Global Innovator in Medical Education 153.0

Dr. Khryss breaks new ground in medical education

Dr. Fortunato Cristobal, or Dr. Khryss as he is fondly known, is a globally recognized innovator in medical education. Like many such leaders, he is a stranger in his own land!

Since 1998, his school has graduated about 30 students per year of which 80% – 90% pass the board exam as doctors compared to the 53% – 63% national average from 2007 – 2009.

More importantly, about 90% of those who became doctors have stayed in their communities as family physicians instead of going abroad, moving to the cities or training to be specialists in tertiary care.

Social Benefit. After 11 years of embedding doctors in Western Mindanao, Dr. Khryss says that the family doctors have raised by a visible increment a social measure of health. They have significantly reduced infant mortality in Region 9, Northwestern Mindanao for the 5-years-and-below cohort. With time, it would not be illogical to expect improvements in other measures like ‘life expectancy at birth’ to become visible.

Because of these achievements, Dr. Khryss has excited calls for validation through evidenced-based studies and social audits by European health activists, a formality prior to emulation. More quickly, there are request for visits from health leaders in emerging market democracies like India that have similar problems with doctor availability in rural areas.

A Quick and Short History. Despite a policy environment where health is not a right but a privilege, Dr. Khryss patiently put together this effort as a ground-up, community project in a Foundation with three academicians, five businessmen and seven doctors in Zamboanga City in 1994.

Father William H. Kreutz, then President of Ateneo de Zamboanga, provided the inspiration and the classrooms for free. At the start, the doctor-instructors just got paid with honorariums. Everybody agreed that the region needed a school of medicine to train doctors as the area was very under-served under the prevailing policy environment.

Fortunato Cristobal, MD. Dr. Khryss was an inspired choice to head the foundation. By then, he had helped lead the government regional hospital in Zamboanga to accreditation.

He had graduated from the UP school of medicine and had a London-hospital graduate degree in pediatrics and gastroenterology (both under scholarships).

At the hospital, he emphasized intervention research to document findings on the ground. These research by his staff won awards in national competition in succeeding years. He has continued a heavy research and documentation orientation at the School (see applied research topics at the website below).

He was the only pediatrician in Zamboanga city when he first returned to his home city and made it his mission to train more in the hospital and, later, in the school.

In 1998, when the school first graduated its doctors, Dr. Khryss was also awarded the “Most Outstanding Pediatrician of the Philippines Award” by the Philippine Pediatric Society, an acknowledgment of his technical leadership.

Because of his prior involvement in further training of local doctors, he did not have difficulty getting them – all 51 local doctors as teachers and as community preceptors – to volunteer to the Foundation.

The Foundation. From the beginning, the Foundation designed the medical education to be community-oriented. He was inspired by the ideas and questions raised by Thomas McKeown but innovated – in intuitive and wondrous anticipation by a full eight years the concept of the health gradient (Link and Phelan, 2002) – to focus on health variables (as contrasted to healthcare) like clean water, sewerage, hygiene and sanitation, etc. – rather than McKeown’s original social variables like wealth redistribution to benefit the population and not just the individual patient. He also credits the help of overseas visionaries from New Zealand and Canada in refining the design of the school curriculum. The School’s vision:

A medical school that will pioneer and implement a curriculum that combines competency and problem-based instruction with experiential learning in the community … it will be sensitive to the social and cultural realities of Western Mindanao.

The medical school’s mission is:

To help provide solutions to the health problems of the people and communities in Western Mindanao. It will strive to produce competent graduates who, in the practice of their medical profession, are self-directed physicians, effective health administrators, applied health researchers and committed medical teachers.

In 2005, with seven years of successful operation under its belt, Ateneo de Zamboanga decided to absorb the foundation to become its School of Medicine. Dr. Khryss, a founder, became its first Dean until the present. With its consistent success in traditional measures like Board passing and in social measures and the crying need for better health for Filipinos, it may be time for us to learn how they have done it in Zamboanga.

Meeting Dr. Khryss. I first read about Dr. Khryss’s success from an interview in the Fall 2008 issue of a Cuban medical journal. It seems that there are only eight similar successes in the world though the search continues for role models globally.

Note: Two out of the eight are from the Philippines; the other model is slower using a stepladder approach by a Leyte medical school.

I particularly remembered the interview because Dr. Khryss clearly expressed his frustration about the Philippine situation where the government and most of the private medical education sector were closed to his approach to medical education.

I visited him in Zamboanga for this blog last week. Based on his competence and resume, he could have been a wealthier doctor in a bigger city. He seems to have made the “providential” choice – a favorite word, to extend his talents instead in the under-served region of Western Mindanao. He is not Ateneo-schooled and is Lutheran but seems, to me, the perfect example of “a man for others.”

Industry Context. Most of the rest of the medical education sector were focused on training doctors for specialist work in tertiary care (with a hidden bias for the city hospitals) or for the overseas market. Teaching out of hospitals rather than being school-based, I think, creates financial pressure for larger monetary returns.

They were suspicious of his pedagogy that had a social rather than a biological focus. The course was actually designed to cure the top ten causes of mortality and morbidity of Filipinos according to the Department of Health statistics rather than on the universal medical science approach. The question from the traditional sector: “Will his course produce good doctors?”

The maiden issue of Kumpit, the official student publication of the school, reads like a manifesto in support of social-biological medicine – a defense against the attacks of the traditional medical education sector.

Course Pedagogy. The course requires that students spend as much as 50% of the time on health rather than healthcare issues in the communities. By this (health) we mean, leading populations to clamor – in their absence – for clean water, better sewerage, better nutrition, etc – on the assumption that cured patients who return to live in unhealthy social conditions become sick again.

With 50% of their School time spent in such community leadership, it is no wonder that the students’ socialization process leads to a special concern for the communities they serve. I would not be surprised to see involved political leaders coming out of the medical profession in the coming decades. I believe this socialization process provided the psychic and material returns that make the doctors to stay in place. This is something Zamboanga can teach the rest of the world.

Others see the success of the approach as a disruptive threat to the status quo. It is good that, by traditional measures like board passing rate, the School is at the top quartile. I do believe it is wrong for the tertiary care sector and traditional medical schools to see Dr. Khryss’s success as a threat. A longer-term view clearly shows it to be a benefit to the whole industry.

Opportunities. More needs to be done to extend Dr. Khryss’s innovative success maybe to the rest of Mindanao. Indeed, community-based doctors are the ideal outer nodes for innovative technology-enabled mobile and tele-medicine that are connected via ICT links.

These links will likewise strengthen the doctors’ connection to the center via work-related interactions.

Other Benefits. The benefit of health as wealth and of extending life expectancy of our most experienced citizens – i.e. as transmitter of learning for their own communities – are immeasurable.

Nurturing children helps mothers strive for an inclusive society that protects these children.

In Conclusion, Health as a Right. Maybe it is timely that America is starting to accept health as a right. Much as I would prefer for Filipinos to go where their own reasoning tells them is the best way to go, emulation, if it saves time, is alright by me. Dr. Khryss and his team has opened a door. Let us walk through quickly and enjoy the benefits of their work!

Note: Click here for a link to the website of the Ateneo de Zamboanga School of Medicine. In the website, click on the Alumni Database to show the distribution of community doctors in the Zamboanga peninsula. Also interesting is the list of applied research abstracts at the bottom left box. You may click on “Doctors Bring Hope” to see videos of teachers and students study in the community setting.