants to start the program going, Dr. Hare herself financed the original expenses.

Over the next five years 20 Russian students had a chance to get acquainted with American medical education by going to classes in their respective specialties together with American students.

The Soviet Union collapsed in 1991. Four years later the University of Rochester School of Medicine and Dentistry received a two-year grant from the U.S. Agency for International Development (USAID) to establish a partnership between four U.S. medical schools, and three Russian and two Ukrainian medical institutes. The objective of the program was to help change clinical teaching curricula and to introduce standardized testing in evaluating student achievement. For that purpose, testing centers were to be established at the participating medical institutes (nowadays called medical universities) and, in addition, national testing centers were to be created in both Ukraine and Russia.

In addition to bringing in students, the grant enabled senior faculty and high-level administrators from Ukraine and Russia to come to Rochester in 1996 for two conferences: "Innovations in Medical Education" and "Innovative Teaching Methodologies." The visitors also attended two "Introduction to Human Health and Illness" classes, where several new approaches were presented, such as using literature and movies to spark discussions on psycho-social, biomedical and medical ethics issues.

The grant also sponsored trips by U.S. medical faculty and young residents to Ukraine and Russia to conduct seminars on ways to improve medical education. Sadly, Dr. Daphne Hare died of melanoma in 1995 and did not see all the fruits of her efforts.

In 1997 the grant money expired and the program was in danger of ending. At this point Nataliya Shulga, Ph.D., a young biologist from Ukraine who was working as a research associate faculty member at the department of biology at Rochester University, appealed to the local Ukrainian community to save the program for students from Ukraine.

A Ukrainian Community Fellowship Committee (UCFC) was organized and an agreement was signed with the University of Rochester providing the 50-50 financing of the program: the university would waive tuition, tailor the programs to the needs of individual students and help in obtaining student visas; the UCFC would contribute the costs of round-trip airfare, visas, medical insurance, and room and board.

For the UCFC this amounted to an estimated cost per student of $3,500 and the goal was to bring four students per academic year for a total cost of $14,000.

A fund-raising campaign was launched and, with substantial support from the Rochester Federal Ukrainian Credit Union, the necessary funds for the first year were collected. Since nothing comparable was done on the Russian side, the program with Russia ended.

From now on the name of the program was "Medical Education Partnership and Training Project with Ukraine" and to date 21 medical students from Ukraine were able to complete the medical clerkship, during three-month rotations in various departments of the Rochester University School of Medicine and Dentistry. Seven additional students completed the clerkship earlier at Yale University, the State University of New York (SUNY) School of Medicine at Syracuse and SUNY Brooklyn VA Medical Center - a total of 28 students.

The Ukrainian students came from the National Medical University in Kyiv and the state medical universities in Dnipropetrovsk, Lviv, Chernivtsi, Odesa and Ternopil. They were "cream of the crop" medical students, selected via a careful procedure that involves both the University of Rochester and Ukrainian community input.

Six U.S. medical faculty members and residents traveled to Kyiv and Dnipropetrovsk to introduce new teaching methodologies. The Rochester crew introduced Ukrainians to the "ward teams" approach, which, while caring for patients, provided students with practical, hands-on medical education, starting already in their second year of study in American medical schools.

In the U.S. students learn the basic sciences on the undergraduate level, and medical education requires four years of graduate training. In Ukraine the student enters a medical university immediately after completing his/her secondary education and studies both basic sciences and clinical subjects in a medical university for six years.

In the United States medical students start caring for the patients already in the second year of their training. Under the supervision of the resident physician and the patient's physician, they examine the patient, order laboratory tests if necessary, and discuss their findings with their supervisors. It is worthwhile to note that in this "ward teams" process both the student and the resident physician receive medical training. This approach differs radically from the practice in Ukraine where the student does not get a chance to examine a patient until the very last year of his/her medical education.

The Rochester medical visitors also conducted clinical rounds in Ukrainian hospitals. They found that students were not encouraged to ask questions of their teachers. The attitude was that the teacher knows best, and one did not dare to question his teaching - this was the old Soviet system. The teacher would simply lecture to the students who would listen and take notes silently, even if sometimes they did not understand what was said. The Americans encouraged students to ask questions of their teachers. Ukrainians were surprised when someone asked a question of the visiting American professor and he responded candidly that he did not know the answer to it.

A Learning Center, containing a library of English-language medical books and journals, as well as video recordings of some surgical interventions opened in Kyiv. Most important, a national Testing Board was established in Kyiv, which introduced for the fist time in Ukrainian medical education standardized testing for objective merit-based evaluation.

Several persons in Ukraine contributed to the success of the program. Dr. Marianna Shershneva, M.S., was involved in the partnership program since 1995 and is credited, together with Iryna Bulakh, M.D., in creating the national Testing Board. Dr. Shershneva, a rheumatologist, was dissatisfied with the old system, particularly with the lack of continuing education offered to physicians. The senior colleagues with whom she worked were often outdated in their knowledge and there was no one to consult in case of need, no one she could trust. Dr. Shershneva felt that the best way to change health care in Ukraine was "from bottom up," i.e. to work on changing the medical education and doing away with the old system. Presently she is working toward a Ph.D. in the Continuing Medical Education Program at the University of Wisconsin-Madison Medical School.

Dr. Bulakh is the present director of the Testing Board. She recently defended a doctoral dissertation on objective evaluation in medical education. She was particularly helpful in dealing with Ukraine's Ministry of Health which had total control over medical education and was reluctant to give it up.

Dr. Yuri Kovalenko from the Ministry of Health visited the University of Rochester with the first group of administrators and became convinced of the transformative value of objective exams in medical education. Thus, he was an "insider ally" in the struggle for the change.

Marina Mrouga, M.D., is presently deputy director of the Testing Board. She was one of the first students who, thanks to the efforts of Dr. Hare, was able to complete her three months of clinical rotation at the State University of New York Brooklyn VA Medical Center.

The "old system" did not easily give up its positions. The above-mentioned persons in Ukraine had to deal with resistance, suspicion, threats and even with attempted bribes to buy the tests. The greatest challenge to the old guard came from the introduction of objective, merit-evaluation written exams. Due to the efforts of Drs. Mrouga, Shershneva and Bulakh, and with the support of Dr. Kovalenko inside the Ministry of Health, standardized objective testing is currently in use in Ukrainian medical education, including the licensing of physicians.

It was Ralph F. Jozefowicz, M.D., the first administrator of the USAID grant, who was most helpful in teaching Ukrainian partners how to create multiple-choice questions. He had experience in item-writing while working for the American Board of Medical Education. The Ukrainian Testing Board has a working arrangement with its American counterpart.

To sum up, major changes are taking place in Ukrainian medical education, thanks to the partnership with the University of Rochester School of Medicine and Dentistry. No longer are there subjective oral exams. It is now impossible for a student to "buy" better grades, admission to the university or a final diploma. The results of testing are published, and available for discussion and analysis among professional educators. Based on those results, a ranking of medical universities is possible which provides a stimulus for self-improvement on the part of individual institutions.

The trend toward objective, merit-based assessment testing is now spreading to other areas of college education in Ukraine, and Dr. Mrouga is sought as speaker at conferences and seminars devoted to this subject. Also, Dr. Shulga of Rochester was invited to address the International Conference on Higher Education in Ukraine in the city of Mykolaiv on September 29-October 2. Her topic: "International Partnership as a Tool to Enhance Curriculum Teaching Methodology".

Unfortunately, the yearly tab of $14,000 turned out to be too much for the Rochester Ukrainian community to bear alone. In 1997 the Fellowship Committee wrote to the leaders of the Ukrainian Medical Association of North America (UMANA) inviting them to become partners in this project. In answer UMANA provided the committee with addresses of its members - some 700 individual physicians and dentists in the U.S. and Canada, with a suggestion to directly contact them. The committee sent letters to all of them, outlining the Rochester medical program and asking for tax-deductible contributions in support of its project. Some 20 UMANA members responded, and the total collected was about $1,000. The leadership of UMANA was approached again in 2004, and this time it gave the committee $500. An additional $500 was donated by the UMANA Chicago chapter.

Lacking adequate funding, the Rochester medical program was forced to reduce the number of rotating Ukrainian medical students from four to two per year. If it were not for the continued generous support of the Rochester Ukrainian Federal Credit Union, the program would not be able to continue. This would be a great loss for medical education in Ukraine, where graduates of the Rochester program are now in leading positions as junior faculty and in private practice.

In spite of the present situation in Ukraine, medicine is still a calling profession there, as was frequently observed by participating American physicians. I would like to finish this report by quoting from a letter that Lyuba Milevska, a recent graduate of the Rochester program, wrote to Dr. Shulga, chair of the UCFC:

"Dear Ms. Nataliya! I would like to share with you current events in my life. ... The Seventh International Congress of Students and Young Scientists took place at our Ternopil Medical Academy. There were many guests from other cities and countries. I had a great chance to present my independent project [as a part of their Rochester training students are required to work on an independent project.] in two languages - English and Ukrainian. I don't want to be immodest, but it was a triumph! I was awarded two diplomas at once - the diploma for first place and the diploma for the best report. And at the closing of the congress I was asked to present my report once more. Thank you so much! Because in my project there is a great part of your soul and your efforts, too."

Roman Tratch, Ph.D., is a member of the Rochester Ukrainian Community Fellowship Committee. He resides in Penfield, N.Y.

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