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Kosovar exchange is a "profound educational experience" for DMS

When Dartmouth Medical School offered last year to help rebuild Kosovo's only medical school—after years of ethnic cleansing and months of bombing had decimated its programs and buildings—the offer was intended as a humanitarian gesture. Little did DMS administrators, faculty, and students know that Dartmouth would gain as much as it gave.

Bombs: For 10 years, Albanians were systematically barred from Kosovo's educational programs and hospital staffs. Then incessant Serb bombing destroyed much of the country's infrastructure. But as soon as peace was brokered, the Albanian Kosovars returned and began to reconstruct their health-care system and refound their medical school at the University of Pristina.

Several DMS faculty members have since traveled to Kosovo to assess the situation. Former dean James Strickler, M.D., current dean John Baldwin, M.D., and neonatologist George Little, M.D., brought back discouraging reports: a hospital that barely had electricity, medical students with no books, and a general sense of despair.

But the Kosovars have rebounded quickly, with help from the International Rescue Committee (which Strickler cochairs), the World Health Organization, and DMS, among other organizations. Already, medical education has resumed there.

This year, two groups of visitors from Kosovo have come to Dartmouth. The dean of the Pristina medical school and two students spent a week here in January, and two more medical students—Lili Bajraktari and Florian Gegaj—spent the summer at DHMC, doing clinical rotations, shadowing Dartmouth clinicians, and staying with DMS students and faculty to get an idea of American life.

What is there to be learned from such a different medical culture? Quite a lot, it turns out. According to Strickler, medical education in Kosovo is still firmly rooted in the old Soviet-bloc (and even older European) model. "Teaching was almost exclusively in the hospital, and the relationship between students and faculty was far different than it is in the United States," Strickler says. Even now, he notes, "there's not the freewheeling exchange we have here; students are less accustomed to asking questions of their teachers."

Eager: Third-year DMS student Jennifer Keller, one of the coordinators of the DMS-Kosovo project, agrees, noting that following one clinician for the whole day can be very instructive. But in Kosovo, she says, "a teacher comes in and asks which student would like to go see an asthmatic patient." So, she adds, "if I've seen 30 asthmatics this month, I might want to wait for another teacher to come by and offer to take me with him to see someone with diabetes."

Keller is eager to continue her involvement with the project. "Absolutely," she says. "It's really broadening, from both a personal and a professional point of view. Medical students probably learn as much from each other as they do from books," she notes, "and I've never had a colleague who had actually seen the mumps and tuberculosis!"

During Bajraktari and Gegaj's recent visit to DMS, they spent time at primary-care clerkship sites as well as in specialty clinics at DHMC. Exactly how to structure their time here was a subject of some discussion, because whether Kosovo's scarce resources should be spent on primary, versus tertiary, care is at the heart of current debate about how best to restructure the country's health-care system.

Debate: The World Health Organization, Strickler says, wants Kosovo to gear its system to primary care and prevention, while many Kosovars feel a need to build up tertiary capabilities to replace the old Soviet pattern of sending patients needing services such as heart surgery or dialysis out of the country, to Croatia or Belgrade.

The Soviet-style medical system was centered on the hospital, with separate "institutes" devoted to different specialties, which hampered the free flow of information among disciplines, Strickler says. For example, neonatologist George Little, who visited Kosovo in July, says both the pediatric and the obstetric institutes in Pristina have neonatal intensive care units—but that there is virtually no communication between them.

Teaching is fragmented as well, Strickler notes, and is hierarchical —teachers lecture, students take notes. "But we're not trying to tell them what to do," he adds. "It's a common problem in the developing world. [Foreign] medical schools aspire to recreate the Massachusetts General Hospital in Pristina or Beijing, while public health professionals worry about the focus on such services at the expense of primary care.

"DMS is trying to steer a careful course," he says. "We have said repeatedly, 'We are here to show you what we do—you have to decide what's best for Kosovo.'" But he doesn't recommend, he adds wryly, that Kosovo duplicate the American way of financing health care.

Respect: Both faculty and students at DMS have developed great respect for the Kosovars. Keller describes the visiting students as "very flexible people— they bounced with whatever happened," she says, laughing at the memory of a blueberry-picking outing that went awry. "In the end, we couldn't find the farms, so we went blueberrypicking in the supermarket," Keller recalls. "And they were laughing and happy about it. They'd never been in a supermarket. They had a great time, no matter what happened."

Strickler agrees about the two-way value of the exchange. One thing Americans can learn, Strickler says, is "how competent, intelligent people in other parts of the world can do outstanding work, even without the resources that we have."

He also says that "it gives our students an understanding of how medicine is practiced in other parts of the world, in different economic systems and different cultures. And it makes us understand how blessed we are in this country.

"There's something about becoming intensely aware of what some of the real problems in the world are," he adds, "how victimized people become by war, politics, and power struggles. It is relative innocents who are victimized —women and children— and this educational experience allows you to extrapolate, to understand the complexities of politics, economies. It's a profound educational experience."

Megan McAndrew Cooper

If you would like to offer any feedback about this article, we would welcome getting your comments at DartMed@Dartmouth.edu.

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