Teaching as Part of the Great Commission

 

Jesus gave His disciples instructions to include preaching, teaching and healing as key parts of their work and mission. Christian mission hospitals are excellent sources of providing witness and healing. While some teaching takes place in mission projects, there have been few reports of formal medical education programs, specifically such as family medicine residencies, in missionary hospitals.

 

Our experiences over 20 years with several international consultations demonstrated to us the immense value of adding medical education programs to the service and witness components of missionary activities.

 

This article highlights insights from 66 distinct family medicine education consultations in 23 countries in six areas of the world. These visits assisted in the development and sustenance of family medicine residencies, academic departments and other programs. It reviews the types of consultations provided, organizations involved, typical recommendations and some lessons learned. Although our focus was family medicine, the consultation model can easily be applied to other specialties. Locally trained physicians are beneficial for patient care and improve access to care and physician retention. Local training can be key to preventing “brain drain,” which is when a country’s skilled and educated workers move to another country.

 

The consultations were performed through In His Image International (IHII), which is a component of the fully accredited In His Image (IHI) family medicine residency program in Tulsa, Oklahoma. Goals of IHII include the training and empowerment of healthcare professionals to impact the world for Christ by improving health and meeting the spiritual needs of the unreached. One of its missions is to train family physicians to work internationally, with an emphasis on serving in missionary settings.

 

IHI residency graduates working globally recognized a need to develop training efforts for new community-oriented family physicians who were ideally situated to practice family medicine in a bio-psycho-social-spiritual manner. A consulting service was created to help start and sustain excellence in family medicine residencies. The emphasis was on missionary settings in low- and middle-income countries while permitting freedom to explore appropriate methods of education based on local needs, resources and cultures. The programs ranged in size from two residents at program start up to an academic program with more than 60 residents in three years.

 

We became the first two consultants and worked as a team to provide free consultations and initially paid our own expenses. IHII later developed the capacity to help with travel expenses. The consultants took time off from their regular positions, and most local expenses such as lodging, food and local transportation were provided by the consultees. This arrangement made it possible to provide advice to mission settings that could not afford the usual costs of international consultations.

 

Varied Opportunities and Synergies for Medical Education

 

Each of our consultations involved a one- or two-week onsite visit. The consultations were initiated by personal invitation. We utilized pre-visit questionnaires with prospective consultees to learn their desired goals and outcomes for the consultation. Each visit resulted in a formal written report, with follow-up communications such as emails, phone calls, webinars and repeat continuity in-person visits as needed.

 

Each consultation was as varied as their geographical distribution, in terms of needs, resources, cultural, ethnic and linguistic diversity. They have expanded to include family medicine, activities and organizations. For example, residency consultations included:

 

• Feasibility studies
• New residency startup (missionary and non)
• Development of an existing residency
• Continuity consultation
• Curriculum and faculty development

 

Additionally, we had opportunities to work with several other organizations, and consultants were invited to serve in various capacities including visiting professors and continuing education development.

 

As residency programs evolved, additional areas of need were identified. A sending agency was developed and led by Matt Acker, MD, so new faculty could go to serve the new residencies as teachers. Additionally, a residency network was formed to support communication and mutual help among the new residencies, and this important endeavor is facilitated by Chris Place, MD.

 

Curriculum and Faculty Development

 

Medical schools were frequently interested in collaborative relationships with residencies in mission settings. Our consultations involved helping with chair and faculty development, interactions with other specialties, teaching medical students through residency training and providing continuing education to graduates and practicing physicians. Assistance with curriculum development and guidelines was especially important.

 

Incorporation of spirituality into teaching and the lives of the faculty and residents was another frequent advice request. We encouraged each interested program to develop a curriculum plan to incorporate exploring spirituality among their patients and tailor this to fit the individual needs and interests of patients, residents and faculty. Academic programs particularly sought advice about improving their research capabilities, research methodologies, data collection and analysis, the process of writing for publication and collaborating with international researchers. We observed faculty recruitment, and development was the single greatest need. Hybrid consultations included medical education conferences to facilitate teaching skills for faculty development, including workshops and continuous professional development.

 

To assist with structure and organization, we helped with written plans, documentation and written job descriptions. It was unusual to have a well-organized mission statement and a set of goals and objectives, which are necessary for effective evaluation. We assisted in planning for long-term financial sustainability, securing clinical space and training administrators, mentors, community health workers and education and activity coordinators. This led to help in assessing the needs for family physicians in the country and using the resources available and vision statements to develop a formal growth plan.

 

Partnerships and Collaborations

 

We frequently found it of value to explore expanding plans and developing relationships beyond the residency itself. Some countries had accreditation and/or certification agencies, and it was imperative for them to be aware of any regulations they needed to comply with before getting too far into development. We also discussed developing organizations to help provide jobs for new graduates of established programs. Hosting cross training for residents with other specialty residents through didactic experiences was an opportunity for innovation and team building with other departments. Interdisciplinary cross training was encouraged where training in areas such as physical therapy, clinical officers and education for faculty development could be utilized.

 

Collaborative relationships in nearby countries can be of value. For example, during our consultation to a hospital in Papua New Guinea, we realized it would be advantageous to develop the residency along the Australian model of the master’s degree in general practice.

 

Lessons Learned

 

1. Sustainability and Leadership: It is imperative sustainability be provided from the beginning of new programs. Dr. Warren Heffron performed our first consultation as part of a sabbatical leave, which he spent studying applications of the new specialty of family medicine at a Christian medical school in Asia. During this year, a fledgling family medicine residency was started. After he returned to the U.S., within two years sustainability proved inadequate as budgets were cut and leadership had not infiltrated the medical school power structure for support and other departments cannibalized the residency positions.

 

2. Internal Differences of Priorities: It is ideal to have near unanimity of direction and local decision making and leadership to create new programs. Another consultation asked us to evaluate the possibility of starting a family medicine residency. At the end of the evaluation, we concluded this rural hospital was unusually well fitted to meet local needs while training indigenous physicians. There were good candidates for residents from the national medical school. The current medical staff were expat physicians and excellent candidates to be faculty, with an interest in training indigenous practitioners and future faculty for the residency. However, initially only about half of the physicians were interested in teaching, while the other half were dedicated to a service model. It took two years to develop the sustainable resources for the residency. The physicians in the hospital used this time to look at the long-term needs; then, by the time the residency opened, they were unified in their interest in adding medical education to their program. They also developed solid leadership in this interval and their decision was locally based.

 

3. Internal Conflict: Be extremely careful that all participants be given the opportunity to participate in expressing their opinions and establishing agreement on next steps. One consultation was to a program that was a part of a religious, non-governmental organization. They had a history of providing healthcare teams to remote and underserved areas. These were short-term mobile efforts and met a lot of health needs for underserved rural citizens. As a religious organization, they had an interest in providing healthcare services while offering spiritual support and care and an evangelism program. It had grown to be quite large and was successful in these two primary efforts.

 

We were asked to evaluate the feasibility of adding resident rotations to this program. While continuity of care was not possible in this setting, it was an intriguing idea, and we felt it was a worthy experimental educational program. However, the evangelism and service teams were quite opposed to adding medical education to their mix. We did not discover this until a later rift took place, which resulted in no new educational programs being added and some of the leadership leaving the program.

 

4. Flexibility: Adversity may contribute to our process over the long haul. The onset of the COVID-19 pandemic affected our ability to travel. Subsequently, we worked through a series of online consultations using the internet. This may permit us to offer follow-up or interval consultations at significant cost savings.

 

5. Consultant Teams: A team of two or three consultants is much more effective than an individual consultant. In some interviews, they can divide and interview a much larger cohort of local faculty, administrators and other key participants, as well as participate in a larger number of teaching sessions. For group interviews, it is helpful to have one person be the key interviewer while the other observes nonverbal communication and other interactions.

 

6. Time on Site: We found international consultations were more time consuming than a consultation in the U.S., often one or two weeks in length. Jet lag was a factor and cross-cultural language and communication took more time. By including educational programs, we were able to address larger audiences. Continuity is important, and follow-up communications can be offered through repeat visits, Zoom, email, phone or letters.

 

7. Financing Consultations: Such a program can be financially viable if the sponsoring organization permits faculty to be away from the core responsibilities of performing consultations. In our cases, both consultants worked part-time for parts of their careers in order to take additional time to perform consultations. Volunteer donations of time on the part of consultants permits them to work at no cost to mission programs. The sponsoring program can be helpful in underwriting the costs of transportation or raising funds specifically for consultation activities.

 

Call to Action

 

For persons interested in improving global health, assisting in the creation and development of family medicine residencies may be a strategic mechanism for working toward equity in healthcare. Locally controlled and led educational programs may contribute more than going and providing healthcare. Missionaries almost universally are excellent educators, and role models and students exposed to this work frequently have a career call to participate in this type of work.

 

Education programs can be excellent sources for medical education across all medical specialties, for medical student and resident rotations as well as nurses, community health educators, social workers, physical therapists, occupational therapists, counselors, administrators and other members of the healthcare team. Other medical specialties can offer valuable and collaborative parallel education opportunities.

 

In summary, we feel adding family medicine education, providing consultations and training consultants are valuable additions to mission efforts and help fulfill the Great Commission of Jesus.

 

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About the Authors

Dr. Chris Jenkins is a faculty member of the In His Image residency program in Tulsa, Oklahoma.

 

Dr. Warren Heffron is a professor emeritus at the University of New Mexico School of Medicine and a volunteer faculty at In His Image. He is a past president of CMDA.