Educating Doctors to Be Leaders and Changemakers - Dr. Abebe Bekele, Dean of the School of Medicine at University of Global Health Equity, Rwanda

Shiv Gaglani: Hi, I'm Shiv Gaglani and today we have a very special episode of the Raise the Line podcast.  I'm actually here on set with Dr. Abebe Bekele, who's the dean of the University of Global Health Equity here in beautiful Butaro, Rwanda, which you can see behind us. Now, we at Osmosis have been working with UGHE for about six years, ever since we met Partners in Health in Boston at the AAMC conference. Dr. Bekele has a very impressive background. He's a cardiologist and thoracic surgeon, and he was the dean of Addis Ababa's Medical School before becoming the Dean here at UGHE. 

I spent the last twenty-four hours touring the campus, meeting with students and faculty and being really impressed with the infrastructure and the quality of education that he and his team have set up here at UGHE, which I think is a model for global health and many medical schools, not just here in Rwanda, but in Africa and worldwide. 

He has a very impressive background, which we'll include in the show notes, but for now I just wanted to welcome you, Dr.  Bekele, and thank you for taking the time to meet with me. 

Dr. Abebe Bekele: Thank you. Thank you, Shiv. Thank you for having me. 

Shiv Gaglani: So, tell us more about yourself? What got you interested in a career in medicine and then surgery?  

Dr. Abebe Bekele: Well, career in medicine, I think I followed the footsteps of my brother and sister. We are three in the family. I'm the youngest, and my sister went to medical school, my brother went to medical school, so I thought I should go to medical school. That's how it happened. Then, midway in my medical school when I started my junior clerkship in surgery - I went to medical school at the Gondar Medical College in Ethiopia - and three young surgeons joined the faculty, just out of the residency. They were really good teachers, so I can say what brought me to surgery was role modeling, very good role modeling. The three young surgeons shaped my career, shaped me. 

After I graduated from medical school, I was retained by the same university as a lecturer for about two and a half years, then went to residency in general surgery at Addis Ababa University in Ethiopia. After four and a half years of residency, I was again retained by that university as an assistant professor, started my cardiothoracic fellowship, then became a cardiac surgeon around 2012. It's been eleven years now since I became a surgeon. I think role modeling played a huge role in my being a surgeon.  

Shiv Gaglani: Definitely. I mentioned to you that I spoke with a number of your students yesterday, and several of them are interested in careers in surgery, one specifically citing the eleven-hour surgeries you've done in cardiothoracic surgery as well. So role modeling, I think, is one of the core reasons people go to medical school versus just learning online. 

Now, one thing that's impressed me in our conversations is you've also invested a lot, not just in being a surgeon and an academic leader, but also in improving your own educational skills, simulation-based training, and teaching in the classroom. Can you tell us a bit about what got you interested in a career in education?  

Dr. Abebe Bekele: Yes. When I took the job as a young general practitioner, as a lecturer in Gondar, I immediately became a teacher to medical students and to health officers. Then I realized that I enjoy teaching. I love teaching. I spent some extra time with the medical students, the other health professions students. I also started to prepare for my residency exams. Then, apparently, the students thought I was a good teacher. The students started appreciating it, giving me some awards, certificates. That encouraged me a lot. 

Same thing happened in Addis Ababa University. I used to teach a lot in undergrad and postgrad, general surgery and undergrad medical students. I helped examine, as an external examiner, in several medical schools in the country. By then, when I finished residency, simulation-based education was just coming in Africa. That was introduced to my medical school, but it was not yet structured.  I thought someone has to probably learn this and set up a good sim lab in Addis. So, I started my fellowship in simulation-based surgical education at the University of Washington. It took a year to complete, several months in Seattle. I think I became a well-qualified simulation-based educator in surgery. That helped me set up a very good skills lab in Ethiopia, developed some quite good curricula, and the skills lab I helped set up became the seed for the establishment of several sim labs in the country. 

Then, one day I received a phone call from the president of the university. I was told I am the associate dean of the School of Medicine. I said, “What's an associate dean?” Apparently, it means Dean of Undergraduate Students. We had about three thousand medical students there. So I said, “Okay, but how did you select me?” “Oh, the students preferred you. Apparently, you are a good teacher. They preferred you to be the dean.” I said, okay and went to the office.  Three months later, I said, “President, I'm leaving. I'm resigning.” He asked why.  “I don't know what I'm doing. The office, the secretary, knows better than I do. Even without a dean, it's an old medical school. It has systems. It goes without the dean. It can function without me.” Then he kind of said, all of us went into leadership this way. It's better if you think of it as professional development, personal development, and grow on the job. 

That's why I started the FAIMER Fellowship in Philadelphia, the medical education fellowship, about two and a half years ago. It really shaped my career in academic leadership, teaching, assessment, curriculum, monitoring and evaluation, program evaluation, and innovation. After I finished my fellowship, I think I did some good stuff in Addis. I served as the dean, associate dean, for about five years, I think. The CEO position of the Tikur Anbessa Hospital was also added. Then I was the dean and the CEO of the hospital. Quite a heavy undertaking but managed to do some good work. I retired from that position at the end of 2016, joined UGH in 2018. I can say the work I'm doing here is probably shaped by what I did in Addis and the different CPD programs I took, the personal development programs, the education I did in simulation and medical education. 

Shiv Gaglani: Yeah, clearly. I mean, I've toured the campus over the last day and seen how intentional the curricular setup you have is and who you've hired, obviously, taking deep interest in not just being a researcher or clinician, but also being an educator. You have a great faculty, it seems. So, tell us about UGHE, like the founding story, how it's related to Partners in Health and what the last several years have been like? 

Dr. Abebe Bekele: UGHE is eight years young, set up in 2015. We are fully owned by Partners in Health. Partners in Health have two institutions in Rwanda: the health delivery arm, known as Inshuti Mu Buzima, and the academic arm, the UGHE. So we are two sisters of the same organization. We have a school of medicine, the Institute of Global Health Equity, the Institute of Global Health Equity Research, Centre for One Health, Centre for Gender Equity, the Centre for Equity in Global Surgery, our educational development center, we also have a center for women's and midwifery, and several others. The School of Medicine at the moment has 108 students, 70% of them are women. By policy, we recruit more women than men. We started recruiting from just Rwanda, the first two cohorts. Last year we expanded it to Uganda, Tanzania and Burundi.  This year we'll also recruit from the PIH African countries: Sierra Leone, Malawi, Lesotho and Liberia. We started with just thirty students and the plan is to increase this six every year until we reach at the summit of sixty. 

So hopefully by 2028, we're going to have 300 medical students in the campus, sixty in each cohort. Our senior students have now entered their senior clerkship year. They are doing their attachments in ENT, radiology, dentistry. The curriculum is set up in four phases. The first one is what we call the liberal arts and humanities, social sciences, social medicine, gender and social justice. The students spend about seven to eight months doing these modules. We believe in a strong foundation in liberal arts and humanities. Social sciences are a pillar to the formation of tomorrow's doctors. 

Then they start their basic medical sciences years. We follow an integrated curriculum, we don't teach anatomy, we don't teach physiology, but we teach system-based integrated modules. The current students are doing their GIT and nutrition module. It's followed by a respiratory system, the cardiovascular, the vascular system. After these two years, they go to their clinical clerkship years. It's one year of junior clerkship, one and a half years of senior clerkship. Then they go for their government mandated one year internship here in Rwanda, and then they come back to come and do the Master of Science in Global Health Delivery Program. So by the time the students finish their program with us, they will leave with their MD, which is called MBBS in Rwanda, and MGHD, a dual degree program. That's the system we have tried to create here. 

Shiv Gaglani: That's very unique. We talked about this yesterday where I think there are a lot of schools that offer the option to do an MBA, MHA, and other masters, a PhD. But here, every medical student who graduates also gets this masters with one of four tracks, I believe, as you said. So hopefully your vision, it seems, is to train not just providers, but providers who become leaders and promote global health. Is that right? And then they go back to the countries where you recruited them from and improve healthcare capacity there? 

Dr. Abebe Bekele: Yes, that's absolutely right. Our vision is to produce health care providers who are not just providers, but also leaders and change makers. The pillar to this is training. That's how in 2015 we started the MGHD program. At the moment, the MGHD has three tracks in health management, one health, and sexual reproductive health. This year, the global surgery track will start, and next year, the community health track will start. So, by the time our medical students are ready for the MGHD program, they will have five tracks to choose from. 

It's a good quality medical school, good quality MGHD. So it's bound to be expensive. Setting it up, running it is expensive. However, in Africa, expensive education will be reserved for those who can only pay. The majority, overwhelming majority, will not be able to afford it. Our decision, therefore, is to give them scholarships as long as they pass the very stringent selection criteria we have. Our selection rate is about three to four percent at the moment. Anyone who passes through this stringent selection criteria can join us. 

However, nothing in life is free. They have to pay this forward. They have to agree with their own Ministry of Health to serve the nation, wherever they are assigned at least for five to six years, at least. So, we expect agreements with the Ministries of Health of these countries. The students should agree with us to make sure they finish the program, the two degrees, and they should sign a contract with their own government. The government should also commit to employ them as a doctor when they come back, and to assign them to positions that will help them be more productive and bring change, serve as leaders, serve as professionals. 

Shiv Gaglani: Yeah, that's wonderful. And that's the reason we call this the Raise the Line podcast. As you recall, when the COVID pandemic began, everyone was talking about flattening the curve...how do we avoid overwhelming the healthcare system by keeping people physically distanced, wearing masks, taking the vaccine when it came out. The other equation is raising the line, which is how do we strengthen the healthcare system with telehealth and cheaper access to drugs and more clinicians, more doctors, nurses, etc. Clearly, that's what any medical school does. It's what your school is doing. It’s trying to raise the line and train more people from the local communities. You recruit a lot of students from their local communities with the hope that they go back contractually, but also that they want to go back because that's where they're from, they have family. 

What are some ideas you have for further strengthening the Rwandan but also African healthcare system in terms of raising the line? There are only so many physicians we can train, you know, a wonderful school like this, sixty a year at capacity. What else do we need to be doing to improve the healthcare system?

Dr. Abebe Bekele: Well, all my life I've been an educator and a service provider. So, my comments will be restricted to just healthcare, education and research. I think governments should pay attention to what's going on in medical schools. Quality is really needed. The quality of a provider that was envisioned fifty years ago is completely different from what the world needs for tomorrow. It’s completely different. The world needs not just doctors, but doctors who can serve as medical directors and leaders of health centers; doctors who can think, who can write articles, understand articles, who can serve as deans of schools; doctors who know how to collaborate with politicians, with journalists, with policymakers; doctors who influence ministries in policy, who can support the ministry; doctors who can manage projects, who can raise money. Such competencies are needed today. That's what COVID has shown us. 

None of us were prepared to handle such a thing, and that's why I think the world paid a huge price. Millions of people died. There is no guarantee another COVID is not coming in ten years. The solution is to be prepared. So, I think Africa should invest better in its schools -- nursing schools, medical schools. Faculty should be trained better, should be supported to provide better education, better assessment, better selection criteria, and the trainees should also be given opportunities to acquire better competencies such as MD MBA, MD MPH. This was considered a luxury ten years ago. It's now mandatory. 

Africa should look at situations of providing such trainings for the trainees. There is a lot of brain drain. A lot of trainees leave the continent. I doubt if it's mainly for salary reasons only, for benefits only. It's because of opportunities. So, educational opportunities in residency, specialty, subspecialty, fellowships, should be made available, and better things should be put in place to retain them here. Retention is not just salary. Several other things come into action. So, Africa needs to learn how to retain its own people and Africa needs to use its own people. 

There are amazingly brilliant, well-trained people in Africa who are just relegated to healthcare, to hospital. These people should be utilized better, should be listened to, should be consulted when policies are considered or implemented. The last thing is quality. We should really believe in quality. Quality is not cheap. It has costs to it. Expense might not automatically translate to quality, but every quality has a cost attached to it. We cannot pretend or insist we need quality care and refuse to invest in it. I don't think that works. It has failed the past fifty, sixty years. It will continue to fail. 

Shiv Gaglani: Yeah. I think Einstein said, “insanity is doing the same thing over and over and expecting a different result.” You're speaking our language. We're an education company at Osmosis. We love filling in knowledge gaps. I guess this is a two-part question: what could we be doing better to help your mission at UGHE in improving the quantity but also the quality of training for healthcare professionals here in Rwanda and Africa and globally; and number two, if you could snap your fingers and teach any audience -- whether it's patients, medical students, physicians, nurses -- something that we could develop a course on, what would it be and why? 

Dr. Abebe Bekele: Well, I think the key word is access. These young boys and girls are really smart. You give them something, they latch into it.  They know what they're doing. It's just that many of them do not have access. Our students are lucky. They have access to Osmosis and other digital resources. They make the best use out of it. Sometimes I wish...there are more than fifty medical schools in the region, how many of them have access to these splendid resources? So, if there are any way medical schools in Africa could get access to such a beautiful resource, that would make a huge difference. Especially for medical schools where the number of faculty is very low, access to live teaching is reduced, funding is not so much in these medical schools. I think that would make a huge difference. So I think the key would be access. 

To rephrase your question, how can we make Osmosis different or better?  I'm sure you'll do it sometime soon, but we could also concentrate on the minor attachments in medicine like ENT, dentistry, radiology, dermatology, just like what you're doing for surgery, medicine, OBGYN and others. If we can create resources to address these courses that would be great. If I could also add some courses around medical ethics and law and health proficiency education, I think those would really be helpful.

Shiv Gaglani: Yeah. 

Dr. Abebe Bekele: Because these are probably the most neglected components of healthcare education. 

Shiv Gaglani: Definitely. Yeah, as we discussed yesterday, we have some content we're packaging into those areas, but then producing more content on those fields as well. Because that's where the long tail is, but that's where a lot of need is as well. That's helpful. 

What advice would you give to our audience? I mean, you advise all these students here on campus, what advice do you give them that maybe you could transfer to our audience about meeting the challenges of this moment in medicine and approaching their careers in medical education or medicine?  

Dr. Abebe Bekele: Well, I think not just them, but all of us should be prepared. We kind of know where the world is heading into. We shouldn't be surprised when that happens. It's obviously clear. We've seen COVID two years ago. It's coming sometime. I don't think we should make that mistake. Climate change, we're seeing it coming. Physicians need to be prepared. The young should be prepared. The direction of healthcare is towards AI, digital health, innovations, e-learning. Today's medical student cannot hide from this fact. When I was trained as a medical student, even in surgery, laparoscopy was a luxury and if you mentioned just the word laparoscopy during your exams, you'd pass because you know laparoscopy. Not anymore. Laparoscopy is a day-to-day practice, even in Africa now. So the innovations of today, medical students should be very much aware of. You should be prepared for tomorrow. 

The last would be, we can't do this alone. The world is so intertwined, it's so interdependent, we're so dependent of one another, we just can't do it alone. A medical desert somewhere means medical desert everywhere. We just can't do it alone. So, today's youth, medical students, should learn how to partner, how to develop partnerships with global north and south, south-south, north-north. That I think should be seriously considered.

Shiv Gaglani: Your students certainly have an appetite for it. I've seen it. As I mentioned yesterday, I met with about forty of them in the first year of class, and I was impressed with how they want to collaborate. Obviously, many of the faculty come from other institutions for visiting fellowships, one week, two-week, three week, lecturers, but also have come from other countries to come lecture and teach. 

The other thing on digital health and AI -- and it's one reason we have the podcast and feature guests talking about where the puck is headed,  what is the practice of medicine going to be like, not today, but in two years, in five years, in ten years -- and I was really happy to hear when I asked the students about  if any of them had explored the generative AI, artificial intelligence tools like chat GPT,  about a third of them already had. And it's only been two months since they came out. So, I'm really glad to see that. And your faculty, too. About a third that had tried it, and I'm sure that'll increase over the next few months.

Dr. Abebe Bekele: Yeah. Well, that's more headache for us, the faculty, you know. ChatGPT is not going to make our life easy, but that's life. These are innovations we have to deal with. Everybody has to understand what it means, understand the challenges, and be prepared. 

Shiv Gaglani: This is one thing I was brainstorming with your students and faculty about. I think there are ways that it could make the jobs of both easier, hopefully lean towards the positive on that. 

Dr. Abebe Bekele: Oh, absolutely. It's just that we can't hide from it. You cannot say, “Oh, it doesn't involve me.” It's just a matter of time. It will.  

Shiv Gaglani: Yeah. And this will be help by other improvements in technology. As you know, I was born in Namibia. I returned to Namibia six years ago after twenty-five years of not having been back, and the internet was not great. Once you left the University of Namibia campus in Windhoek, it just wasn't fast enough to even play Osmosis videos on a phone. But now it's much faster because our coverage has improved dramatically, and you were mentioning that even on the trip from Kigali to Butaro on a dirt road -- two and a half, three hours -- you have plenty of good internet to watch Osmosis videos.  

Dr. Abebe Bekele: Exactly. Exactly.  

Shiv Gaglani: That's the trend of the technology. 

Dr. Abebe Bekele: Absolutely. Absolutely, and today's trainees need to be prepared not to just be part of it, but to lead it eventually. To be part of innovation, to innovate things.  At the end of the day, we are talking about access to health care and quality health care. 

Shiv Gaglani: Yeah. Awesome. Well, I want to be respectful of your time. So my last question for you is, is there anything else that we haven't covered that you'd like our audience to lead with?

Dr. Abebe Bekele: Not so much, except to thank you very much for thinking about creating Osmosis.  Our students enjoy it a lot. They learn a lot. The faculty use it very well. It has been such a huge resource for us. And Osmosis and companies like that who provide e-learning access to medical students, I think that should be highly appreciated, and thank you very much for your partnership.  

Shiv Gaglani: Thank you. Really appreciate it. And thank you for being such a generous host and coming on the podcast. And with that, I'd like to thank our audience for joining us for this episode of Raise the Line. Remember to do your part to raise the line since we're all in this together. Thank you again, Dr. Bekele.