Arch Iranian Med 2009; 12 (1): 87 – 92

History of Contemporary Medicine

Shiraz University School of Medicine: Its Foundation and Development

Khosrow Nasr MD•*

Abstract members. Then, there was little to no up to date The history of University School of scientific literature in . This Medicine (the former Pahlavi University School of decision, enforced by Dr. Ghorban and the faculty Medicine) is important if we are to understand the members, allowed access to recent scientific development of medical education in during the th information at the same time that it allowed 20 century. This took a unique path to its development including full-time faculty recruitment of more up to date faculty members members, use of English as its institutional fluent in English. English, as the institutional language, and emphasis on self learning. However, language, therefore, became an important pillar of the most important of all is that it applied scientific Shiraz School of Medicine. method and modern knowledge to the problems of Iran and that it emphasized the importance of Another important pillar was the development relevance of medical education to the problems of of a modern and well-equipped hospital—the the region. Nemazee Hospital, which eventually became a This article summarizes the foundation and major teaching hospital of Shiraz Medical School. process of development of this school, emphasizing Haj Mohammad Nemazee, the founder of this its unique features. This is not the history of hospital, initially wanted to buy and bring a 25-bed individuals who were critical to its development. Nor a history of structures and buildings. Rather, it is World War II prefabricated hospital to Shiraz. the story of its intellectual development, and its Then, he was living in the . He process of change as the University became contacted Dr. Torab Mehra, a US-trained Iranian relevant. who had a strong commitment to the care of the poor and the underserved populations. With Keywords: Medical School ● Shiraz Mehra’s input, the Nemazee project grew up into a 250-bed hospital. What was the most impressive The foundation of Shiraz School of Medicine was the planning that went into this project. This was 1948 and for those who remember, water was he medical school in Shiraz was being brought into homes in buckets and established in 1952 by Dr. Zabih “doroshkeh” (carriage) was still the major mode of TGhorban (1903 – 2006), a graduate of public transportation. Haj Mohammad Nemazee, American University of Beirut. From the inception, with the help of Dr. Torab-Mehra, established the it was based on a unique foundation, making it Iran Foundation to implement the Nemazee different immediately from other medical schools project. This foundation was overseen by a board in Iran. Established as a medical school in 1952, that included some of the most prominent Iranians the most unique characteristic of this new in the US as well as selected American institution was the selection of English as its academicians such as then the Chairman of institutional language. This immediately opened a Pediatrics of Harvard Medical School and a larger scientific world to students and faculty prominent surgeon from Columbia College of Physicians and Surgeons. A review of the minutes Author’s affiliation: *Capitol Gastroenterology, Roseville, from the Board’s meetings shows that they California, USA. followed a very scientific approach to the •Corresponding author and reprints: Khosrow Nasr MD, 4 Medical Plaza Drive, #205 Roseville, California, 95661, USA. development of Nemazee Hospital. This is best Tel: +1+916-773-6200; Fax: +1-916-782-8483 seen in the decisions to start the school of nursing E-mail: [email protected] and to build housing for physicians prior to Accepted for publication: 24 September 2008

Archives of Iranian Medicine, Volume 12, Number 1, January 2009 87 Shiraz University School of Medicine building of the hospital. Planning extended beyond These faculty members were not only competent just the facility to the training or hiring of clinical but also highly dedicated to teaching. These young as well as administrative personnel for the hospital. energetic full-time faculty members became This was truly very unique for the post-World War another important pillar of Shiraz University. II period in Iran. The physician staffs were initially The fifth pillar was Shiraz, the City itself. selected from the prominent US faculty or from Shiraz was not only an attractive city, but it also Iranians who were trained in outstanding programs openly welcomed non-Shirazis. Very few Iranian in England or the US. Although it initially only cities at that time had this welcoming attitude offered a one-year internship, over time, this first toward outsiders, including foreigners. Some came rate modern medical facility became a major to Shiraz and stayed a few weeks to many years. It training site for the school. Through this affiliation, is difficult to define what it was that made this city Nemazee Hospital became the second pillar of so attractive. Was it the poetry, the gardens, or the Shiraz Medical School. history? Whatever it was, Shiraz had it. The third pillar was the bylaws that were The last pillar were the students. They were not enacted with establishment of the former Pahlavi only smart, but also willing to accept change. They University. This related to the desire in Iran to were enthusiastic about learning and were able to establish or promote one of its existing universities keep up with all the educational challenges that into a great regional university. A committee of came their way. international experts recommended the selection of These were the major pillars that shaped this Shiraz University, partly because of its unique School of Medicine. But all did not go smoothly. medical institutions. For this purpose, the For example, the physicians at Nemazee Hospital committee also recommended that this institution wished to keep their independence while the become affiliated to a major university in the US, University was set to bring Nemazee Hospital into namely University of Pennsylvania. Establishment the University system. Those involved in this of the former Pahlavi University also required “battle” were some of the very best physicians in development of new bylaws, essential for such a Iran, and unfortunately some left Shiraz. modern University. Amongst the bylaws was the requirement that all the faculty members be full- Development and achievements (1968 – 1979) time, a truly new concept for Iranian universities. It was during this period that I came to Shiraz. The full-time system was created to allow the ………………, The development in this period faculty members to dedicate their full attention to was the product of not a single individual but a teaching and research while providing care to group of people who had been there before and patients. It was hoped that this full-time scheme during this period. Therefore, any credit should go would also allow the faculty members to focus on to all the faculty. For this reason, I have decided the development of the University, becoming the not to name anyone in this paper. When I arrived instrument of change so critical to the creation of in Shiraz, similar to others, I immediately felt an excellent educational institution. comfortable in the city, the medical school, and Following creation of the former Pahlavi especially the Department of Medicine. The University, Nemazee Hospital became Department of Medicine had a small but highly incorporated in the Shiraz School of Medicine. competent faculty members, but very few This, however, was not without a fight. Although residents. The patient floors were managed by Namazi Hospital was supported by the income externs and interns. My first year in Shiraz generated from Shiraz waterworks, it was unable to happened to be the odd year with only 16 or 17 support itself financially and, therefore, depended interns. I remember that on my first rotation as an on the subsidy from the government. attending, I was caring for nearly 25 patients with Government’s continued financial support was only one extern. But, all the right ingredients were conditional on the Nemazee Hospital becoming there. We, the faculty of the Department of integrated with the University. Despite some Medicine, agreed to focus on creating an strong opposition, this was finally accomplished educational organization that would serve the creating an alliance between a world class hospital mission of the department. Included were morning and a newly-organized medical school with reports at 7:00 AM to review patients admitted progressive bylaws. This alliance attracted some of overnight, weekly grand rounds and, other the best trained Iranian physicians and scientists. organized teaching conferences. We were aware

88 Archives of Iranian Medicine, Volume 12, Number 1, January 2009 K. Nasr that Iranian physicians had traditionally preferred unique solution which evolved through extensive the surgical specialties, making a career in internal discussions in faculty forums. Our major potential medicine less attractive. But, we felt, perhaps source of income was Namazi Hospital which correctly, that internal medicine must take the lead cared for a large number of paying or insured in innovations in medical education. This meant patients. The physician’s fee system was based on that we had to first develop an excellent residency sharing the total clinical income among all clinical program. Over the next few years, with recruitment faculties independent of their site of practice. The of several outstanding faculties, the Department system recognized a difference in income between was able to build strong educational foundations. surgical and medical specialties allowing 3:2 ratios Among this group of faculty members were the between them. This allowed calculation of total new chair and associate chairs of the Department clinical income for each department. Each depart- who became a major force in the development of ment was empowered to divide its clinical income the medical school. Within 10 years, the amongst its faculty based on an internal formula. Department developed an impressive educational For example, if a faculty member wished to program for training of residents and students. commit more time to research compared to another This allowed the Department to become the “Core faculty who spent more time in clinical activities, Educational Department” leading the educational the department could credit them differently and innovations at the medical school. These changes take into account the total activity of each faculty were the main reason that for the first time we had regardless of the money generated by clinical a turnaround in students going abroad for their activity of each. Similar credit for clinical activity residency training with some of the best choosing was given to activities in Saadi and Namazi to remain in Iran. At the same time, other clinical Hospitals, although Nemazee Hospital was where departments moved along similar lines developing the money was being generated. This allowed us to excellent training programs. The dramatic continue to provide care to the poor at Saadi improvement in the residency programs reflected Hospital without punishing the faculty who the overall improvement in the quality of the provided this care. This physician’s fee system departments in the medical school. This could not saved our full-time program. It nearly doubled the have happened without the full-time system. income of clinicians, decreasing the rate of faculty Although the full-time system was relatively departures while making us more competitive in successful, it faced a major challenge in early recruiting new faculty members. I should add that 1970’s. This was the beginning of a financial boom the physician’s fee system also improved the in Iran resulting in a rapid increase in spending in financial well-being of Nemazee Hospital. the healthcare sector. This included availability of Furthermore, this program, as well as many government-sponsored or private health insurance other innovative programs, could not have been to a large sector of the population. This resulted in implemented without the strong support of the a marked increase, as much as tenfold, in the university Chancellor and Vice Chancellor. The income of physicians working in the private sector. physician’s fee was strongly opposed by the The increase in salary of full-time faculty members Ministry in Tehran. But, we were able to was, however, much more modest. Therefore, a successfully establish it because the Shiraz good number of clinical faculties left the University leadership recognized that the full-time University for private practice in Tehran or Shiraz. system was essential to the development of a great This loss was compounded by our inability to university. We needed the full-time system and the successfully compete with the private sector or full-time system needed the physician’s fee other medical schools in recruiting new faculty program to survive. members. One obvious solution was to abandon Another creative project program was the the full-time system and accept the part-time development of a visiting professorship program to scheme used in other medical schools by allowing complement our relatively small faculty. At any the clinical faculty members to enter private one time there were up to 12 outstanding visiting practice in Shiraz. This, we felt, would have professors working in our medical school. Each destroyed the medical school as we knew it. visiting professor was paid a base salary similar to Therefore, a unique system, the so-called our own faculty, approximately 2000 U.S. dollars a “physician’s fee” system was created. I will month. We also provided a small furnished present details of this program because it was a apartment in the Nemazee compound and access to

Archives of Iranian Medicine, Volume 12, Number 1, January 2009 89 Shiraz University School of Medicine the Hospital canteen at no charge. We, however, tion (WHO) as a WHO Regional Teacher Center did not pay for their travel cost. Through this for the Middle East and Eastern Mediterranean program we were able to attract some of the most Region. At that time, there were six such centers in renowned physician scientists from all over the the world and to the best of my knowledge the world, primarily from the US and England. The center in Shiraz was the only one which has been visiting professors made rounds, gave lectures, and considered “successful.” One of our faculty spent time with our students and residents. Each members spent a year and obtained masters in became a long-term resource for our development. education at the University of Illinois. In addition, They all loved their experience in Shiraz and eight other faculty members completed a one- encouraged others to take advantage of this month training at the same institution. The program. Their experience in Shiraz, working side- objective of our center was to train faculty to by-side with our own faculty coupled with their become better teachers, changing their focus from evaluation of our program gave a sense of topic to relevant clinical problems and from confidence to our residents and students about the teaching to learning. We developed training quality of the training they were receiving in workshops for not only our faculty but for faculty Shiraz. members from over 20 countries in the Middle As stated previously, we felt that a strong East and Eastern Mediterranean Region. In residency program was essential to the addition to nearly all our faculty, over 1000 faculty development of a strong department. In Shiraz, we members from this region as well as other Iranian had some of the best students but they preferred to medical schools attended our workshops, including go abroad, often joining training programs in small those on educational planning. community hospitals in the U.S. In reality, the This process initiated a dialogue among our residency program in many departments were own faculty regarding the pedagogical principles weak despite the presence of a small number of of medical education. This discussion resulted in excellent and highly dedicated faculties. But, as the the development of objective-driven teaching units residency programs in these departments improved with and evaluation reflecting these same over time, more students selected to stay in Shiraz objectives. Since we were training physicians for for further training. One program that helped patient care, the emphasis was to discuss real greatly was a unique faculty development program. problems presented by real patients. We moved Through this program a resident would spend three away from didactic teaching and our exams years in Shiraz and then would be sent to selected became problem-based using simulation of actual centers abroad for more specialized training, clinical problems. This approach changed all lasting two to three years. They were supported aspects of our educational programs. This through continuation of their salary which was evolutionary change also helped us recognize that often supplemented by funds from the host medical schools should not be ivory towers institution. These residents were therefore able to separate from societal realities but rather should enter outstanding programs which were partly define their objectives in relation to these realities. established through the strong support of many of This meant that our medical school had to identify our visiting professors. Through this program our and solve the problems of the region, i.e., Fars residency training improved tremendously. We had Province, by training the healthcare personnel for now taken a major step to become a modern this region. It was evident to us that responsible progressive medical school, designing and organizations, such as Ministry of Health and the planning for our future development and growth. Red Crescent (formerly Red Lion and Sun), had By 1979, there were 40 such residents in our not been successful in responding to the health faculty development program, all in outstanding needs of the region. Thus, by default our medical institutions abroad. One distinguishing element of school had the responsibility to help find solutions this program was that the training was at a to this enormous problem. This moved us subspecialty level; this did not allow our residents increasingly away from the western university to sit for their specialty boards and practice in the model that had served as our initial model. This host country. sense of responsibility led us to develop a variety Another event that had a significant impact on of programs. Our Department of Community our educational programs was selection of Shiraz Medicine developed programs for village health School of Medicine by the World Health Organiza- workers to train “behdar” for Iranian villages. This

90 Archives of Iranian Medicine, Volume 12, Number 1, January 2009 K. Nasr required extensive research focusing on the health students learning on their own and in small groups. needs of the people living in small villages of Fars The second tract focused on the development of and the type of healthcare worker that could clinical skills. Once again, the students were respond to this need. This included defining divided into small groups, each with a clinical competencies needed by these individuals in both preceptor. Each group were assigned selected public health and therapeutic medicine. This patients and were expected to gradually learn how program has now become the model for the health to do a complete history and physical examination. network in Iran and has been copied in other parts Using library resources, students were also of the world. expected to develop differential diagnoses and The medical school and its facilities in Shiraz management plans for each patient. The third tract became the referral center for patients from focused on public health. Each group of students southern and Central Iran as well as the countries were assigned to a village and was expected to bordering the Persian Gulf. Nemazee Hospital was improve its health status in three years. They were expanded to 600 beds with an outpatient clinic expected to identify the major public health designed to reflect its ability to provide specialized problems and develop strategies to deal with these care. Hafez Hospital, specializing in rheumatology problems. In all three tracts, the students were in and rehabilitation, joined our other two major groups of four to five with an instructor. The last teaching hospitals namely Saadi and Khalili. An three years was spent in the hospital and outpatient affiliation was also establishes with the newly clinics as well as in an assigned village. The constructed hospital called Shiraz Hospital which emphasis would not only be on patient care but belonged to the Ministry of Health. also on public health. As most graduates of Shiraz/Pahlavi Medical The major philosophy underpinning this School pursued training in highly specialized pedagogical approach was that the students under areas, there was a need to develop a different kind supervision of their preceptor, using research of medical school focusing on training of general methodology, were able to independently learn the physicians. We chose two cities, Fasa, and content knowledge and skills required to become a Mamasani (later on, Jahrom was also added) as the competent physician. This competency included sites for development of this new type of medical therapeutic competence in managing individual school. If this experiment was successful, we felt it patients as well as competence in community would allow us to train the full complements of health through with an approach to health that healthcare personnel from village- based “behvarz” would include prevention and public health. In and “behdar” to general physicians and specialists addition, most importantly, they were expected to for our region as well as potential faculty for other develop the skills to become life-long learners. It medical schools in Iran. should be noted that this approach, which now has In Fasa, we designed a unique educational become universal, was very new and was only program. We selected students with average implemented in a few centers in the world. This is scholarship scores who were chosen on the basis of why WHO considered “Fasa Project” a major interviews focusing primarily on their interest in experiment in medical education. For us, it was the medicine and their ability to handle a challenging application of all that we had learned as educators. educational program that required a great deal of Education must identify and resolve real problems. self learning. The first three years in Fasa Medical The outcome was our way of dealing with the School was organized along three parallel tracts. health challenges as we saw them in . One tract was devoted to the study of simulated We saw the solution in development of an patients, each reflecting a specific medical integrated health network from village health problem. The students were expected to do centers to the tertiary care centers in Shiraz. independent research, collect, synthesize and As the 1970’s came to an end, our medical analyze the pertinent data, and discuss their school had developed an educational program for findings with other members of their small group students and residents which inarguably surpassed (four to five students with a preceptor). The all other schools in Iran. Increasing international simulated cases were selected so that in a three recognition through our WHO-sponsored Regional year period the students were expected to develop Teacher Training Center as well as innovation in in-depth knowledge in all areas of basic sciences education in response to health needs, the former relevant to clinical problems. The emphasis was on Pahlavi Medical Congress and the former Pahlavi

Archives of Iranian Medicine, Volume 12, Number 1, January 2009 91 Shiraz University School of Medicine

Medical Journal allowed us to connect with the ideal, we felt that this was the best solution for the world of biomedical sciences on a regular basis. time. We hoped that this would strengthen the We also had begun to plan for our future needs. sense of ownership of the school by its faculty.,so We had developed an architectural plan for a major critical to development of a great university. university hospital with 900 beds and a research In summary, Shiraz presented a unique center, emphasizing highly specialized tertiary challenge to a young group of faculty who applied care. The plan for the research institute was to science to education and related education to real focus on selected areas or topics of local problems. The outcome was training of a importance, such as immunity and infectious workforce to provide primary care network from diseases, using a multispecialty approach. We the village healthcare worker to the tertiary care expected that this research institute would become through highly trained specialist in Shiraz. It is the backbone of our planned PhD programs. important to record the events that allowed one And, as we looked to the future, we also looked medical school in Iran to use limited resources to at our governance. Faculty members had to feel deal in a creative way with multiple challenges at a that they played a major role in running their unique time in our history. I hope that this history departments and school. We, therefore, put into of our school will be of some use to educators and practice the concept that the chair of each university leadership who find themselves dealing department would be selected by the dean from with similar challenges at this time. two candidates presented by the faculty’s department. Each chairman would also have Acknowledgement periodic reviews and a term limit. The same I wish to thank Asghar Rastegar MD and process was to be used for the selection of the Faramarz Ismailbeigi MD for reviewing this dean, but this was not accepted by the Ministry in article, and their most valuable comments. Tehran. Although this selection process may not be

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