A New Medical School Designed For A New Generation - Dr. Ramin Ahmadi, Dean and Chief Academic Officer of the American Canadian School of Medicine

Shiv Gaglani: Hi, I'm Shiv Gaglani, and today on Raise the Line, I'm really happy to welcome Dr. Ramin Ahmadi, the Dean and Chief Academic Officer of the American Canadian School of Medicine which is a relatively new institution located in the Commonwealth of Dominica in the Caribbean. Dr. Ahmadi is a former professor of medicine at Yale and worked with faculty from Yale and the Penn State Medical Schools to develop the curriculum for ACSOM. 

He has developed new and innovative primary care residency programs for community health centers and community hospitals and has been awarded more than $20 million in competitive grants by HRSA for his program development over the last two decades. Dr. Ahmadi's interest in public health is not merely academic. He has participated in human rights investigations and humanitarian missions in Chechnya, East Timor, and Sri Lanka. 

He is also the author of two books of poetry, numerous articles and short stories in Persian and English, and has also published books on Iran's longest-held prisoner of conscience. 

Dr. Ahmadi, it's a pleasure to have you on. Thanks for joining us. 

Dr. Ramin Ahmadi: Thank you for having me. I'm delighted to be here.

Shiv: Well, as we often start with Raise the Line guests, we'd like you, in your own words, to tell us what got you interested in medicine and then ultimately a career in internal medicine and primary care. 

Dr. Ahmadi: Well, you know, I was really a history major and I did not think about medicine as a career early on in life, but gradually I was attracted to the profession. I was attracted to the profession because I felt not only that it was a calling for me, but also the fact that you were able to care for people, that you were able to really be very important and impactful in someone's life. Those were very, very important to me. As a history major, you are very preoccupied with the past and you do not really get a satisfaction about the moment, the present. And the present, I think, can be very rewarding when you are able to hold somebody's hand, to take care of them, to take care of their family, and to be important in their life. So, that was why I finally, after years of being a history major, I switched careers and went into the field of medicine.

Shiv: That makes sense. Before we started recording this interview, we both shared the fact that we're mutually acquainted with Dr. Lisa Sanders at Yale, which seems to attract people like yourself and her who are non-traditional medical students. So, I'm glad that they do it. Do you mind walking us through you earning your medical degree at Yale and then you got a master's degree in global health, and you've done some really interesting human rights work. Do you want to talk a bit about that before we go into the medical school stuff?

Dr. Ahmadi: Sure. I did my residency in internal medicine at Yale and went on to get a Master of Public Health degree at Yale with an emphasis in global health and, of course, I was attracted to global health because of the background in history and an interest in human rights and humanitarian missions. It was early on in my career that I also discovered that I love teaching and I love medical education and so I dedicated my entire career to that. 

After finishing residency, I did a year of chief residency and then became an associate program director for an internal medicine residency program at one of the small affiliates of Yale, and stayed in the business of medical education until today. It has been a very rewarding career for me and within that, if you will, sphere of medical education, I have done other works that I have truly enjoyed in the area of global health, in the area of health and human rights, humanitarian emergencies, and so forth. So, that's what has brought me finally to this point today. We have a brand-new medical school that we are opening in Dominica. 

Shiv: Well, we can dive into that and then circle back to your experience running residency programs, which I know will be interesting to our learners, as well as obviously your public health work and humanitarian missions. So, congratulations on starting a new medical

school. We've worked with a bunch of new medical schools from Kaiser Permanente to the UNTHSC in Texas, and we know how hard it is, secondhand, to start a med school. And you guys are in an interesting position because you're in the beautiful island of Dominica, which I've

had the opportunity to visit twice in the past, back when it was Ross University School of Medicine. Can you give us an overview of how the American Canadian School of Medicine came to be and what you think sets it apart from other medical schools?

Dr. Ahmadi: So this school initially started in Kazan, Russia and the reason was because Yale had a very good relationship with Kazan, Russia that goes back more than twenty-five years. In fact, I was the first Yale resident that was sent to Russia as a part of this collaboration that began with a grant from USAID in 1993 and I volunteered and went for two reasons. Well, certainly number one, nobody else wanted to go. But number two was because I had spent my previous life and career studying Russian history. I was very interested in Russian literature and Russian culture. So, I was very familiar with that environment, and I was excited to go. 

After my visit it was selected as the site for the Yale activities and it became a site where a lot of Yale faculty and students every year would go. In return, many Kazan State Medical University faculty and students would visit Yale University and stay at Yale Medical School for various periods of time, sometimes up to six months. As a result, within a period of two decades, Kazan State Medical University had a revolution in medical education. They transformed themselves from the old ways of doing medical education by essentially adopting many of the methodologies and approaches to medical education that they had learned from Yale and Yale colleagues. 

So, this was as a result an environment that was very open to us and so with my Yale colleagues, and with our colleague Jeff from Penn State, we decided to start first a residency in internal medicine in Kazan. We got full accreditation for it from Royal College of Canada, which by the way was the first time in the history of medical education that a residency program outside of North America had full accreditation, equal to accreditation inside Canada. Our first graduate of that residency program in fact came to the US with a Nephrology fellowship and then on to become an attending at the University of Maryland. So, it was a proven track. 

It was working very well, and so we decided upon that to build the first American medical school in Russia, in Kazan, with a curriculum that was very much similar to Penn State and Yale. For four years, we trained faculty that was ready to implement that curriculum and then there was a war, of course, and because of the war, we had to pull out. That was the end of the project at that point. We were all very sad. Years and years of effort went into that. 

Then the government of Dominica approached us because they had a beautiful empty medical school campus on the island, and they said, “Would you come to us?” And of course, you know, we did. We brought the curriculum, the faculty, all of that work of several years here and we started here on the island and we're opening that school in August for the inauguration class. 

I think the most important feature of the medical school is its curriculum. It's a very modern curriculum. It's very different from all other traditional programs in international medical schools. The approach is a very progressive sort of “flipped classroom” approach to educating their students. We have done away with essentially all that business of putting 700 students in an auditorium and lecturing them because we believe this is a generation that doesn't do well with that. We have taken, as you know, of course, Osmosis as a major piece of our platform and that's where the students do a lot of practice and learning. 

So, what happens is essentially on day number one, they get all of the material and the lecture that they need for their two years of medical education downloaded on an iPad and given to them because that's how this generation likes it. If they want to listen to a lecture, they will find, for example, an Osmosis YouTube video that talks about the physiology of the renal tubules and they're going to listen to it. They're not going to sit in an auditorium for hours and listen to somebody like me with a heavy Middle Eastern accent to tell them about the renal physiology. That would be crazy and that would be crazy to expect them to do it.

What we do instead is that we give them all those resources within a very well-designed canvas, that has been designed by people with a lot of expertise to organize every day of their education. After they go and listen to all the Osmosis pieces, all the lectures that are there pre-recorded for them, readings that have been selected for them -- they do all that on their own -- then the next morning, when they complete that homework, hopefully, they come to school. They come into these small group classrooms where eight to ten of them are paired with an MD physician, sometimes an MD PhD, but all of them are physicians and they're trying to train clinicians, and they have a number of cases that are prepared for them. They give them these cases as a group to work on, to solve, based on what they have done the night before. It takes usually about three hours that morning to do those cases, one by one and they sit there and do it until the faculty is satisfied.

The faculty has usually a checklist and they'll be satisfied when the checklist is complete and then they go in the afternoon to the anatomy lab, which at that point is a very traditional anatomy lab. It's all about dissection and learning the anatomy of the body. So, that's really our curriculum. It's very unique. The canvas is a proprietary canvas that is very unique and extremely well organized and resourceful with resources such as Osmosis available to the students. We prepare them, of course, for becoming a competent physician, but also making sure that 100% of them pass their board examinations successfully. 

What is different is that this kind of school just doesn't exist outside of the United States and certainly on a Caribbean shore as far as I know. So, this is very unique. It's different from American schools, obviously, because it's outside the United States. But in terms of the approach and the curriculum and the way each of these integrated system-based modules are taught, it is, I would say, almost identical to Penn State. Dr. Wong, I think, would agree they're very similar to Yale in many aspects. It's almost a hybrid. I brought my experience from our side, and he did from his side and then we had a group of very talented faculty that was integrating and putting this together over the course of the last four years.

So, we're excited. We're excited. It's here, and it's a very unique international school and opportunity for the students who want to explore it. 

Shiv: I love that. I think there's a lot of threads to pull on there and obviously, we're really happy about the partnership and the fact that you guys have gone all-in on evidence-based education, flipped classroom, all of that. My perspective going through med school myself -- and as you know, I'm back in med school at Hopkins -- is that the reason you go to a school is those small groups with professors like yourself and people who eventually become mentors who help us decide which residency program to go to. Or maybe we're very interested in a career in public health and humanitarian rights like you've had, and then you become a mentor to some of your students. That has much more of an effect, I think, on what type of clinicians we train and can we keep them in the career as long as we can versus the incremental test question or basic science knowledge or even clinical science knowledge. 

I'm sure the other thing that's unique about your background is all the experience you have launching and running residency programs, because obviously one of the biggest concerns of any students who come to any med school -- let alone a new med school, let alone one in the Caribbean -- is will I get into residency in the US or Canada or elsewhere? Can you comment a bit about how you're integrating clinical learning opportunities and then what do the third and fourth year look like or the rotations look like for these students, knowing that they're just starting their journeys right now?

Dr. Ahmadi: We have three major clinical campus sites that we have designed for them in Florida, California, and Connecticut. But what we do is the clinical training really starts from day one. We have also in Dominica clinical settings and community-based settings for them to get experience in clinical medicine. We have a course, a non-traditional course, that runs throughout the two years called Being a Doctor, where it's all about learning bedside clinical medicine skills. It starts with, of course, some sort of a program that's called Cyberpatient. It's a virtual platform of having patients to interview, to talk to, to examine, to manage. Of course, you can make mistakes and you will make mistakes as a medical student. When you do make mistakes, even costly mistakes, these are just virtual patients. You're forgiven, but you learn. 

Then you move from that to a simulation center that we have designed to be fairly heavily and extensively focused on standardized patient programs from the community here, where you start practicing. You go from the virtual patient to standardized patient. Then you are observed, recorded, your recording is analyzed and shared with you, and you get your feedback. 

From there, you graduate into the real clinical setting with real patients, but of course, again, under supervision of your faculty because they're very organized. Each faculty member are all day long with ten students. On two afternoons a week, they take in half of the group with them to the clinical setting. You have one half an afternoon per week as a student of going into the clinical setting and interacting with patients, again, under supervision. This is all first two years. Year three and four, when you go to clinical campuses, you are going to structured rotations at teaching hospitals that we have contracted with. That gives you very good, strong, I believe, clinical training. 

The residency match is, of course, an entirely different problem. You can be an international graduate. You can be a very seasoned clinician and have had excellent training and have difficulties in the match or getting matches because the numbers are not in your favor. Of course, the number of available residency spots is a fraction of the number of all the graduates who are applying to a particular international graduate program. What we do is, just as we develop clinical campuses using our experience, we develop residency programs also as a part of our project. Residencies that are affiliated with our medical school for our medical students. Essentially, clinical training grants for residency training of our medical students. 

That is a longer-term process to make sure that if there is a percentage of our graduates that are not matched in the general residency match, we have backup options. This was why we created the residency in Kazan. We would be looking into developing a similar type of accredited residency right here in Dominica, and then in other centers in the United States. We developed it in Connecticut in the Federally Qualified Community Centers with success. The residency that we created there in internal medicine, about eight years ago, is still going on successfully, graduating residents.

So, we know that we are able to create these residencies. We know that they will be successful. We know that our graduates can count on them. We are hoping to really provide a new model in terms of an international medical school. One that makes no compromises in the first two years in terms of curriculum, and is progressive and evidence-based. And then makes really very little or no compromise in the future years and the residency years by making sure that absolutely no student is left behind. 

And we feel so strongly about that. We announced in our communications and promotions policy that essentially, if we didn't give you a residency spot, we will give you tuition back. We feel very strongly about this. We feel that it's our responsibility. We take the students for four years. It is our responsibility that they get their residency spot. There are special circumstances where residencies such as ophthalmology, such as orthopedic surgery...these are highly competitive residents, and it doesn't matter. Forget the international graduates, the domestic graduates have a difficulty matching all of them into those residency spots. 

If you put aside ENT, orthopedic surgery and ophthalmology, and if you focus on the business of primary care -- where the country has a shortage of physicians -- if you concentrate on internal medicine, pediatrics, psychiatry, even obstetric gynecology, these are really specialties that the country needs, people need, and they are rewarding. These are the areas that we will develop relationships and we will develop new residency programs as well as developing a relationship with some of the existing primary care programs in the country to make sure that we place all of our graduates in the primary care residency program. That's our mission. 

We feel very strongly both about our primary care mission as well as the global health mission. I forgot to add when we talked about the curriculum that we do have six weeks of a required elective in global health for our students during their fourth year where they would rotate to one of our global health affiliates in Africa. That's a rotation that's very close to my heart. I have seen how medical students from Yale or from other schools, when they come to say Uganda or Zimbabwe and they go through a six-week elective they are transformed. They are not the same person at the end those rotations. It has a huge impact on them, and it gives them a different perspective on their life and on their career as a physician. 

Shiv: Wow, that's incredible. I mean, I definitely want to highlight to our audience that very unique and incredible commitment to the students that they'll get into residency program. So, aligning incentives fully, which I think is something, very few, if any schools are doing. That's something people should look at. And then obviously you're speaking to our heart at Osmosis and my heart in particular with the global health focus, having been born in Namibia and I was just in Rwanda in February, visiting our partner school, the University of Global Health Equity, who we've worked with for some years. 

I did want to ask you just more about your personal global health work going to such interesting places as Chechnya, East Timor and Sri Lanka. Do you mind commenting a bit about some of the experiences you've had and what you've learned and what you want your students to

take away from having similar experiences in their global health rotations? 

Dr. Ahmadi: Sure. I was attracted to global health because of my interest in looking at inequalities and looking at the question of justice and can a physician be instrumental in those areas? Can a physician use their expertise, their prestige, their power, their position in the society to advance the cause of justice and human rights?  I was in East Timor in 1999 at a time when Indonesian paramilitary forces had attacked the country because the country voted for independence and they were essentially burning the country down, creating a humanitarian emergency. I was there creating a clinic in Delhi with the help of a family practitioner, Dr. Dan Murphy from Iowa City, Iowa. He was really a man of integrity and committed to the cause and was not going to leave no matter what. Even when the militia would come by the clinic on their motorcycles and shoot at the walls of the clinic to scare people and to scare the physicians to leave -- they wanted the foreign doctors to leave -- there was a strong sense of commitment amongst us to stay and not leave the country.

I think we survived that humanitarian emergency for about eleven days before the Australians and United States peacekeeping forces through the UN mandate intervened and saved the country and saved the people. More than a million lives were saved. Because in the previous version of this years ago, in the 70s, Indonesians did commit genocide in East Timor, as we all know. 

So, this was one occasion that I witnessed personally where the intervention saved a nation from genocide and I found that very rewarding. The clinic that I built there to this day is there. It's expanded into a hospital. We had a donor from China who came and allowed us to do that and to expand it. And then later, I believe the Japanese came to support and help it. So, there was a lot of international help in order for that project to survive. But that was my experience in 1999 in East Timor. While, fortunately, I was prevented from witnessing genocide, I did witness people suffering and it does transform you, it impacts your life. 

The following year, 2000, I was asked by Physicians for Human Rights to go to Chechnya, to Russia during the war. This was the second time that Mr. Putin had invaded Chechnya. This was the second war declared in Chechnya and he was doing pretty much what he's doing to Ukraine now, to Chechnya in those days. Of course, nobody wanted to go as usual. It was a war zone. So, I went along with a lawyer. I was the physician, the lawyer was for the purpose of the legal documentation. I was there to look at the victims of torture and violence, and look at the attacks on the clinics and hospitals...look to see if there was any evidence of mass killings or, if you will, crimes against humanity, for which we found enough evidence. 

In those days, though, none of the Russian neighbors were willing to react to this. So, with the help of Physicians for Human Rights, which is an incredible organization, a great organization, I want to take the opportunity to tell all our young medical students, if they're listening, that is a beautiful organization to be part of, to become a member. It's an organization with integrity, and they do a lot of great work. So, we did prepare, as an organization, a 300-some page report called Endless Brutalities: Russian War Crimes in Chechnya and we submitted that to Mary Robinson, at the time the High Commissioner of Human Rights in the United Nations. Ms. Robinson could not really make an impact, could not do anything about it, and in fact, eventually over this, she resigned. But unfortunately, those events in Chechnya...we couldn't stop the atrocities, but we documented them, we reported them to the world, and let the people know what was happening to the people there. So, that was my experience in Chechnya in 2000. 

In 2004, after the tsunami happened in East Asia, I took a group of students and residents with me to Sri Lanka during a civil war with Tamil Tigers. Each part of the country was under the control of Tamil Tigers, and the government and everybody else was afraid to go and deliver any kind of help there. So, they felt that, you know, as international doctors, they will not attack us or kill us because we are not Sri Lankan. So, we had a little margin there for our operations to go and help, and it was true, because they were very nice to us. There were many child soldiers that I got to know during those days, but nobody really would try to harm us. 

Most of these child soldiers, I think, once they got their small pack of M&Ms or a Three Musketeers from me -- I had a lot of those with me at the time -- they were very good friends. They would forget that, in fact, they even were carrying a gun, and their eyes would light up with the chocolate and they would be your best friend. 

So, we did three weeks of going to various parts of those areas and trying to do our best. There was more of a sense of being witness to what was going on, documenting what was going on, and trying to get help and support for many of the families. There was very little medical help you could do, because if you were hit by the tsunami, you were not alive. So, there were more smaller wounds and dislocations and that sort of thing that you were dealing with, with a population that was internally displaced as a result. That was my experience there. The experience was really incredible for the young doctors who were with me. I think that really for most of them, it just really impacted their life and changed their life. 

After that, I've been always involved with international projects, humanitarian missions, human rights work. I’ve done human rights work also in my country of origin, in Iran. We created the Iran Human Rights Documentation Centre at Yale, documenting human rights violations and writing the story of the victims with the help of our colleagues from the Yale Law School who have been involved in that project and have done great work with us together to document those cases. 

But yes, that was my calling. I felt I've been all my life attracted to the cause of democracy and human rights and justice for the people who are suffering in these countries, and then when you come home, I think with that perspective, also your perspective changes quite a bit. You tend to be a lot more, I think, sensitive to the underserved population around you, to the underserved population that live right next door to you or in your communities. It just changes your perspective overall as a physician and just as a member of the community. 

Shiv: Wow. That's an incredible and very impactful background. I think you're the only Raise the Line podcast guest we've had who's given child soldiers candy as part of a humanitarian mission. From that to getting millions of dollars in grants to start residency programs in the US,

it's a pretty interesting life you've led. I'm sure your students are going to be privileged to learn from you and other faculty.

I want to be respectful of your time, so I only have two other last questions. The first is, what advice are you going to give to your students when they start and what advice would you give to early-stage healthcare professionals at this point? 

Dr. Ahmadi: The biggest danger that threatens their career, I believe, is exhausting yourself, is losing heart, is what we call nowadays burnout, and then as a result, developing a negative attitude towards your profession, your surroundings. It will make you bitter and it will make your career really a torture rather than a joy. So, I think the one thing I would always tell my students and my residents is don't forget this sense of purpose and meaning in your work. To have that sense of meaning in your career is the most important because everything else can fall into place. 

You all more or less -- through whatever medical school and training -- you will finally achieve clinical competence. The system has been designed as such in the United States. Ninety-nine percent of the time it prevents an incompetent person to get to the final stage and become a doctor. So, we do produce competent doctors all the time. But do we have doctors that always maintain a sense of purpose and a meaning in their life and that they enjoy deeply what they do every day? This has to do with them sort of achieving this thing we call transcendence. You know, believing that you're part of something bigger and that you are serving the community and other people and you are there for that purpose. Your training is in the service of the people and the community, and this should give you fulfillment. It should fill your heart. 

It should make it much easier to deal with all the insurance companies, with all the problems that you have in terms of the hospital surrounding, with all the difficulties that the various regulatory bodies impose on you on a daily basis. All of those things suddenly become very small, minor things. You smile at them. You go and figure them out and you move on because of that sense of purpose. That sense of purpose, that meaning will make you successful always and make you a good physician. 

When I talk to my medical students, I tell them, make sure that you don't forget your purpose. You're here to learn, so you have to always come every morning to school with a burning question in your mind. What is the answer? Because if you don't have that, then after a while, everything becomes a problem. The cafeteria food doesn't taste very good. The bed in your dormitory is uncomfortable. But if you have that, you will forget. If you have that burning question in your mind, you will forget what you ate today at lunch. You will forget where you were sleeping last night because you are driven by something more important, something bigger than those kinds of small issues around you in the daily life.

So that's, I think, the most important advice I can give to the students and to our young physician colleagues. Do not forget the purpose and the meaning and as long as you're connected to that, I think you will do very well. 

Shiv: Wow, that's beautifully articulated. And hopefully many of your students will take it to heart as they move in. As a med student myself, I know there are plenty of challenges, but I agree with you that as long as you can stay connected to the broader purpose of what you're doing and remind yourself of it and surround yourself with other people who have that sort of passion as well, it's contagious. So, hopefully your students will be able to do that. 

Is there anything else you want to get across to our audience about you, about ACSOM, or any medical education residency? Open mic, anything you want to share?

Dr. Ahmadi: Well, to those who are looking for a very high-quality medical education, I encourage you to look at us. I think we are trying to offer a medical education with no compromise, and we have a group of faculty and staff that has their heart in the right place. I hope that I connect to students that really think the same way, that their heart is with the community and with improving the life of their community and people around them, and I hope to be able to be a positive factor in their life and in their development as a health professional.

Shiv: Well, I have no doubt about that, just based on this short conversation. So, Dr. Ahmadi, thanks so much for taking the time to be with us on the Raise the Line podcast, and more importantly, for the work that you've been doing over the past several decades to actually raise the line and train more healthcare professionals all over the world and deliver care.  

Dr. Ahmadi: Thank you, and thank you for inviting me and having me on your program. 

Shiv: Absolutely. And with that, I'm Shiv Gaglani. Thank you to our audience for checking out today's show and remember to do your part to raise the line and strengthen our healthcare system. We're all in this together. Take care.