Don't it always seem to go

That you don't know what you got 'till it's gone.

I've been where it's gone, so I know what I got.

Academic Medicine in Albania

Perhaps the most startling feature of Albanian medicine for me was the degree of government control. The only medical school in the country is run by the state; postgraduate training is offered only by the state; all hospitals are run by the state; and the state is the only medical employer. It was illegal for physicians to open a private practice until 1995, when only senior professors were allowed limited private practice. Thus, there are no physicians in pure private practice. The ties between government and medicine are very strong; before his election, the president of the country was the premier cardiologist of Albania. The parliament, with the president's approval, appoints the dean of the medical school. The current dean is the cousin of the prime minister and is related by marriage to the minister of health. He is also one of eight members of the governing council of the Democratic Party. The foreign minister is a pediatrician, and the chancellor of Tirana University is the former chief of nephrology of the University Medical Center. The alignment of the medical academic structure with the government is so widely recognized that most physicians with whom I talked predicted that a major change would occur in the medical school's administration should the Democratic Party lose the majority in the upcoming elections. (In a controversial national election held in May 1996, the Democratic Party won an overwhelming majority [more than 80%] of the seats in Parliament.)

A second surprising feature was the lack of generalist training that physicians receive before launching into specialties. The curriculum for students and trainees in internal medicine is a series of rotations on subspecialty services during which students and trainees are given no responsibility and little direct exposure to patients. The situation is aggravated by the "Balkanization" of hospitals: Tirana has a cardiology institute, a psychiatric institute, a neurology institute, and a pathology institute; a "specialty medicine" hospital with separate floors dedicated to hematology, gastroenterology, endocrinology and nephrology; and separate hospitals for maternity care, plastic surgery, surgery (which includes urology), general pediatrics, pediatric specialties, infectious diseases, oncology, and pulmonary care. The pulmonary and maternity care hospitals are several miles from the University Medical Center. Indeed, the faculty at the University of Tirana seemed to have no true general internist (although, as I left, a department of primary care had been created by the dean and a curriculum was being planned). The effects of this stratification are undesirable. There is little subspecialty crosstalk, consultations are slow, and triaging of patients to the appropriate hospital is inaccurate. I saw patients sent to and transferred from as many as three hospitals during the course of their care.

Two factors keep the quality of postgraduate medical training in Albania well below western standards. The first is a reticence on the part of senior faculty members to delegate responsibility and authority to junior faculty members. Innovation and creativity must always emanate from the chief. This legacy of Communism (and, perhaps, of Albanian society before Communism) is dispiriting to young faculty, too many of whom see no future for themselves in Albania. In the United States, by contrast, creativity and initiative in students, trainees, and faculty alike are valued, and chiefs view these qualities as assets, not threats. In Albania, I saw chiefs of departments do more than 80% of medical procedures while younger faculty members and trainees could only watch with envy. I saw junior faculty members penalized for winning grants independent of their chiefs. I saw functions go undone because chiefs refused to delegate them to junior faculty members. Most tragically of all, I found that many junior faculty members and trainees were dreaming of escape.

The second factor that compromises the quality of postgraduate medical training in Albania is the lack of up-to-date learning facilities at every level of medical education. The Medical Center's library has few modern textbooks or current journals, and cataloging is primitive. Persons are not allowed access to the stacks; books can be obtained only from a single librarian who sits, like a ticket-seller at a theater, behind a small window to take orders. The small adjacent reading room had no heat or electric light. In a different building was another small reading room, which had current French-language clinical journals donated by the French Embassy and was open irregularly 2 hours per day. Another small library was funded by the Soros Foundation. It was open from 9 a.m. to 5 p.m. daily, had recent texts in English, and subscribed to several good English-language general medical journals. It also had a small seminar room with slide projection and videocassette capabilities. Unfortunately, the dean did not renew this library's lease; it closed in October 1995 and awaits relocation to a site just outside of the main hospital compound at a date not yet specified. Offices are poorly lit, are furnished only with bare wooden chairs and tables, and are usually shared by four or more junior faculty. Classrooms are unlit, are furnished with ancient fixed wooden desks, and often lacked glass in the windows. Blackboards are just that—boards painted black. The chalk is so hard and the paint so glossy that legible marks are difficult to make. There are no erasers.

What Can Be Done?

The system of medical training in Albania is not working. Poverty explains some of the problems: lack of electricity, lack of water, lack of technology, lack of comfortable classrooms, lack of acceptable hospitals, lack of books and recent medical literature. Monetary and technical assistance—the easiest and most appreciated things to give—are the first things most charitable agencies donate. Aid flows from the European Community, the United States, and other countries in the form of medicines, technological equipment, money to repair the infrastructure, and fellowships allowing professionals to study for short periods in various countries. The United States Agency for International Development is funding a project to improve the departments of emergency medicine and women's medicine at the University of Tirana.

Such assistance is absolutely necessary, but alone it is ineffective. Although certain things can be fixed with money, others cannot. Useful texts become sequestered in faculty offices. Medical equipment disappears from hospitals and reappears in small private offices or for sale outside. Alternatively, it may go unused for lack of expertise. Such assistance, therefore, must be accompanied by a change in mentality. One of the newest faculty members at Tirana, who completed most of his undergraduate training before the change in government, expressed feelings of discouragement. "Things are worse than they ever were. At least before someone cared. Now no one does. It's not the money. Nothing will be better until there is a change in mentality." Having worked in the system for 10 months, I understood.

There is a bright spot. My experience convinced me that medical students, trainees, and young faculty in Albania are not different from our own in their desire to improve their medical skills. They are able to absorb and implement modern western methods of clinical practice. The seed is there; the problem is providing the appropriate soil for learning. A comfortable learning environment for students and staff must be created. I was disappointed to see that little is being done to improve facilities for clinical education within the University Medical Center. I heard of no plans to replace the only lecture hall in which the entire medical school class could assemble. Currently, the lecture hall has no electricity or heat, and most of the windows are broken. Plaster and stucco are flaking, and the blackboard is half torn from the wall. I heard of no plans for creating a functional library that would serve the needs of students, trainees, and faculty alike. Yet such facilities will influence the training of future physicians who will use the clinical care facilities and technology currently being donated and created.

Given this situation, can anything be done immediately to strengthen clinical training? One possibility is to make clinical training, which is very weak in Albania, available elsewhere to motivated Albanian students and trainees. At present, fellowships to study clinical medicine abroad are restricted to faculty and are not available to students or trainees. Although it is students and trainees who must be reached, they are unlikely to qualify for clinical training in the western nations. The United States Medical Licensure Examination and equivalent examinations in other western countries are impossible for Albanian graduates to pass without intensive and expensive tutoring. Other routes are occasionally open. Individual persons can be brought over in a research capacity. Competitive Fulbright grants provide this opportunity to faculty members (but again, not students or trainees). If research is sufficiently clinically oriented, Albanian physicians could learn much by observing clinical activities and even participating in a closely mentored situation. It is an excellent program. However, because these arrangements cannot be pursued on a large scale and because they are restricted to faculty members, I do not believe they can have the major effect I would like to see on the clinical training of Albanian medical graduates.

If we cannot bring young physicians from such environments to western countries for training, then can we bring the training to them? The answer is yes, but the task is not easy. One of the most discouraging statements I heard frequently in Albania was that, precisely because of fiscal deprivation, Albanian physicians had all become master clinicians. This is not true. It is critical to reintroduce the intellectual discipline of medicine—assembly of a thorough clinical database and use of that data-base, through deductive logic, to arrive at a reasonable differential diagnosis—into the educational system. Without this process, technology is misused and wasted. To teach these arts, it is critical to work with the physicians in their environment and to teach by example. I believe too little teaching is done this way, even in the United States.

There is, of course, a language barrier. All teaching is in Albanian, and my knowledge of the language never reached a conversational level. For historical reasons, French rather than English is spoken by most of the senior professors. The dean prohibited me from lecturing to students because he thought that some students would be at a disadvantage and because the University Medical Center could not provide an interpreter. Younger faculty, trainees, and students, however, appreciate the role of English in science, medicine, and business. More than 80% of the medical students and more than half of the trainees I met could understand a lecture in English if it was delivered slowly, and any group always contained several capable interpreters. As a result, I did a lot of small-group lecturing. One of the most successful teaching vehicles was the American College of Physicians' Medical Knowledge Self-Assessment Program. Trainees could read the questions, give their answers, and have a group discussion in their native language while I served as a resource person who was accessible through one or more interpreters.

Another barrier has to be circumvented. Clinical training is closely guarded in most countries, and Albania is no different. I found many limitations placed on what I was permitted to do. An element of suspicion surrounded my arrival. Most foreign "experts" and "technologists" come extravagantly funded (by Albanian standards) and are housed by their home countries or corporations. I, on the other hand, lived as the Albanians do: without an automobile and driver, wearing clothes from which mud could be washed, and carrying a canvas briefcase as I walked to work early each morning. I was informed by Albanian friends (after my departure) that I was viewed as probably impoverished and, therefore, probably an unsuccessful physician in my own land. The medical credibility of expatriate physicians is further weakened by the belief that they will soon retreat to the luxury of practicing medicine in their native countries and need not maintain the level of effort routinely required to practice medicine in Albania. Such xenophobia is not unique to Albania; it is common in all cultures, and it takes time to overcome. It takes time to gain the trust of students, trainees, and faculty; to get used to the new environment; and to develop the most effective teaching methods. Fortunately, I had the time. I made myself available to see any and all patients in the hospital without regard to the specialty under which their condition fell or the presence of an attending physician. Consultations were few at first but increased steadily over 10 months. By the time I left, I was seeing patients not only in gastroenterology but also in nephrology, cardiology, hematology, and general surgery. I began to teach endoscopy to gastroenterologists in the Central Poliklinik (the outpatient clinic in downtown Tirana that is not affiliated with the university) and to surgeons at the university. Social invitations swelled to the point where I actually began to gain weight. I got the feeling that I was finally being accepted and, occasionally, even listened to. I think that it was a bad time to leave because I making progress, and I left with a strong desire to return.

I concluded that it is possible to become an effective clinical teacher in that environment. To do it, however, one must be able to do more with available resources than is usually done. Because this cannot be accomplished in a few days or weeks, I believe that sending 1 physician for 10 months is far better than sending 10 physicians for 1 month. The problem is how to get that 1 physician. How many retired physicians might there be who, still full of energy, would like to participate in such an experience? The need is there, and not just in Albania.

Epilogue

My experience in Albania was too alive, too vivid, and too full of rewards and lessons for our own situation to be ignored and forgotten. I can still see the ruin of a society brought about by the practice, perverted or not, of the Communist philosophy. Because I've been where it's gone, I no longer chafe at negative peer reviews of my papers. I no longer sigh at requests to attend long meetings with tenured faculty members during which the appointment, advancement, and promotion of junior faculty members are considered. I now happily serve on the university-wide ad hoc committees, seemingly countless, which advise on policy, appointment, and promotion. Although some have called our systems of peer review and objective assessment antiquated and inefficient, they are absolutely necessary. Nor can I take our comfortable offices, libraries, and classrooms for granted any longer. I know what we got.