The Serbian Connection: UCSF Teaching Goes International

By Jeff Miller Igor Mitrovic, MD, UCSF associate adjunct professor of physiology, still remembers the unexpected email that showed up on his campus computer screen in the spring of 2005. The author was Ljiljana Mijatovic, MD, PhD, then vice dean for curricular reform in the School of Medicine at Serbia's Kragujevac University. "She had met Lawrence Tierney (UCSF's multiple award-winning teacher) in Japan, and then run across my name on the UCSF Academy of Medical Educators website and recognized that I might be from the Balkans," he recalls. (Mitrovic is indeed Serbian, although he was born in what is now Croatia.) But it was the nature of her request that intrigued Mitrovic most. "She had researched a number of European and American medical schools, and concluded that UCSF's integrated medical school curriculum was the best from their standpoint. She wanted our help in bringing the same kind of program to Serbia." Now, after an exchange of visits, elements of UCSF's teaching approach and philosophy - honed in the small-group, problem-based learning curriculum that characterizes UCSF - have taken root in Serbia's largest medical school. Moreover, the freedom of inquiry and new interest in teaching skills the UCSF connection has unleashed might soon be spreading to the liberal arts curriculum at Kragujevac as well. "I have to admit that when this was first proposed, I thought Ljiljana was Don Quixote," Mitrovic laughs. "Even after she came here, met people and observed UCSF's curriculum in action (which included seeing UCSF Chancellor Mike Bishop's lecture on cancer), I figured that Serbia was in such a shambles after the war [over Kosovo] that it could not be ready for big changes. But I was wrong." Not only are the faculty hungry to learn how to communicate better with their students," says Mitrovic, "they now have a completely different attitude about what good teaching is." In short, the Serbian instructors have started to move from a pure lecture, knowledge-based format to an attitude-based, patient-centered approach consistent with the UCSF model. "For me," says Mitrovic, whose office wall is also full of framed excellence-in-teaching awards, "this has been the most professionally satisfying thing I have ever done." Clearly, the administrators at Kragujevac would agree. During the weeklong visit by UCSF faculty in the spring of 2006 - made possible by support from the UCSF School of Medicine's Office of Medical Education, ACDI-VOCA and the US Agency for International Development - they called a news conference, securing press coverage throughout Serbia. "The UCSF name is known there," says Mitrovic. "They kept asking, 'Why does such an important university like UCSF want to help us?'" Goodwill and Good Practice The answer, apart from taking seriously UCSF's outreach mission, is the belief among UCSF's medical educators that they have something important to offer. "When I first heard about this idea," says Katherine Hyland, PhD, assistant adjunct professor of biochemistry and biophysics, "I was excited and proud that our medical school curriculum had been singled out as a model. When I thought about why we were singled out, I think it is because ours is the only curriculum that has fully integrated the basic and clinical sciences." How it would translate to Serbia remained an open question, adds Hyland, who was one of four medical educators - including Carrie Chen, MD, Tracy Fulton, PhD, and Marieke Kruidering-Hall, PhD - Mitrovic asked to participate. Also joining them on the trip was a fifth woman, Ana Lazic, PhD, a UCSF pharmaceutical chemistry postdoc, who by chance happened to be from Kragujevac. Lazic coached the team on cultural differences before their departure.

Left to right, Carrie Chen, MD, MSEd, Marieke Kruidering, PhD, Tracy Fulton, PhD, all of UCSF; and Irena Vukovic, MD, graduate student, and Vladimir Jakovljevic, MD, PhD, professor and chair of physiology, at UKSM.

"The reaction to having Igor show up with five women in what is a more reserved, male-dominated culture was something we needed to anticipate and prepare for," says Hyland, whose class in Prologue - an interdepartmental block in the medical school curriculum -was among those previewed during Mijatovic's scouting expedition to UCSF. Preparing a whirlwind "Innovations in Medical Education Faculty Development Course," complete with small-group feedback sessions, was yet another challenge. "We wanted to do a good job," adds Kruidering-Hall, assistant adjunct professor in cellular and molecular pharmacology, "because we didn't want to stain the UCSF name with a bad experience." Planning for Success The eventual plan also had to be modeled around a culturally sensitive imperative, namely that the UCSF team did not have all the answers. "We had to frame our presentation in a way that made it clear that while we did things a certain way, they had to decide what would work within their confines," says Hyland. Among those constraints are teacher-to-student ratios. At UCSF, there are 1,400 faculty for the 140 students in each year's class; at Kragujevac, the ratio is 140 faculty for the 240 medical students admitted each year. Mitrovic also spent precious time recounting UCSF's history, particularly the personal rivalries, disappointments and backroom politics that colored the University's 19th-century beginnings. "UCSF had its dark days too," Mitrovic told his Serbian colleagues. "I also wanted them to know that new people came to UCSF with new ideas in the 1960s, and that the same thing could happen in Serbia too. What had been accomplished at UCSF was not only possible in San Francisco." Topics covered during the weeklong series of presentations included teaching skills, theory, active learning and large-group/small-group interactions. Reaction was muted at first. "What they thought wouldn't work was the mixing of clinical and basic skills; they only have lectures for the first two years," Hyland explains. As minds started to open by the second and third day, the UCSF educators faced their biggest hurdle. Serbian educators, it seems, are not used to getting feedback, particularly when it comes to discussing changes in how and what they teach. Indeed, during the communist era, feedback was a frequently abused form of behavioral critique, and is now an unpleasant reminder. Not surprisingly, participants in the small groups were tentative at first, the UCSF contingent reports. The groups also tended to separate out by gender. When mixed, men took the lead. Still, with practice and some gentle encouragement, momentum and trust carried them along. Before long, their Serbian counterparts were practice-teaching to each other and listening to advice. By the end of the week, hugs had replaced crossed arms. "It was a love fest," says Hyland. In the months since, change and renewal have reshaped Kragujevac's teaching culture. Second-year students, for example, are no longer allowed to continue if they do not pass their first-year exams. Laboratory exercises have also invited students to solve problems, not memorize solutions, engaging them as active learners. Indeed, during Mitrovic's last visit in December 2006, he lectured on educational research, a topic dear to the heart of Kragujevac's medical school dean Nebojsa Arsenijevic, MD, PhD, who wants to develop educational research as a curricular cornerstone. In September 2007, UCSF will send famed immunologist Abul Abbas, MBBS, to Kragujevac to deliver three lectures. As to what will follow, Mitrovic does not speculate. But he is certain of UCSF's impact. "We gave them the tools and they like the results." How does he know? "They want us to keep coming back." Related Links: Medicinski Fakultet, Univerzitet u Kragujebcu Igor Mitrovic, MD Haile T. Debas Academy of Medical Educators, UCSF 2003 Distinction in Teaching Awards UCSF Academic Senate advancing health worldwide™ website