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Poor conditions--but hope--in post-Communist Albania

From the December 1995 ACP Observer, copyright 1995 by the American College of Physicians.

Editor's note: William G. Hardison, FACP, spent nine months on a Fulbright lectureship in Albania last winter on educational leave from the San Diego VA Medical Center, where he is a gastroenterologist and professor of medicine. Here are excerpts from his journal.

Nov. 22, 1994

I have been two months now in Albania. It's an adventure and not exactly what I had imagined. First, life is really hard here. The flats have cold water without heat except for electric portable heaters. Since the electrical system of the old regime was not built for such things, the electricity keeps going out in the winter. We have had no electricity from about 6 to 9:30 p.m. the last four evenings and I am afraid the winter is just beginning. Since all cooking is electric, it creates a bit of a problem there, too.

The first disappointment--I have not revolutionized Albanian medicine single-handedly, at least not yet. It has taken the past two months for me just to get used to a new universe and for the physicians here to begin to trust me. Also, shortly after my arrival I was told that I could not lecture medical students because they would not understand English and using a student as a translator was not appropriate. Yet over 80% of medical students understand English well enough to follow a lecture that is given slowly and articulately. I cannot care for patients directly because I was not authorized by the state. So I spend most of my time with medical residents, specialty fellows and English-speaking junior faculty.

I had thought that physicians, except for differences in technical resources and levels of sophistication, would be pretty much the same in their approach to and treatment of patients. Not so. Certainly the academicians who are of the age to be the deans, department chairs, etc., all lived (and succeeded) under the communist totalitarian tradition. The chief of the department or section appears to wield the same powers as the nautical captain in the old British Navy. The result is that he (there are few female chiefs) makes proclamations that the underlings then are expected to follow without question. Little autonomy is allowed. Yet this system has a monopoly on training.

Furthermore, there are few books to study and no comfortable, warm, lit place in which to study them. The "blackboards" are just that--boards painted black. The chalk they have is too hard to write on the boards. There is no such thing as slide projection capability.

Consequently, most physicians come to work at 7:30 a.m. and depart at 1:30 p.m. It is true that even if they were to stay to take care of patients, they would have no ancillary services to help them since radiologists and pathologists leave at about the same time, and cultures and blood drawings for labs are done only once a day in the morning.

The hospital is full of patients who should not be there. There are three reasons. First, patients come by referral from all over Albania, and they are too poor to afford a place to stay in Tirana. Hence, they are put in a hospital bed. Second, although the government claims it offers free medical care to all, in fact medicines are paid for only in the hospital. Patients, therefore, tend to remain in the hospital for their complete course of therapy. Finally, the extremely slow turnaround for ancillary services (e.g., one week for a biopsy, two days for routine biochemical tests) leads to very long hospitalizations for trivial workups.

It seems the self-assessment question format of MKSAP is the best spark to ignite the dormant curiosity of the third-year fellows I work with. Because their whole experience to date has taught them to hide ignorance, they almost never volunteer answers to questions or question the speaker (or article, or book or whatever). Since I am only beginning to pick up some Albanian, they can talk and I do not know what they are saying. Rather, I am a resource person to answer questions they cannot work out. This gives them a feeling of safety from authority and allows them to argue with peers, etc. After working with the questions for only about two weeks, the fellows are beginning to come in to take out the textbooks that I brought over.

With my experience so far, I have not elected to pass the material on to chiefs. Rather, I gave them to junior faculty. Books given to the chiefs of their respective divisions or departments either go home with the chief or end up locked up in their offices, where they may never be read.

The hospitals often have broken windows repaired by patients with newspaper. Heating is minimal, so many patients' families bring in electric heaters to warm the rooms. This year some reasonable beds and blankets are available. It is always cold in the winter, however, requiring two layers of clothes under the white coat and at times an overcoat too.

Some families cook for the patients in their rooms so that rounds might find two or three pots boiling on portable hot plates. There is no reliable phone communication, so the only way to do business with other doctors or departments is to walk there. And, consequently, there is no way to notify trainees of a patient's change of condition promptly. Only the physician on call (who usually does not know the patient) is notified. Therefore, there is little sense of clinical urgency or control. The formulary is limited to a very few drugs purchased by the state plus whatever might be available from recent aid shipments.

Fellows cannot admit patients to or discharge patients from the hospital. They must follow the directives of their staff doctor, often without knowing why. I have not yet witnessed a dispassionate discussion between staff and trainee about the best course of action for a given patient. The fellows in gastroenterology (my subspecialty) after two and one-half years of training have not yet been allowed to perform an endoscopy or do a liver biopsy, and they will not be. Although the hospital performs 2,000 to 3,000 upper endoscopies a year, the argument is that the hospital's one endoscope is too precious to allow the inexperienced to use it. Why they cannot do liver biopsies I have not yet discovered. The full-time faculty who teach trainees and students receive a salary (about $80 per month) for teaching only, and no salary for their patient activities. The physicians paid for clinical care receive a lower salary (about $50 per month), but get extra income for teaching hours when they are needed.

The approach I am taking is to make myself available. A few of the overworked junior faculty asked me to give covert lectures to small groups of students (who understood me quite well). The students were all enthusiastic, bright and unbelievably respectful (by American standards). It was a pleasure. I organized a weekly GI-pathology conference. This was a feat in itself since there is no history of dialogue between clinicians and pathologists.

Initiative, inquisitiveness and debate have been and are part of our social and academic fabric. In Albania, however, these were precisely the traits in the past that ensured a short career and certainly did nothing to improve one's grades in school.

As one might expect, the level of clinical training is not high. I believe this is partly a result of the system's strict specialty orientation. Up to the present, fellows have not had extra prior training in internal medicine before they embark on their specialty training. The short time alloted to patient contact, the obvious nature of disease in many of the patients and the uncomfortable environments in which patients are seen do not engender full history-taking and complete physical exams. Moreover, there is no general medicine experience for the students, only subspecialty rotations. This means that all workups are specialty targeted. Specialists here are very quickly out of their depth when they stray from their own organ system. Because of this, I have tried to function as a general internist more than as a gastroenterologist in any consultations or bedside teaching I perform.

Whatever happens in the next six months, I believe I shall have to leave just as I am getting started. It takes time for people to get used to foreign ways. This is why I believe one person for nine months is 10 times better than nine people for one month. The short visit is enjoyed but the effects will not be lasting. Nor, I believe, can the deficiencies be alleviated by Albanian doctors taking time overseas. When they return, they return to a system with inadequate technology, funding, education and support from their superiors. And they are powerless to change it. Many of the physicians who go abroad never return.

Feb. 27, 1995

Each day brings something new. Recently, surgery was given an old ACMI fiber-endoscope from Australia. One of the young faculty invited me over to teach the staff how to use it. Suddenly, after five months of ignoring me, surgery is inviting me over to consult on patients, to do endoscopies and even (wonder of wonders) to start a series of medical-surgical lectures to include gastroenterology.

March 25, 1995

Grades are often not awarded on the basis of academic merit. Instructors are occasionally threatened--and often bribed--by students and their families to obtain passing grades. The dean insists on oral examinations only. I pointed out that an objective written exam would solve the problem of graft. At least two junior and one senior faculty informed me, however, that that would severely limit faculty influence.

The USMLE-1 course that I give two hours per day, four days per week, is going well. As might be expected, the attendees are the most highly motivated in the medical center. Certainly, the course is not sanctioned by the university or medical center and will gain them no local recognition. On the contrary, it may make them suspect. I believe with continued hard work, these students have a good shot at passing the exam.

Also, I am now teaching the GI doctors at the polyclinic to use the clinic's endoscope. Before I came, there was a monopoly by the medical center circuit-rider diagnostic endoscopist who came one-half day per week. But since I am training their fellows, and the fellows were promised such training, the chief could not disapprove.

April 3, 1995

I am getting a bit worn down. Although Albania has changed since the days of communist totalitarianism and absolute isolation from the rest of the world, much of the old mentality persists. Change and innovation are a threat to those in charge, and unfortunately they have the power to prevent change. The dean is appointed by the Ministry of Health, with the Albanian president's approval. The dean then has absolute authority over every detail in the medical academic establishment--and he exercises it! For example, he picks the textbooks to be translated, published by the university and sold to students as the current accepted text. They are not the best or most current texts available. He has absolute power over any faculty who works in the medical school and, by extension, over many of the working doctors on Tirana's government payroll.

May 26, 1995

My reservations are made for the trip back home. It has been quite a year. I saw things I could not have imagined and never would have believed if I had not seen them myself. Communist influence remains in the fabric of Albanian medicine. There is little inquiry, and innovation is regarded with suspicion. There seems to be an overriding necessity to maintain the status quo.

Nonetheless, I feel my presence has been important. When students and young faculty see you managing under their conditions, they conjure up a little hope and lose some of their depressed apathy. As more and more receive one or more years of training abroad, I believe there will be more pressure on those in power to change.

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