Gyorgy Baffy, MD, PhD1
1Department of Medicine, VA Boston Healthcare System, Harvard Medical School, Boston, MA 02115, USA
Correspondence should be addressed to G.B. (gbaffy@partners.org)
My first semester in the new academic year promised to be quite out of the ordinary. I packed my bags and planned to spend 3 months in Hungary teaching at the medical school where I graduated in 1980. This was the culmination of a year-long process during which I successfully applied for a Fulbright US scholarship and proposed an elective course entitled “Comprehensive Review of Obesity and Associated Disorders,” to be offered within the English language program of graduate medical education at the University of Debrecen.
The Fulbright Program was founded in 1946 and has since become one of the largest international exchange programs in the world. The program is overseen by the J. William Fulbright Foreign Scholarship Board under the sponsorship of the Department of State’s Bureau of Educational and Cultural Affairs with the support of national Fulbright commissions or foundations in most participating countries. There are more than 325,000 “Fulbrighters” who either came to the United States or, as in my case, went abroad to study, teach, and conduct research in all fields of arts, sciences, and public affairs. The Fulbright Program has had a tremendous impact on international collaboration, and many Fulbright alumni have occupied key roles in academia, industry, and government [1].
The Core US Scholar Award is one of the numerous bilateral teaching and research opportunities provided by the Fulbright Program. Between 2006 and 2014, a total of 6,631 such awards were granted, and 26 of these went to Harvard faculty members; in the current academic year alone, Harvard received ten additional scholarships. Within the 8-year period, there were 186 scholarships funded in Medical Sciences and 106 in Public and Global Health, of which 10 projects were related to various aspects of obesity and weight management. During this time, Hungary received 97 Fulbright scholars, including seven in the healthcare profession.
When I learned that the Hungarian-American Fulbright Commission would not only condone but in fact also encourage the idea of teaching a semester at my home university, I decided to apply. There was also little doubt as to the topic of the course: obesity was a clear choice based on my long-time clinical and research interest in fatty liver disease, mitochondrial bioenergetics, metabolic reprogramming of cancer cells, and other pathophysiological aspects of sustained nutrient excess. Obesity’s presence in our current society is staggering. Furthermore, its complex nature relates to most facets of medicine. This choice enabled me to take advantage of my own clinical skills and research expertise while developing an interdisciplinary teaching program.
The application guidelines asked for a syllabus proposal specifying the course agenda, educational objectives, timetable, and evaluation methods, along with two sample seminars with major teaching points and recommended literature. I submitted my application to the Fulbright Program in the summer of 2013 for a starting date in September 2014. My objective was to focus on current advances and generate as much interest in the classroom as possible. Most of the topics were strongly related to my own clinical and research expertise and have been presented at various courses many times. For the sake of comprehensiveness, I included lesser-visited titles such as neurological control of appetite regulation and metabolic surgery (Table 1). The course was deliberately designed to be different from the traditional electives, with the overarching goal of reviewing every possible aspect of obesity, from molecular biology all the way to societal implications. Obesity and its adverse health effects have become a pervasive problem in most parts of the world. Why is this trend growing? What are the long-term consequences of obesity? What can we do to prevent further escalation of the obesity epidemic? Health care professionals around the world are forced to confront these questions. Through this project, I aimed to help students understand these challenges, acquire the skills to prevent and manage adverse outcomes of obesity, and disseminate these values upon returning to their countries of origin.
The medical school at the University of Debrecen is one of four similar institutions in Hungary. There are almost 1,000 students at any given time in Debrecen who attend the English language curriculum based on the traditional 6-year structure of medical education. This has essentially doubled the number of medical students in Debrecen compared to the 1970s when I attended the school. The English program has become particularly popular after Hungary joined the European Union, in which university diplomas enjoy mutual recognition in member countries. Class sizes have grown accordingly, and the current faculty/student ratio is now less than originally envisioned. The European Union has also made a great impact on the campus by funding an unprecedented pace of development in areas such as clinical genomics and stem cell therapy.
Table 1. Agenda for Course. Comprehensive Review of Obesity and Associated Disorders.
The Department of Medicine was quite supportive of the project, creating a webpage for the course where all documents, including the syllabus, timetable, student choice papers, and 20-25 full-text articles for each topic were accessible to the students with password protection. The website was updated after each class with my handouts and the attendance records. The start was a bit slow, as many students signed up at the last minute. I did not receive official leave for my Fulbright fellowship and had to avoid contiguous absence from my workplace for extensive periods of time. Accordingly, I developed a rather complicated timetable in which we had two classes in some weeks and none in others, depending on whether I was in town or not. As a result, I traveled back and forth between Boston and Hungary four times during the semester. It was therefore a limited imitation of a sabbatical, but sticking with the convoluted classroom schedule still worked out well even with interruptions of up to 2 weeks.
In the first 2 weeks, a total of 32 students from 17 countries (Bangladesh, Belarus, Brazil, Ghana, Kenya, Malaysia, Nigeria, Norway, Iceland, Iran, Israel, Italy, Saudi Arabia, Sweden, Uganda, Ukraine, and the United States) signed up for my elective course. Most were in the fourth or fifth year of their medical curriculum. Teaching such a multiethnic group was a challenging but terrific experience. Cultural differences between representatives of various geographical areas were palpable, as Scandinavian students were generally outspoken and quite active, while those from West Africa remained more reserved and participated in the classroom discussions only if encouraged to do so.
During classes, I followed a teaching model based primarily on our GI pathophysiology seminars in the HST.120 program at Harvard. In the first hour, I gave a PowerPoint lecture on each topic followed by the students presenting their mini-seminars, 15 minutes each, about a paper selected from a list of original contributions in leading journals of the field. I ended each talk with a few “concepts recap” slides, just to reinforce the most important definitions and to give the students another opportunity for interaction with the material or further clarification if necessary. I also encouraged the students to come up with a few pieces of “obesity wisdom,” which often proved to be the focal point of our classroom discussions. It was generally understood that no matter where they were from, students would eventually face the challenges of obesity when they returned to their homeland or practice elsewhere. Thus, parallel curves of growing obesity prevalence in the US across various geographic locations, ethnicity, or socioeconomic status indicate globally similar trends and may well apply to other countries and communities [2]. All agreed that it might be just a matter of time before these curves grow sufficiently high to put obesity on the radar screen even in the leanest of countries.
Although students were initially reluctant to adopt the journal club format, ultimately, their presentations became increasingly comprehensive and elaborate. Some of them closed their talks with a cartoon relevant to the topic, a trick that I often used to boost the attention of my audience. Watching and listening to the students during these mini-seminars was perhaps the most revealing of their personal qualities and cultural diversity. The PowerPoint talks represented a wide range of skills and creativity, often defying my expectations based on prior classroom activity. Snappy, funny, and visually rich student presentations originated from every corner of the world.
There were ample opportunities for real-time teaching. Fortuitously during our course, the FDA approved a new obesity drug (naltrexone/ bupro-pion), and the glucagon-like peptide 1 receptor agonist liraglutide was slated for approval to treat obesity shortly thereafter [3,4]. In addition, the city of Berkeley passed the first soda tax in the US [5]. We monitored the weekly blog of Dr. David Allison from the University of Alabama compiling recently published articles and news pieces about obesity [6], watched a video on weight bias of health care workers produced by the Rudd Center for Food Policy and Obesity of Yale University [7], and watched a YouTube edition of the plenary talk by Drs. Steven Woloshin and Lisa Schwartz from Dartmouth College on the risk of over-diagnosis in medicine [8]. We spent time discussing the risks and benefits of having an enormous amount of information about obesity on the Internet and the challenges of filtering this information for our patients and ourselves.
In the final class, we spent an hour on informal student feedback, discussing what the students liked and disliked most about the course. This was probably the liveliest conversation of the entire semester. To my great relief, no one criticized or complained about my hectic timetable. The students primarily appreciated the multidisciplinary nature of the course in which we combined bench research findings with advances in medicine, surgery, and health care policy. This stood in contrast to their other courses, whose structure was more rigid. They also enjoyed discussing the latest advances rather than having a textbook-style recapitulation of what is known about obesity. The best reward was that the students asked if I was planning to teach another elective in the next academic year, and if so, they promised to sign up without hesitation.
Regrettably, even if I could qualify for a Fulbright award the second time, my vacation leave balance would not accommodate such an ambitious plan in the foreseeable future. Therefore, I will have to return to the earlier routine of giving lectures and seminars ad hoc whenever I have a chance to visit the medical school in Debrecen. The course has taught me many things of which I will also benefit when teaching at HMS. Finally, I understand now much better why there are so few of us in the medical profession who may benefit from the rewarding experience of a Fulbright scholarship, which requires a time commitment difficult to meet. Nevertheless, it is a challenge worth trying.
The Fulbright Program can be accessed via http://www.cies.org, which provides an overview of the grant opportunities and accepts applications.
REFERENCES
(2014) US Department of State Bureau of Educational and Cultural Affairs. The Fulbright program. Retrieved from http://eca.state.gov/fulbright/about-fulbright/j-william-fulbright-foreign-scholarship-board-ffsb.
Sturm R, An R (2014) Obesity and economic environments. CA Cancer J Clin 64:337-50.
US Food and Drug Administration (2014) FDA approves weight-management drug Contrave. Retrieved from http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm413896.htm.
US Food and Drug Administration (2014) FDA approves weight-management drug Saxenda. Retrieved from http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm427913.htm.
Isidore C (2014) CNN Money. New Berkeley soda tax costs 68 cents per two liter bottle. Retrieved from http://money.cnn.com/2014/11/05/news/economy/berkeley-soda-tax/.
Allison DB (2015) Obesity and energetics offerings. University of Alabama. Retrieved from http://www.obesityandenergetics.org/.
(2013) The Rudd Center for Food Policy & Obesity at Yale University. Videos exposing weight bias. Retrieved from http://www.yaleruddcenter.org/what_we_do.aspx?id=254ity.
Woloshin S, Schwartz L (2013) Preventing Overdiagnosis: Winding back the harms of too much medicine. Dartmouth College. Retrieved from http://www.youtube.com/watch?v=nvhs10XnsoI.