BUILDING CURRICULUM CHANGE THROUGH GRADUATE DOCTOR FEEDBACK, BASED ON EXPERIENCE IN PERIPHERAL HEALTH INSTITUTIONS
Item
- Title
-
BUILDING CURRICULUM CHANGE THROUGH GRADUATE DOCTOR
FEEDBACK, BASED ON EXPERIENCE IN PERIPHERAL HEALTH
INSTITUTIONS - extracted text
-
PROJECT : STRATEGIES FOR SOCIAL RELEVANCE AND COMMUNITY
ORIENTATION IN MEDICAL EDUCATION
- Building from the Indian Experience.
BUILDING CURRICULUM CHANGE THROUGH GRADUATE DOCTOR
FEEDBACK, BASED ON EXPERIENCE IN PERIPHERAL HEALTH
INSTITUTIONS.
AN EXPLORATORY STUDY
(A CHC / CMAI / CHAI PROJECT)
Society for Community Health Awareness,
Research and Action,
3J6, V Main Road,
I Block, Koramangala,
Bangalore - 560 034.
'ne &2-t\ ^<^7^
COMMUNITY HEALTH CELL
3UILDING CURRICULUM CHANGE THROUGH
GRADUATE DOCTOR FEEDBACK,
BASED ON EXPERIENCE
IN PERIPHERAL
HEALTH INSTITUTIONS.
AN EXPLORATORY STUDY
O&l
PLEASE
NOTE
This Report of the Graduate Survey is part of the two
year Project, 'Strategies for Social Relevance and
Community Orientation in Medical Education - Building
from the Indian Experience', sponsored by CMAI and
CHAI. This is a draft manuscript. It is being rele
ased to the CMCs and a few other contacts for restricted
circulation, collective reflections and feedback, if any.
We would reguest that no part of this manuscript be
reproduced or circulated. It may however be shown to/or
referred by faculty interested in medical education to
get an idea of the key findings of the Project. It
should also not be quoted at this stage,.
Any suggestions or feedback if received by the end of
December 1992 may be incorporated into the final format
of the publication.
An abridged and edited version of the key elements of
the report will be released as a publication for wider
circulation early next year.
The report has been passed by the Project Advisory
Committee and is currently with some reviewers for an
independent peer review.
While the final publication is in the process of
evolution, we release it to all our 'peers' at this
stage in a spirit of interactive dialogue and
solidarity.
Thelma Narayan '•>
Research
November 1992
Project
Ravi Narayan
Coordinators
COMMUNITY HEALTH CELL
47/1 St. Mark's Road, Bangalore - 560 001
THIS BOOK MUST BE RETURNED BY
Tt,r DATE LAST STAMPED
"Call it by whatever name, the need is for a new
breed of physician, who has a broad understanding
of human biology, who is imbued with the
ingredients of rural and peri-urban societies and
their way of life, who can communicate effectively
with the patient's family regarding the nature of
the ailment, who can "address himself to preventive
aspects in the homes, who will be an effective
leader of health workers, and who will use his
knowledge to stimulate other community building
programmes.
We need in effect, a social biologist.
Mass public health and hospital patient care,
however well developed, cannot fill this gap".
- V. Ramalingaswami, 1968
CONTENT
LIS T
PART- A
si *
No
Page No.
Topic
1.
P reamble
1
2.
Objectives
2
3-
Methodology
2-4
4.
Limitations
4-5
5.
Findings
A. A profile of the respondents work experience
in Pills in India;
5-11
B. Feedback on the Preclinical Disciplines.
11-12
C. Feedback on the Paraclinical Disciplines.
12-13
D. Feedback on Primary Clinical Disciplines.
1 4-15
E. Feedback on Community Medicine/Preventive
and Social Medicine/Community Health.
15-16
F. Feedback on other Clinical Disciplines.
16-17
G. Feedback on other possible subjects/areas
in which training is required.
18-19
H. Feedback on other aspects of the Medical
course•
1 9-20
6.
Discussion
21-30
7.
Bibliography
31
8.
Acknowledgement s
32
9.
Appendix - I
33
PART - B
(Detailed feedbacK from respondents on the different subjects and
aspects of the undergraduate medical curriculum)
1 .
Introduction
34
2f
Table 1
35
Comments on Table 1
36-37
2
si.
N c.
3.
Topi c
Page No .
1. Pre-clinical phase (First MBBS )
Anatomy
1 .1
1.2 Physiology
Biochemistry and Biophysics
1 .3
1.4
Biostatistics
1 -5A So ciology
1 .5B Psychology
1 .6
General suggestions during the Pre-clinical
phase
k
Patho logyMi crobiology
PharmacologyForensic Medicine
44
44-45
46-47
47-48
3. Clinical Phase
3.1
3.2
3.3
3.4
3.5
3.6
3.7
3-8
3.9
3.10
3.11
3.12
3.13
3.14
6.
43
2 ._ Paraclinical Phase
2.1
2.2
2.3
2.4
5-
38
39
40
4o-4l
41-42
42
Medicine
Surgery
Obstetrics a. Gynaecology
Paediatri cs
Preventive & Social Medicine/
Community Medicine
P sychiatry
DermatologyOphthalmology
E.K.T. (Otorhinolaryngology)
RadiologyAnaesthesiology
Orthopaedics
DentistrySeveral other general suggestions
49-50
51-53
53-55
55-57
57-59
6o-6l
61-62
62-63
63-64
64-65
65 -66
06-67
67-68
68-69
4. Additional Areas / Subjects
k.1
4.2
4.3
4.4
4.5
4.6
Medical Ethics
Basic Nursing procedures
Communication skills
Management
Training of Health workers/other personnel
Other skills necessary for -work in PHIs
5 . General aspects of the Medical Course
Selection Process
5-1
5 • 2 Teaching Methodology
Curriculum structure/Time framework/
5-3
Semester break-up
Examination System
5.4
Internship Training
5.5
Methods to enhance social/emotional
5 <■ u
preparedness of Graduates for worn in PHIs
Comments on any other aspects of content,
5-7
process, environment or base of teaching
70-71
71-72
72-73
73-74
74-75
75-76
77-78
78-80
80-82
82-84
84-87
87-88
88-89
PART
A
1. PREAMBLE
Ever since the freedom movement in the country and the attainment
of national independence it has been the stated intention by
national bodies, expert committees and several medical colleges
to mould medical education to suit the specific needs and
circumstances of the majority of the population in India.
A study has been undertaken by the Community Health Cell of
Bangalore in 1990-92, to review the past four decades of Indian
experience in evolving and implementing strategies to make
Medical Education socially relevant and community oriented.
an integral part of this broader exercise r
As
was felt that it
would be important to contact medical graduates who had already
worked in peripheral health institutions (PHIs) in the country
and get their views as to how they had been prepared by their
undergraduate medical education experience for the professional
work that they had to carry’ out at the PHIs.
This aspect was undertaken as an exploratory' study and
therefore had several open-ended questions.
It was carried out
sc that broad areas could be identified that could be studied
later in greater detail, possibly by’ each of the different
disciplines as part of a process of evolving relevant
curricular change based or. data.
Thus it was done with the
hope that medical educators would take note of the findings
and develop them further.
It is an effort to link up experience
in the health services and feedback arising from involvement in
health / medical care with the system of medical education.
///////
2
2
2. OBJECTIVES
The objectives of the exploratory study were as follows:
In the context of medical practice in periferal health care
institutions in India:
a)
To elicit feedback on all the major aspects of the
undergraduate medical course;
b)
To identify in the undergraduate medical curriculum,
i) areas that were useful, relevant and adequate;
ii) areas that needed further strengthening;
iii) areas of lacunae;
iv) areas that could be reduced or deleted.
3. METHODOLOGY
3.1 Questionnaire
3.1.1 As an instrument of study a questionnaire was
developed.
The different aspects of medical
education on which it elicited feedback were:
a) all the preclinical, paraclinical and clinical
subjects, including medical ethics;
b) additional skills in patient care and hospital
work like nursing, management, communication
and training;
c) internship;
d) other related aspects like selection or admission
procedures, teaching methodology or pedagogy,
curriculum structure, examination system, base of
teaching, etc.
A total of thirty seven (37) different aspects were
covered through open ended questions.
3.1.2 Information was also collected about the respondents
work experience viz., location of the peripheral
3.
health institution, nature of medical/health
activities, type of facilities available, distance
from nearest referal centre, etc.
This was to
build up a profile of the background of work
experience based on which the feedback was being
given.
3.1.3 The design of the questionnaire, including choice
of aspects to be studied, was based on previous
experience of a workshop on Medical Education held
in 1984 for medical graduates working in PHIs.
held
a
We also
group discussion at the onset of the study
for this purpose with a group of ten medical college
teachers who had all worked in PHIs earlier. Several
other personal interactions and experiences were also
useful.
3.1.4 The questionnaire was pilot tested on 10 respondents.
Modifications were made based on this as well as on
comments by the advisory committee.
3.2 Sample
3.2.1 The criteria for the respondents were as follows:
a) That they had graduated from any Indian medical
college during the 1980's.
This was because we
wanted feedback on contemperory medical education
including any relatively recent changes.
b) That they should have completed a minimum of two
years working experience as a doctor in any
peripheral health institution in India.
This
included work in Government Primary Health Centres
or in community health programmes/small peripheral
hospitals run by Voluntary Organizations. This was
to ensure that they had first hand experience of
understanding and responding to the health needs
of people in rural areas and urban slums and had
worked for
a sufficiently long time to put their
knowledge and skills to use in these circumstances.
.4
4.
3.2.2 The sample was not statistically chosen to represent
any particular region or college.
Finding respondents
who fitted into the criteria given above was not easy
and building a sampling framework was much less so.
This was also at this stage only an exploratory
qualitative subunit of a larger study.
However we did
try and get a mix of graduates from several different
colleges.
Eligible respondents were identified from
applicants to postgraduate medical entrance exams and
from a meeting of a national group called the Medico
Friend Circle (mfc).
3.2.3 Anonymity of the individual respondent as well as the
medical college was maintained as we were wanting to
study issues in the different disciplines along with
other aspects of the undergraduate medical curriculum
and were not studying or evaluating any particular
college.
3.2.4 The questionnaire was given / sent out to 120 eligible
respondents.
Of these 78 were given out by the
researchers and the remaining through contact people.
One reminder was sent after a period of a month.
■ 4. LIMITATIONS OF THE .STUDY
The limitations of the study that must be kept in mind are:
a) the small number of respondents;
b) because of the variations in different universities and
medical colleges and the absence of a statistical sample,
generalisations cannot be made from the findings.
However
areas have been identified which can be further studied;•
c) there was little literature available on a study of this type;
d) the study was wide ranging with open ended questions.
Based
on these findings however follow up studies could have more
structured questions which can elicit responses from all
respondents on specific areas, with greater detail.
e) Most of the respondents had worked in mission/voluntary
.. 5
5
hospitals.
Only 2 were from Government PHI1s and 2 from
community health projects.
practitioners.
There were no general
These other sectors also need to be
considered in later studies.
5. FINDINGS
The number of responses received were 53 out of a total of 120
questionnaire given out i.e., the response rate was 44.16%.
In Part A of the report a
summary of findings is presented under
the following headings - (a) profile of work experience of
respondents, feedback on each of the following viz.,
(b) pre-
clinical disciplines (c) para-clinical disciplines (d) primary
clinical disciplines (e) preventive and social medicine/community
medicine (f) other clinical disciplines (g) possible additional
subjects and (h) other aspects of the curriculum.
Part B of the report gives the detailed feedback according to
each subject / aspect of the curriculum.
This is being made
available so that it can be considered by the staff of the
various Departments as they work towards continuously evolving
curricula in their respective subjects.
A. A PROFILE OF THE RESPONDENTS WORK EXPERIENCE IN PHIS IN INDIA
A summarized collation of different aspects of the work
experience of the graduates is given, as it forms the context
based on which the feedback is given.
i) Year of Graduation
The following table shows that the majority of respondents
are recent graduates. The feedback therefore relates to
current practices in medical education.
Table I'c.l : Year of graduation
SI.
No.
Year
Ko. of re spondents
1e
1970's
2 (3%)
2.
1980-84
21 (40%}
3.
1985-88
30 (57%)
6
6
ii)
Geographical location of the PHIs
The graduates have worked in a total- of 80 peripheral health
institutions which were located in 10 different States of
India and 1 Union Territory.
Table Ko.2 : Geographical distribution of PHIs
Ko.
_u_ of
PHI s
SI.
No.
26(32.5%)
Northern States
No. of
PHIs
1.
Guj arat
6(7.5%)
2.
Maharashtra
4(5%)
3.
Tamil Nadu
13(16%)
Andhra Pradesh 12(15%)
3.
Uttar Pradesh
4(5%)
4.
Karnataka
8(10%)
4.
Madhya Pradesh
2(2.5%)
5.
West Bengal
2(2.5%)
6.
Bihar
1(1%)
SI.
Ko.
- ■
.
Southern
States
1.
2.
Kerala
TOTAL:
59(73.5%)
TOTAL:
KB; There were 2 in the Andaman & Kicobar Islands.
19(23.5%)
Thus the
feedback arises from work in PHIs in different parts of
the country, though there is a predominance of experience
in the four Southern States.
The majority of the PHIs (>90% ) were located in rural areas.
iii) Years of work experience in PHIs
The respondents together represent a total of 152.4 person
years of work experience.
The average duration of work
experience per respondent was 2 years and 10 months.
However
there was a range, with most of them having worked for 24-28
months, some for 36-42 months and one respondent for a
maximum, of 132 months.
SI.
No.
Ko. of PHIs / graduate
No. of respondents
1.
Single PHI
28 (55%)
2.
Two PHIs
20 (38%)
3.
Three PHIs
4 ( 7%)
7
7.
iv) Size and nature of PHIs in which the graduates worked
According to the information provided, most of the experience
of the respondents has been at the level of providing the
secondary level of medical care.
However, they have often
been linked - sometimes in the same institution - to the
primary level of care as well.
The table below gives the
bedstrength of the institutions.
Table Ko.4 ; Bedstrength of PHIs
SI.
No.
1.
v)
No. of PHIs
Bed Strength
Less than 50 beds
52 (65%)
2.
51-100 beds
16 (20%)
3.
More than 101 beds
12 (15%)
Departments in the PHIs
The following two tables shew the number of Departments per
PHI and the frequency of the different types of Departments.
Table Ko.5 : Number of Departments per PHI
N ’
No. of Departments
1.
No Department
2 (3%)
Community Health Project
2.
1 Department
2 Departments
41 (51%)
Mainly general
11 (14%) I
11 (14%) |
These were various
No. of PHIs
3.
4.
3 Departments
5.
4 Departments
6.
5 Departments
6 (7.5%)I
1 (1%)
|
7.
6-10 Departments
7 (8.7%)
8.
More than 11 Depart
ments
1 (1%)
Comments
combinations of General
Medicine, Obstetrics &
Gynaecology, Surgery
and Paediatrics.
65% of the respondents were functioning in PHIs with 1 or 2
Departments (mainly general and Obg/Gyn) and therefore had to
take care of problems of ill health relating to all the different
sukjects/departments.
PHIs with more than 3 Departments had
additional doctors working who were more experienced/had post
graduate qualifications.
. .8
8.
Table No. 6 : Departments present in PHIs
SI.
No.
Department
No. of PHIs
1.
General admission ward only
38 (47.5%)
2.
General admission Department +
additional Departments
10 (12.5%)
3.
4.
Obstetrics & Gynaecology
29 (36%)
Surgery
25 (31%)
5.
Medicine
24 (30%)
6.
Paediatrics
20 (25%)
7.
Ophthalmology
7 (8.9%)
8.
Leprosy
4 (5%)
N.B: a) General admission wards admit a variety of cases.
b) Other Departments were uncommon viz., ENT - 3(4%),
Orthopaedics - 2(2.5%), Psychiatry - 2(2.5%),
Dermatology - 2 (2.5%), Community Health Department-2(2.5%)
Epidemiology - 2(2.5%).
The last Department was present
in
institutions also involved with research in leprosy
and TB.
Thus it can be seen that approximately 25% of PHIs have the four
primary clinical specialities most often with post graduate
doctors.
For the rest the young graduate has to handle these cases
vi) Number of doctors available in the PHIs
The following table indicates the availability of doctors
(including the respondents) in the PHIs.
Table No. 7 : Number of doctors per PHI
N.E: *The respondents functioned as a single doctor.
9
9
vii)
Diagnostic facilities available in PHIs
The following table indicates the type and frequency of
investigative facilities in the 80 PHIs.
Table Ko.8 : Type of Diagnostic facilities in PHIs
SI.
No.
Diagnostic facility
No. of PHI
3 (4%)
Nil
1.
Simple labs (for routine
investigations)
24 (30%)
3.
Simple labs + X-ray machines*
35 (44%)
4.
More sophisticated labs +
X-ray machines
3 (4%)
Simple labs -r X-ray machines +
ECG equipment
10 (1'2.5%)
6.
all 3 above + ultrasounds
2 (2.5%)
7.
all 4 above + endoscopy
3 (4%)
2.
5.
K.B: * Two of these had screening facilities only.
Majority of the graduates had to carryout/supervise and
interpret simple laboratory investigations and plain
X-rays at the minimum.
Categories 2 and 3 which account for 75% of the PHIs
may not have specially trained staff to handle the
diagnostic facilities.
Doctors are required to provide
some technical support to their functioning.
viii) Average work load in the PHIs
The next two tables give the average number of out patients/
day and inpatient admissions/day according to the size of the PHIs.
Table No.9 : Outpatient seen per day in PHIs
SI.
No.
Bed Strength
1.
Less than 30 beds
35
Average No. of
outpatients/dav
49 / day
2.
31-50 beds
17
85 / day
3. .
4.
51-100 beds
16
115 / day
More than 100 beds
12
207 / day
No. of PHIs
The larger institutions had a proportionately larger number of
doctors.
day.
On a rough average each doctor sees about 25 patients/
iu.
1•
Less than 30 beds
2.
31-50 beds
3 / day
12 / day
3.
4.
51-100 beds
17 / day
More than .100 beds
25 / day
o
Bed Strength
’
X tn
Table No. 10 : Inpatient admissions / day in PHIs
Average No. of admissions
Per dav
N.B: This question was asked to 43 respondents only.
The next table shows the number and nature of community level
programmes in the PHIs.
Table No. 11 : Community level programmes in PHIs
SI.
No.
1.
Community Health Programmes *
48 (60=%)
2.
TB control programmes
24 (30=4)
3.
4.
Leprosy control programmes
19 (24%)
7 (11%)
Type of programme
Programmes for the disabled
No. of PHIs
* Host of these included Mother and Child Health Programmes.
Some' also mentioned Health Education and Nutrition programmes
and the running of clinics at outposts.
The three preceding tables indicate that the respondents have
gained a fair degree of experience of hospital/health centre
based medical work es well as of involvement ir. community level
health work.
ix) Nearest Referral Facility
The following table indicates the distance in kilometers to the
nearest referral facility.
Table No. 12 : Nearest referral facility to the PHIs
SI.
No.
Distance in Kms.
No. of PHIs
1.
Less than 12 kms
24 (30%)
2.
13-25 kms.
15 (19%)
3.
26-50 kms.
21 (26%)
4.
51-100 kms.
11 (14%
5.
More than 100 kms.
4 (5%)
__
N.B: 5 respondents did not answer this question.
Forty five per cent
had the nearest referral centre more than 25 kms. awav.
In conclusion the profile reveals that the feedback given by the
respondents arises from e wide range of experience in peri feral
health care, some of the important characteristics of which were:
- it relates to medical education of the 1980‘s;
- the work experience was largely in South India;
- it was predominantly rural based;
- it was at the level of provision of a secondary level of medical
care in institutions of varied size.
They were most often linked
to community health programmes and to the primary level of cere
as well.
Thus the respondents have lived out for a minimum of 2 years
the
larger goal of medical education as enunciated by various expert
committees, namely of being basic doctors catering to the health
problems of the majority rural Indian population.
medical education given by
The feedback on
them according to the different subjects/
phases is therefore based on this first hand, recent work
experience.
This is probably the most important qualifying aspect
of the respondent group.
We are sure the findings will be
considered seriously by medical educators.
FEEDBACK OK THE PRECLINICAL DISCIPLINES
The main points that have emerged pertaining to this phase are :
i) There is a need to have a strong clinical orientation
throughout this phase - to relate and ccmnare the
normal to the abnormal, with the areas of clinical
importance to be chosen according to the commonly
prevalent problems in this country’, particularly those
seen in PHI's.
ii) The need to develop practical skills even at this stage.
iii) The need to integrate teaching between the pre-clinical
subjects and also with the clinical subjects.
The focus
of the teaching to be the clinical problems that occur
commonly.
iv) To reduce the time period alloted to this phase of the
undergraduate medical course from
year to 1 year, by
deleting unnecessary’ detail in all 3 subjects and
12
reducing the time spent ir. Anatomy.
v) The need to introduce/srrengthen the teaching of
psychology during this phase was almost unanimous.
vi) The need to introduce/strengthen the teaching of
sociology was also expressed.
This should be to enhance
the understanding of the situation in India, particularly
in rural areas.
vii) The need to introduce the students to patient care in
the wards particularly for the learning of skills in basic
nursing procedures at this stage of the course.
This
could be done during the extra time gained by pruning some
of the 3 basic preclinical subjects.
viii) Biostatistics in general does not seem to have made an
impact on the students and perhaps needs a review and
building on the positive experience of colleges like
CMC-Vellore.
ix) The need to
reinforce the teaching of some of the
preclinical subjects during the clinical years.
x) The need to develop healthy attitudes, life styles, and
values including medical ethics during this stage of the
students life.
C. FEEDBACK ON THE PARA CLINICAL DISCIPLINES
A summary of the main responses tc the 3 major subjects covered
in this phase viz., Pathology including Microbiology,
Pharmacology and Forensic Medicine are as follows:
i) The need to focus on clinical and practical application
was again stressed, viz., to place greater emphasis on
clinical pathology and clinical pharmacology.
ii) In Pathology, there is a need to be proficient in
carrying out and interpreting routine investigations in
clinical pathology since diagnostic laboratory facilities
and pathologists are not available in rural areas.
13.
iii) The need to be skilled in blood banking procedures.
iv) The ability to support and supervise technical staff
in laboratories.
v) In pharmacology, to focus on: commonly and currently
used drugs; on drug use in pregnancy, lactation, and
in the paediatric age group; drug interactions; rational
therapeutics; cost effectiveness of drugs; knowledge of
trade names and drug companies; along with the need for
frequent continuing education because of the rapid
developments in this field.
vi) Both these subjects to be taught
also in the wards and
along with clinical teachers around the medical problems
of patients.
vii) The need to reduce unnecessary’ detail in both subjects
e.g., detailed histopathology of uncommon disease in
systematic pathology, and in pharmacology drugs not
currently in use, making of mixtures, experimental
pharmacology etc.
viii) Need to introduce postings in the hospital pathology lab
and blood bank, participation in blood donation camps
postings in final year and internship, analysis and
discussion on prescriptions.
ix) The need to know how to organize and run a simple
pharmacy was mentioned in a later section.
x) The need to enhance the teaching of Forensic Medicine
was strongly expressed by respondents as many aspects
were particularly relevant to practice in PHI's.
Important areas were medico legal aspects of consumption
of poisons, snake bites, accidents, injuries.
The
ability to certify wounds, certify deaths and the cause
of death, and to conduct medico legal autopsies was also
necessary.
It was felt that this aspect of medical
practice was becoming increasingly important, in which
students need a better grounding so that they can
function more responsibly and securely.
14
D. FEEDBAG?' Or PRIMARY CLINICAL DISCIPLINES
A summary of the feedback on Medicine, Surgery, Paediatrics
and Obstetrics & Gynaecology is presented here.
All four
subjects were considered to be of crucial importance to work
in PHIs, particularly Obstetrics & Gynaecology.
i) There is a need to be able to diagnose and manage
emergencies that present relating to the four areas/
disciplines.
ii) There is a need for greater development of skills relating
to all the four disciplines e.g., intubation, venesection,
lumbar puncture, minor surgical procedures,
episiotomies,
application of forceps, vaccum extractions etc.
iii) The need to develop good clinical skills and not rely on
high tech diagnostics.
iv) The need to focus on the common problem in India in all
the four disciplines, especially on how to diagnose and
manage these cases in periferal/primary health, centres
and when to refer cases.
v) Need to increase the involvement and responsibility of
students in patient care.
vi) The teaching should not be exam oriented but should focus
on clinical management of common problems.
vii) There is e need to integrate the preventive and curative
aspects of medicine and to develop a community orientation
especially in Paediatrics and Obstetrics and Gynaecology.
viii) Periferal institutions could be made use of for the
teaching of clinical subjects.
ix) There is a need to enhance the study of Paediatrics since
a large proportion of patients seen in PHIs belong to
this age group.
This could be done by giving it more time
in the curriculum, making it a separate paper, and
allotting more marks to the subject.
15.
x) Theory lectures could be reduced so also the focus on the
"unusual”, interesting, and exotic cases.
Small croup
teaching to be used with senior students working with
junior students.
The teachers to be coordinators /
■facilitators in the process.
Greater teaching in OPDs,
along with carrying out simple investigations and follow
up of patients in the wards and in the community.
FEEDBACK OK COMMUNITY MEDICINE/PREVENTIVE AND SOCIAL MEDICINE/
COMMUNITY HEALTH
The feedback regarding this subject has been considered
separately as in many colleges it is taught right from the
first year till final year and also is given 25% of the entire
internship period.
The formation/introduction of the Department
in India in the late 1950's was also one of the major strategies
towards making medical education more community oriented and
relevant.
i) There was a widely expressed need for better training in
the subject with more careful teacher selection, use of
more community based teaching, more fieldwork, use of
newer teaching methodologies, and being based in smaller
health centres during the undergraduate course/during
internship.
ii) There is a need to have experience of working in
situations where feasible programmes are functionin in
the field.
iii) There is a need to integrate the curative aspects with
PSM/CM.
Time during internship could be used to also
develop good clinical skills in PHI situations.
iv) There is a need for enhancing practical training in
health education, school health, nutrition, occupational
health, and in the training of health workers/health
guides.
16
v) There is else e need for training in management,
epidemiology and statistics - to learn to assess local
health problems and economic needs through surveys and
to evolve strategies of intervention.
vi) There is e need to establish special cells in the
Department to maintain a link with doctors working in
PHIs/those doing rural service, and to respond to their
needs.
vii) Many of the present methods of teaching/approach need to
be rethought/dropped.
viii) The Department could provide a lead in the community
orientation of medical education, however this can be
done only by committed staff.
F. FEEDBACK ON OTHER CLINICAL DISCIPLINES
A summary of responses to Psychiatry, Dermatology, Ophthalmology,
ENT, Radiology, Anaesthesiology, Orthopaedics and Dentistry
s-
follows:
i) It was generally felt that the concept of these subjects
being considered "short postings" and relatively
unimportant should be changed.
Medical problems relating
to all the above areas are fairly commonly seen in PHI
practice.
ii) The majority felt that Psychiatry’ needs to be given
greater importance with more working hours, a 3 month
posting and a separate paper.
Doctors need to be able to
identify and manage common psychiatric problems, to have
a definite knowledge about serious disorders, to '
understand associated psychological factors in psychosomatic
and somatic illness and to receive some training in
counselling.
iii) Dermatology was also considered to be important, requiring
longer and more adequate training.
Focus should be on
proper management of common skin disorders and Hansen's
Disease.
it.
iv) While several felt that the training in Ophthalmology
was sufficient for practice in PHIs, the suggestions
were that focus could be on management of common
conditions eg., infections, like conjunctuvitis and
trachoma, Vit.A deficiency, trauma to the eye including
removal of foreign bodies, cataract and evaluation of
vision.
v) Several respondents felt that the training in ENT was
adequate.
Important areas commonly encountered were
problems in children viz., rhinitis, tonsillitis and
otitis media; management of epistaxis; removal of
foreign bodies from the ear and nose; and removal of
ear wax.
vi) In Radiology, it was felt necessary to be proficient in
the reading of plain X-rays of the chest, abdomen and of
different types of fractures and also in screening.
In
some PHIs it was necessary to take and develop films
and to handle X-ray equipment.
vii) In Anaesthesiology it was considered important to be
trained in giving local anaesthesia, regional nerve
blocks and spinal anaesthesia so that minor and emergency
surgical procedures could be performed.
It is also
necessary to develop skills in intubation, ventilation
and resuscitation.
viii) Orthopaedics was found to be very important in PHI
practice.
There is a need to be trained in first aid and
trauma care and in closed reduction of fractures and
application of plaster of Paris casts.
ix) Due to the lack of dentists/trainec paramedics it was
often necessary for doctors to attend to dental problems.
Therefore it was felt that training in management of
common dental conditions was necessary eg., simple tooth
extractions, dental caries, pyorrhoea and abscesses.
18.
G. FEEDBACK ON OTHER POSSIBLE SUBJECTS/AREAS IN WHICH TRAINING IS
REQUIRED
Several interesting suggestions came up in this section.
i) Practice and training in medical ethics needs to be
improved.
It should be e lived experiences in daily life,
where students learn by seeing what their teachers practice.
It is particularly important since there is a general
decline of values in society.
Areas suggested for inclusion
in addition to the usual ones were: treating the poor,
rational therapeutics, choice of investigations and drugs,
not exploiting the ignorance of people, having a human
approach, right to information etc.
ii) The following areas were again emphasised:
ability to provide first aid and emergency medical care;
skill in performing various procedures;
need to focus on common health problems.
iii) There is a need to have an orientation/introduction to
other systems of medicine practised in India eg., Ayurveda,
Homeopathy, Unani, Siddha, local health practices.
iv) To have a few sessions on the different religious
scriptures and their positive features regarding health
eg., the Gita and Koran on health etc.
v) There is a need to impart the concept of 'Holistic Health1
to students.
vi) A majority of respondents felt that there was a need to
develop skills in - basic nursing procedures during
wardwork in the preclinical and clinical years with perhaps
a 3-6 month posting for this.
vii) The need to develop adequate communication skills for
interaction with patients, relatives, the community, and
also with nurses and other colleagues/team members.
viii) For work in PHIs it is necessary to have knowledge and
ability in various aspects of management/administration.
19
ix) A need was expressed for personality development and
leadership skills.
x) There was also a need expressed by a majority be able to
develop some skills in training other health personnel
as it was often necessary for them to provide inputs/
support in training and continuing education of nurses,
lab technicians, multipurpose health workers, village
health workers etc.
FEEDBACK OK OTHER ASPECTS OF THE MEDICAL COURSE
This section includes comments on the selection process,
teaching methodology, curriculum structure, examination system,
internship period, methods to enhance the social and emotional
preparedness of graduates for community work, and comments on
the base of teaching, the educational process and environment.
A summary’ is given here:
i) Among the several attributes to the considered during the
selection process, it was felt that for work in PHIs
students should be older and more mature.
Besides
academic merit and involvement in extra curricular
activities, one should look for aptitude, service
orientation, commitment, dedication, ability to work hard,
ability to undergo hardships, ability to sacrifice social
life, and preparedness to work with the rural poor.
ii) Regarding teaching methodology’, along with a reduction of
lectures it was suggested that teaching should be problem'
oriented with focus on the patient, the community’ and the
common problems of India.
The need for an increased use
of demonstrations and practicals; greater use of audio
visual aids; and more clinics and ward work was expressed
by7 many.
There is a need for integrated teaching which
should not be exam oriented.
The need to have good
teachers was also considered very important.
20
iii) Ar. integrated course in human biology for a period of
one year could replace the present compartmentalised/
departmentalised one and a half year first MBBS course.
The semester system was found useful.
The last
year could be devoted to the study of the
four primary clinical subjects exclusively.
iv) Several respondents felt that the present examination
system was subjective, unrealiable, biased, outdated,
irrelevant to actual practice, corrupt and unethical.
Suggestions included the need to have a continuous system;
of assessment, and to use multiple choice questions and
short objective questions for theory exams.
In the
practical or clinical exams the focus should be problem
oriented, on the approach to diagnosis and management
regarding common diseases, how one would respond in
emergencies etc.
Use could be made of 10-15 short cases
with an attempt during the case discussion to assess
whether the student has acquired the necessary basic
knowledge and skill.
v) The internship period was considered to be very important.
There is a need to enhance decision making capacity, skill
acquisition, patient care responsibility and ability to
manage emergencies.
Compulsory postings could be introduced in casualty,
orthopaedics, radiology and dermatology as part of the
major surgery and medicine postings.
Rural posting could
be in small hospital/health centres.
Discussions on problems of medical ethics to be also
introduced here.
vi) It would be useful to have talks during the undergraduate
course by doctors who have worked in / are presently
working in rural areas / areas of need.
21.
6. DISCUSSION
A. There heve been a few studies done previously in Indie,
where feedback has been elicited from medical students and
interns on the curriculum structure and design (4,5,7,9,10).
Some have looked at the career options of students/graduates.
Others have studied aspects that are different but useful
in the context of community orientation of Medical Education.
A brief summary of the key findings of these studies are now
given.
i) Goal s
In a study by Swain (1978) of final year medical students
in Orissa, “more than 75 per cent of the respondents
suggested that the curriculum be designed to produce a
basic doctor, only 11.4 per cent for a specialist and
10.6 per cent for a scientist".
The study also quoted
the 1971 Conference on Medical Education in Delhi, which
recommended that even' medical college should have a
standing curriculum committee.
This committee should be
active and incorporate changes from time to time
depending on national and community needs.
ii) Teaching Methodology
A study (Clausen, 1970) of 375 medical students in
Karnataka, conducted by a medical student, revealed that
only 0.5 per cent favoured "large lecture classes" as a
learning technique.
Another study of 620 medical
students by Gupra and Patel (1973) in Gujarat found that
learning through small tutorials was preferred to
didactic lectures.
Three-fourth of the students wanted
provision for elective studies.
In a study by Varma and
Varma (1970) in Uttar Pradesh, 95 per cent of students
felt that teachers must know their subject well and also
use interesting teaching methods.
Several felt that
they should maintain friendly relations with students.
In a study by Rajanna, Shivaram et al (1984) in
3) Xi 13 *-•(
COMMUNITY HEALTH CELL
326, V Main, I Slock
Koramangala
Bangalore-56Uw34
22
Karnataka, students preferred clinics and practical
demonstration rather than lectures and seminars.
Thev
suggested that ar. increased use of teaching aids, particularly
They also preferred the use
films and slides would be good.
of more than one method of teaching.
Thus all studies over a
period of two decades are consistent about student preference
for clinics, demonstrations, tutorials, discussions etc., and
.creative use of audiovisual
on the need for greater and more
aids.
The need for reduction of lectures tc the minimum has
also been a repeated suggestion.
iii) Examinations and other aspects
The study by Clausen indicated the need for correlation and
integration of teaching between the pre-clinical subjects and
also the need tc link this knowledge to patient management.
Students felt that Community Health should be incorporated as
a subject during the entire training and that the examination
system needed to be revised.
The study by Gupta and Patel showed that the present syst&m of
examinations was disliked by nearly three-fourth of the
students and almost 90 per cent preferred multiple choice
questions to essay type questions.
About 80 per cent preferred
the semester system to annual assessment.
The Varma study found that 47.5 per cent of faculty members
were unwilling to participate in rural programmes. These
were mostly senior members with postgraduate qualifications.
Several aspects of feedback regarding teaching methodology
and the examination system are similar to that given by
respondents in our study.
iv) Subject Preference
The study by Raj anna, Shivaram et al, found that "Medicine was
the subject liked most by students, irrespective of the year
of study, followed by surgery.
Forensic Medicine, Bio-chemistry
23.-
Preventive and Social Medicine and Anatomy were the subjects
disliked by the students".
iv) Career Options
Regarding future career options,in the study by Swain, 80
per cent of students wanted to proceed for postgraduate
training in India or abroad immediately after internship.
However as their ultimate goal, 33 per cent wanted to work in
the government health services, 34 per cent (particularly
.ladies) preferred to work in a medical college, and 24 per cent
wanted to start private practice.
The study by Varma and Varma
quotes a study by Singh in 1968 in which 89.8 per cent of
interns were willing to work in rural areas provided certain
facilities were available to them.
Gupta and Patel found that
about half the students desired to join government service and
nearly 40 per cent planned to work in private hospitals.
Very
few thought of taking research or teaching as a career.
Even
though nearly 80 per cent wished to go abroad, only 1.04 per
cent desired to settle permanently in a foreign country.
In
case of need, about 80 per cent were willing to volunteer to
serve in rural areas.
They gave various suggestions as
incentives to attract doctors to rural areas, namely increased
salary’, facilities for education of children, satisfactory’
housing and sanitary’ conditions and communication with cities.
v) Knowledge about PHC
A different
et al
but relevant study by Prabha Ramalingaswamy’
(1980) looked at the perception of students from four
medical colleges regarding concepts relating to the team
approach to primary’ care.
The findings indicated that the
medical students had not really understood the concept and were
not aware of who were the persons w’ho constituted the health
team.
The responses to questions about development and an
understanding of poverty also showed an "inadequate awareness
of the medical students to live Indian problems".
vi) The only’ retrospective study’ conducted at the time of the
Silver Jubilee of Baroda Medical College of 1553 alumni, by
24
Bhatt et al (1976) revealed that 15 per cent had settled
in rural areas, 46 ter cent in urban areas of India and
39 per cent abroad.
Analysis of nature of occupation
showed that 50 per cent were in private practice, 40 per
cent in service (other than teaching) and 10 per cent
in teaching.
An analysis of the specialities chosen by
the first ten (in merit) of each batch showed that.7.7 per
cent voluntarily chose general practice and 67.6% chose
one of the four primary7 clinical specialities.
When planning curriculum content and structure it is
important to keep in mind what the graduates would be
expected to do at the end of the course.
The above studies
give some idea about options and actuals.
However each
college would probably need to go through these exercises
in the context of their own institutional goals.
As can be seen from the account just given, the respondent
group and the objectives of enquiry in all these studies
were quite different to that attempted in our study.
However a previous study by Mohapatra (1988) if) Andhra
Praddsh has pointed out the need to develop a link between
the health services and the system of medical education.
This was a study of the level of knowledge of nutrition
among 80 PHC doctors.
in this area.
It revealed a rather gross lacuna
A more recent study by Rangan and Uplekar
(1992) has looked at the level of knowledge and practice
in the treatment of common symptoms and diseases among a
large sample of interns in Bombay.
of lacunae have been identified.
Here too several areas
This includes gross
variations in the treatment of tuberculosis for instance,
which is a major public health problem and for which there
is a national control programme.
These findings need the
serious consideration of all medical educators.
During a workshop organised in 1984 (Mohan A. et al) for
graduates who had worked in rural areas, the nineteen
participants stated "we feel strongly that the process
leading to graduation should be so modified that at the
25 .
end of our five and a half years course, we are specifically
equipped to work meaningfully in rural areas'1.
The main
suggestions regarding the undergraduate course were:a) During rural postings in studentship they should actively
assist interns during their work, for example helping
with dressings, procedures, dispensing medicines.
b) During their clinical years they should be entrusted with
graded responsibilities in patient management and
"should not r*main mere spectators of the daily ward/OPD
routine as at present".
They should be given twenty-four
hours postings in the ward etc., during which they can be
exempted from lectures and classes.
c) Internship should be a "procedure and competence based
programmes" and more importantly should "promote the
capacity for independent decision making".
Appendix I lists out the suggestions made regarding
training during the clinical years and internship.
In summary, the literature review revealed that only the
Mohapatra study and the workshop mentioned above had
respondents who had actually experienced the realities of
working in a PHI.
This we felt was an important criteria
to be considered.
The second aspect that we were interested
was to get concrete suggestions regarding curricular content
and curriculum development.
We felt it was time now
in the
nineties to move beyond generalisations, hypothesis,
subjective impressions and macroanalysis alone.
Therefore
the study was exploratory in nature - to see if the
methodology being used was useful, and also to identify its
limitations.
B. Points arising from the study
i) Respondent group
This respondent group of medical graduates who have worked
sufficiently
long in rural or unserveo areas as basic
26
doctors have lived out the implicit goals of medical education
as it developed in post-independent India.
We feel now at the
end of the study that they are an important group from whom
active, systematic and ongoing efforts must be made to get
feedback in the process of curricular development.
However,
this particular group has worked primarily in small-medium
size hospitals of the mission/voluntary sector.
It would be
equally important to get feedback from doctors in Primary
Health Centres of the government (we had only two) and from
general practitioners in urban and rural areas.
It is not possible to look at the data from the point of view
of identifying regional needs and differences, for example
according to the North, South, Central, Eastern or Western
regions of the country, to be done on an all India level this
would need a larger number of respondents.
The majority of
respondents in our study were from Southern Indian colleges.
It is obvious from the findings of the study that there are
differences between colleges which possibly also reflect
differences between requirements of different Universities ,
for example, some subjects like psychology, sociology and
even psychiatry, dentistry', etc., are not taught in some
colleges. On the other hand, others have not found the MCI
guidelines or the University a hindrance in introducing
additional areas like medical ethics or altering the approach
to teaching.
Several of the ideas that have emerged are not entirely new -
some have been spoken of by expert committees and by various
conferences concerning Medical Education.
Some, as mentioned
in Part A of the discussion, have been identified by students
and interns.
This is especially true of the more general
suggestions like need for greater clinical orientation and
skill development, need for integrated teaching, need for
examination reform etc.
One can say that these changes need
to be implemented more urgently, effectively and creatively.
27
However one of the advantage of a more comprehensive enquiry
of all subjects/aspects is that in the context of the total
course or total experience there are probably some key
changes that seem to be necessary, for example, given the
time framework ano competing demands by different disciplines,
priorities for curriculum time and content need
developed.
to be
It would seem logical to base this on the goals/
objectives of medical education in the country7 and the
particular institution as well as on what the graduates are
expected to do on completion of the course.
If rural service/work in peripheral health institutions/
government PHCs or general practice is considered to be an
important option then feedback from these graduates needs to
be looked at seriously.
It would probably also be useful to
have people with such experience teaching on the staff of
medical colleges and on curriculum, comrr.ittees/medical
education cells.
There is no need to restate the important findings here
however, some new areas/ideaa. that come out from this study
are the importance of the following for PHI practice:
a) Practical expertise in first aid and nursing procedures;
b) All the so called "short postings" that are generally
undervalued, for example, Orthopaedics, Dermatology,
Radiology, ENT etc.
c) Need for some training in Dentistry;
d) Ability to run a small laboratory, pharmacy and taking
of X-ray films/handlinc equipments etc.;
e) Forensic medicine;
f) Psychology and counselling;
g) Sociology.
Another positive output is the identification of a certain
amount of detail -under each subject heading, regarding areas
that are adequate, those that need strengthening and those
which can be reduced.
This could be developed further by7
detailed studies eliciting responses using rating scales
regarding each topic, issue, skill etc.
28.
vii' Over the past four decades there seems to be a Gradual change
taking place in what is expected cf a medical graduate after
completion cf the undergraduate course.
Upto the seventies,
it may not be incorrect to say that most graduates expected
tc and were expected tc practise medicine after the under
graduate course.
There was a still shortage of doctors, then,
even in urban areas.
At that time even the teaching hospitals
offered adequate opportunities for a medical student/intem to
pick up clinical acumen/skills .
During the eighties the trend towards specialisation has
increased.
theoretical.
A variety of reasons has made the course more
It has been recorded that the need to prepare
for postgraduate entrance exams has resulted in even the
internship period being eroded.
This period in fact has been
considered very important by the respondents of this study
for the acquisition of skills, the ability to take
responsibility for patient management and for decision making,
without exams in the horizon.
The presence of postgraduates
in the teaching hospitals also removes the students and
interns a further step away from the patient.
s
They now do
more of clerking and running around.
We need to take cognisance of these changes that have taken
place in the studentship and internship and decide whether
that is what is needed/desired.
viii) Information regarding morbidity and the general situation in
majority rural and poor India seerr to indicate that the old
problems of ill-health continue and in fact are complicated by
the emergence of new ones.
these needs
It seems that the gap between
and the overall direction, quality and nature of
medical education has widened.
ix) Many of the suggestions cf the graduates would demand greater
time and commitment on the part of the faculty along with
requiring the students to be more responsible adult learners.
Besides being doctors, clinicians, etc., the staff are called
29
to be primarily teachers, nurturing the growth of students.
Whether adequate time and interest w’ill be given to this
aspect in. the growing climate of private practice and
pursuance of personal careers will need serious thought.
x,' The primary use of tertiary care level teaching hospitals as
the base for training doctors who are expected to function at
the secondary level is not the most suitable.
Active efforts
to move at least pert of the clinical teaching to District/
Taluk and PHC level or in voluntary/mission hospitals should
be done.
The present postings of students and interns to
these centres is not always effective and
rather than making
any positive contribution to learning it may permanently
put off students from: suck work.
xi) The findings of this or similar studies could be made part
of an orientation handbook for senior medical stuoents/interns
who have decided that they will be opting for rural/government
service.
it may help them to identify which areas to
concentrate on during final year and internship to prepare
themselves for the job ahead.
xii) As we went through the process of the study and its analysis
it seems that for good medical practice in a PHI, especially
in small to medium size hospitals, doctors need to have skills
that are wide-ranging and multi-speciality in nature.
Therefore rather than a postgraduation in any one of the
specialities it may be useful to develop a postgraduate course
in Rural Medical Practice which could span the four primary
clinical subjects and community health along with additional
aspects.
This would need to differ from the postgraduate
courses in general practice in the United Kingdom, for
instance, which has developed in the context of their National
Health Service. The Fellowship of the Christian Academy of
Medical Sciences in India is probably a forerunner of this.
xiii) In conclusion, we would like to restate that attempting to
30
build curriculum using feedback from the field through systematic
study is useful and also enriching.
Identifying respondents with
relevant and adequate work experience is a key characteristic as
they can contextualise the course to the requirements of the
outside working environment.
This is a major advantage over the
alternative of involving students and interns, who have experience
primarily in the teaching hospital.
1. Mohan A., Menezes L., Ravindran G.J., Narevan R., Narevan T.,
1984.
Report of e workshop for pioneers of the rural placement scheme
of St.John's Medical College, Bangalore.
Mimeograph, Catholic Hospital Association of India, Secunderabad.
2. Mohapatra E., Ramoasmurthy V., Ramnath T., and Mohanram M., 1988
Better education for better health care,
World Health Forum, Vol.9, pp 612-614.
3. Narayan T., and Narayan R., 1992
Curriculum change : Building on graduate doctor feedback of
peripheral health care experience - ar. exploratory survey.
Mimeo, Community Health Cell, Bangalore.
(Preliminary communication of this study presented at the XXXI
Conference of the Indian Association for the Advancement of
Medical Education held in January7 199 2) .
4. Varma S.P., and Varma A.K., 1970.
Curriculum Structure; The Student and Teacher.
IJME, Vol.IX, October 1970, pp 482-487.
5. Rajanna M.S., Shivaram C, Vastrad S.A., 1984
Evaluation of Medical Education from the Students point of view;
IJME, Vol.XXIII, No.l, Jan-April 1984, pp 2-15.
6. Ramalingaswami Prabha, Shukla S.K. and Jha D.G., 1980.
Team approach to Primary Care, Views of some student physicians,
- IJME, Vol.XIX, No.2, July-Dec, pp 78-81.
7. Swain. S, 1978
Students perception of present day medical education - their
coal objectives and views on curriculum design;
- IJME, Vol.XVII, No. 2, Jan-June 1978, pp 106-112.
8. Bhatt R.V., Soni J.M., Patel N.F., 1976
These twenty five years - Study cf Medical graduates from
Medical College, Baroda.
- IJME, Vol.XV, No.l, Jan-June 1976, pp 33-46.
9. Clausen. R.W., 1973
Medical Education relevant tc society's needs
- IJI—, Vol.XII, No.l o 2, pp 62-64.
0. Gupta G.P., and Patel D.D., 1973
A study of the socic-economic survey of medical students with
special reference to motivation in the choice cf Medicine as
a career in India.
- IJME, Vol.XII, No.3 & 4, July-Dec 1973, pp 285-295.
.1. Rangan S., and Uplekar. M. 1992
Community Health Awareness among fresh medical graduates of Bombay,
Paper presented at XXXI IAAME Conference, Bombay, January 1992.
32
ACKNOWLEDGE M ENTS
We would like to express our thanks to all those who have contributes
towards making this study possible.
Most especially to:
a) each of the respondents on whose experience and feedback we are
building;
b) tc the sponsors of the study viz., the Christian Medical
Association of Indie (CMAI), The Catholic Hospital Association
of India (CHAI) and Christian Medical College - Ludhiana;
c) to members of the Advisory Committee who have provided us
with much support viz., Dr. C.M. Francis, Dr. George Joseph,
Dr. P. Zachariah and Dr. V. Benjamin;
d) to the medical colleges and the medico friend circle with
whose help the respondents were identified especially.
Dr. G.D. Ravindran, Dr. Prem Pais, Dr. S.P. Kalantri and
Dr. Ulhas Jajoo;
e) for the animation, our thanks to Dr. Shirdi Prasad Tekur, of
Community Health Cell;
f) to the tear, of the Community Health Cell particularly
Mr. M. Kumar, Mr. V.N. Nagaraja Rao, Mr. S.John and Mr. C.James
who have given unstinted support.
33
APPENDIX-"
TRAINING DURING CLINICAL YEARS (MBBS COURSE) - A SCHEDULE OF GRADED
RESPONSIBILITIES
(Taken from. e reference "Report of a workshop for pioneers of the
Rural Placement Scheme, Mohan A. et al, 1984, Mimeo)
a) 0-6 months : Maintaining daily vital signs record, diabetic urine
chart, urine albumin chart, nephritic chart etc.. Administering
IM injections, simple dressings.
b) 6-12 months : Passing Ryle's tube, giving enemas, Mouth & eye care,
maintenance of intake/output record, monitoring of post-operative
patients, special dressings, simple physiotherapy like active
passive exercises, ambulation of bed-ridden patients, assisting at
medical and surgical procedures, assisting at normal deliveries
etc., and compulsory' casualty postings.
c) 12-18 months : giving IV injections, starting IV drips, drawing
of blood for investigations, conducting deliveries, assisting at
forceps extractions, assisting at minor surgery', recording EKG's,
assisting at complicated dressings, therapeutic procedures like
conoys compresses, ECT's, out-petient surgical procedures.
d) 18-24 months : Assisting major surgical procedures, doing simple
post-operative dressings-,- doing O.P. dressings, suture removals,
assisting house staff in side-lab work, helping the CMC in
casualty procedures, physiotherapeutic procedures like postural
drainage, gait training etc., assisting at caesarian sections;
During this time students may also be sent to other/Govemment
institutions for training in the fields of traumatology and trauma
management, obstetrics, etc., where the availability of clinical
material at St. John's would be found insufficient or inadequate.
e) 24-36 months : These 12 months shall be spent in completely
equipping the student to independently function as a full-fledged
doctor. In short he shall be carrying out all the functions
interns are at present carrying out, except not being involved in
decision making independently. During this period too,
arrangements may be made in other institutions to have our
students trained in fields where St. John's is yet to develop
adequate potential.
34
INTRODUCTION
1. This section of the report gives the details of the feedback
offeree by the respondents to each of the 37 units that they
were asked to comment on.
2. We have tried to avoid repetition. However we have included
comments on a point already mentioned if it has a different
nuance or slant.
3. The number and oercentaae of respondents who have all
. independently raisec tne same issue has been given when it
exceeds a certain number. These probably need greater
consideration since several people have raised it in response
to an open ended question.
4. The other suggestions / comments are those of individuals
or more commonly 3-4 people.
5. However we feel that quantity is not the only factor indicating
the importance or priority of any item. An idea raised by
just one person may be very important. This is a matter
requiring the judgement of the medical educators.
6. All the responses to each of the subjects studied have also
been coded according to certain criteria. This has been
presented in a tabular form (see Table 1) through which an
overview picture emerges of the usefulness, relevance and
adequacy of the subjects and their teaching to work in PHIs.
35.
PART - b
TABLE 1
USEFULNESS, RELEVANCE AND ADEQUACY OF SUBJECTS IK THE UNDERGRADUATE MEDICAL
MEDICAL COURSE IN THE CONTEXT OF WORF IN PHIS
SI. '
Subj ect
No.
Not
Ko
Taught Comment
No*
Useful/
Relevant
c
b
c
—
2
4
1
101.
Anatomy
Useful/
Useful/
Other
relevant relevant
Ade Comments
quate
as it is
with
Suggestions
c
c
- /
36
8
26
12
102.
Phvsiclocv
—
6
4.
5
03.
Bio-chemistry
E Bio-physics
-
5
10
-
25
13
04.
Bic—statistics
-
12
12
5
14
8
05.
Psychology’
c
$
1
7
25
6
06.
Sociology
8
12
3
5
19
6
07.
Pathology
-
8
5
6
19
15
108.
i
Microbiology’
-
6
1
5
27
14
09.
Pharmacology
-
5
-
5
30
13
10.
Forensic
Medicine
-
3
4
3
33
10
11.
Medicine
-
2
-
1
37*
13
12.
Surgery
-
2
-
3
41
7
13.
Obstetrics &
Gynaecology
-
-
-
5
43
5
PSK/Ccmmuni ty** *
Medicine
-
1
1
c
36
10
15.
Paediatrics
1
2
-
5
29
14 Excellent-2
16.
Orthopaedics**
-
3
-
•5
22
10 Inadequate-5
17.
Ophthalmology
-
5
3
3
25
16 Inadequate-1!
IE..
Anaesthesia
4
2
1
2c
c Inadecuate-4i
IS .
Radiology
1
8
5
1
5
20.
El"
-
3
5
11 Inadequate-cj
J
13 ineoeouate-d
21.
22.
23.
Dermatology
Psychiatry
Dentistry
—
1
3
8
5
24
7n
7
11
2
7
8
7
1
27
26
11 Inaoequate-2!
8 Inadequate-2!
9 Ina6equate-3|
i
114 .
*
.
____ 19
6 of these also said the teaching was adequate.
** Feedback on Orthopaedics was elicited from 43 respondents only.
** 18 of these said the teaching was inadequate.
Excellent-2
j
3
36
Comments
1. In the questionnaire respondents were requested to give their
comments regarding the usefulness, relevance and adequacy of
each subject. Though this is a rather rough and ready indicator
in which a rating scale was not used, the overall response does .
provide an overview regarding these aspects of the respondents
views.
2. As seen from the table, the subjects not taught in some colleges
are: Sociology, Psychology, Anaesthesia, Dentistry, Paediatrics,
Psychiatry and Radiology.
3. Coloumn 'C shows that subjects found not useful/relevant to work
in PHIs were: Biostatistics (23%), Biochemistry & Biophysics (19%),
Dentistry (13%). When going through the detailed comments also
it appears the relevance of the first two subjects has not been
appreciated by several respondents.
This could be a reflection of
the teaching. In Biostatistics, two respondents have mentioned
that the teaching is excellent and integrated with the pre and
clinical subjects, which helped make its relevance better
underst ood.
4. Obstetrics & Gynaecology elicited the most wholehearted response
with nil 'no comments', close behind were PSM/Community Medicine(2%)
Medicine (4%), Surgery (4%), Paediatrics (4%).
Subjects which had the largest number of no comments were Biostatistics (23%), Sociology (23%), and Dentistry (21%), On an
average for all subjects there were no comments by 10% of
respondents.
5. There was an active process of giving detailed suggestions/comments.
The largest number was to the following subjects - Obstetrics &
Gynaecology (81%), Surgery (77%), Medicine (75%), PSM (68%),
Anatomy (68%).
At the lower end were - Biostatistics (26%), Sociology (36%),
Dentistry (36%), Pathology (36%) and on an average for all
subjects ac.ive suggestions and comments were given by 52% of
the respondents.
6. Combining columns 'o' and 'e' to indicate usefulness and
relevance to work in FBI's a grouping of subjects can be dene
as follows.
I. Most ..useful/relevant ; More than 75%
Obstetrics &■ Gynaecology, PSM/Community Medicine, Surgery,
Medicine.
11. Very useful / relevant 60-74%
Dermatology, Paediatrics, Psychiatry, Pharmacology, Forensic
Medicine, Microbiology, Psychology, Anatomy
37
III. Useful / Relevant ; 45-59%
Radiology, Ophthalmology, ENT, Anaesthesia, Orthopaedics,
Pathology, Sociology, Physiology.
7. A word of caution - too much should not be drawn from this
grouping since ' adequacy'which would reflect the teaching and
'usefulness and relevance'were not considered as being mutually
exclusive items. However there is a basic consistency when one
looks at the responses in different ways.
8. Whet strikes us is that unlike the general pessimism and
negativism about the role of the Departments of PSM/Community
Medicine, feedback from practitioners from the field indicates
that they prioritise the subject in the same category as the
primary clinical subjects, which are considered the most important.
9. Similarly, the para and pre clinical subjects of Pharmacology,
Forensic Medicine, Microbiology, Anatomy and Pathology, and
Physiology are also recognised as being useful to work in PHIs.
10. The "short postings" too were considered as being very useful
or useful.
38
1. PRECLINICAL PHASE
1.1 ANATOMY
i) 15 respondents (28%) opined that a greater emphasis
needs to be given to clinical or applied anatomy e.g.,
surgical anatomy relevant for minor or major surgery
and orthopaedics. Specific areas mentioned were:
a) hand and foot anatomy as these are frequent sites
of injuries, especially resulting from rural
occupational hazards;
b) upper and lower limbs where fractures occur commonly;
c) anatomy of important nerves and arteries necessary
for management of injuries and surgical cases.
ii) It was suggested that anatomy could be taught along
with clinical postings, with the involvement of
clinical teachers using clinical cases e.g., the
relevant anatomy of the heart to be taught in relation
to a patient with Rheumatic Heart Disease with
valvular lesions.
iii) Comparisons between normal and abnormal anatomy with
clinical demonstrations were suggested. Viewing of
operations on video or live if possible, on relevant
parts of the body according to the topic being taught
was also suggested.
iv) 18 respondents (33.96%) felt that the course was too
exhaustive and theoretical, often going into
unnecessary detail e.g., the names of 32 muscles of
the face, which were difficult to remember. They
felt that the course should be reduced and made more
concise, comprehensive and clinically oriented.
v) Areas like embryology7, detailed neuro anatomy,
histology and osteology which may not have much
practical importance for a basic doctor could be
reduced.
vi) It was suggested that 2 semesters or one year should
be adequate to cover Anatomy. It was also mentioned
that instead of being allotted 40% of the duration
of the first M.B.B.S. course, the time allotted to
Anatomy could be reduced tc 20% i.e., the duration
could be halved.
via) Several mentioned that Gray's Anatomy should be
'banned' or used for reference purposes only. The
textbock by R.J. Last was suggested as an alternative
in addition to other clinically oriented textbooks.
In summary the teaching which is exam oriented should be
mace more clinically oriented.
1.2 PHYSIOLOGY
The importance of Physiology in understanding the functioning
of the human body and the basis of medicine was mentioned by
many respondents.
i) Several expressed the need for more clinically oriented
teaching. Suggestions of areas to be covered in this
regard included:
a) respiratory rate/heart rate in different ages should
be taught, especially in the newborn;
b) show patients with disease of the system being taught
as the contrast between the normal and diseased will
be more striking;
*
c) physiology of pregnancy with some teaching in the wards;
d) greater emphasis to be given to nutrition;
e) greater emphasis on physiology'of the gastrointestinal
tract - since a large number of cases are G.I. related;
f) circadian rhythmn - with detailed study of rural
lifestyles and their day to day schedules;
g) limited introduction of pathophysiology;
h) the pathophysiological aspects of shock;
i) spirometry - lung funetion tests in asthmatics;
j) occupation related medical problems.
Other suggestions regarding the teaching were:
i) need to teach physiology of the different systems along
with other preclinical and paraclinical subjects
(especially Anatomy).
ii) Several respondents felt that clinical demonstrations in
the wards should be introduced/increased e.g., spirometry,
heart rate, respiratory rate in different physiological/
pathological conditions. Clinical teachers to also be
involved.
iii) Symposium could be conducted on various clinically related
topics by physiologists, physicians, clinical pathologists,etc
iv) need for improvement of tutorials with more time given
to explanation/discussion.
v) we need follow up sessions in physiology later during
clinical years.
vi) Several felt that the coverage is too exhaustive/
elaLorete/oetailed.
vii) less of obsolete experiments eg., Kymographs etc.
Amphibian experiments to be done away with and experiments
on other animals to be reduced.
viii) non-clinical topics can be deleted.
ix) coverage of the subject to be completed within the first
year.
40
1.3 BIOCHEMISTRY AND BIOPHYSICS
i) As in the previous two subjects several respondents gave
the general suggestion that the clinical/practical
application should be strengthened.
ii) In the context of rural hospitals, where doctors frequently
have to take charge of labs it was felt that it was
important to:
a) be able to conduct simple biochemical tests;
b) be able to standardize tests;
c) be aware of the need for quality control;
.
.
Ou
*i>
d) be conversant with the use of laboratory equipment;
e) be able to start a small lab. for routine investigations
in a peripheral institution.
iii) Regarding the teaching the respondents felt:
a) skills in carrying out tests need to be developed;
b) details should not be emphasised - "one can always
refer to books";
c) the need for better teaching methods - tutorials need
to be improved;
d) the subject also needs to be taught along with the
clinical subjects and during the clinical postings;
e) the need to have postings in the hospital clinical
laboratory.
iv) Regarding content of teaching they suggested:
a) focus
could be on community problems eg., nutrition;
b) there is a need to understand the relevance of
biochemical reactions in the body in normal and
abnormal conditions;
c) it is important to understand electrolytes and acid
base balance, urea cycle etc.
v) There was a need expressed by a few to increase the
students understanding of Biophysics.
1.4 EICSTATISTICS
i) Eiostatistics was considered by a fair number of respondents
as not generally useful to work in a PHI. They felt that
it was useful only for entrance exams, final exams, to do
research and publish papers,for projects, for further
studies and thesis work and probably for health care
administrators.
41.
ii) Other respondents were of the opinion that the subject is
a) helpful in understanding many .aspects of medicine;
b) a help in making an effective assessment of various
situations;
c) useful in designing of studies, data collection and in
the conduct of field studies;
a) in understanding the significance of studies;
e) useful for epidemiological work, for projects etc.
iii) Suggestions regarding the teaching were:
a) to relate the concept to clinical situations;
b) to emphasise practical aspects and develop students
skills in its application;
c) emphasise study design and epidemiological application;
a) during the undergraduate course itself, put it to use
through projects in neighbouring villages.
1.5 A. SOCIOLOGY
i) The majority (30) felt that the subject was useful and
that it should be included in the curriculum. Several
felt that it should be strengthened and given greater
importance and greater coverage. It should "not be
considered a lecture where you can go to sleep)".
ii) The suggestions were that the subject should
a) introduce students to thinking of the sociology’ of the
population they are going to deal with;
b) help in understanding structures in society;
c) help to "make the rigid British prototype system more
socially relevant";
c) help in understanding medical sociology;
e) help in understanding and dealing with patients in
a periferal centre;
f) "help the students who are mainly middle anc upper
class to understand and experience what it is to be
poor and illiterate";
c) it "should help remove any superiority’ feeling and in
still kindness" - it "should help students to be mere
humane";
h) sociological factors relating to clinical situations
should be highlighted.
iii) Regarding the teaching, the following points were suggested:
a) it should be introduced in the first year as a separate
subject or through the department of PSM/Community
J-'.edicine;
42
b) the subject needs to be given greater importance during
PSM postings in rural areas;
c) it should have greater practical field orientation;
d) a few sessions on health politics and economics tc be
included eg., village politics. State politics;
e) discussions on sociological factors- to be held during
internship as well.'
KB: There was a comment by one that the subject can be
Volatile!
B. PSYCHOLOGY
i) There was a strongly expressed statement made by several
doctors (17) that an understanding of Psychology was
extremely important to medical practice. It was felt that
a greater emphasis and a greater coverage of the subject
was necessary during the undergraduate course.
ii) The subject was necessary for medical work for the
following reasons:
a) with advances in psychology, there is a better under
standing of the inter-relationship of the mind and body
which is important for medical practice;
b) because medicine is a profession with -so much of
person to person interaction;
c) to understand the psychology of
sick persons viz.,
how a patient feels, and what it is to be seriously ill
and weak;
d) to understand and know’ how to deal with the common
psychological problems encountered;
e) to build a rapport with patients and people in a village/
in a peripheral centre;
f) in understanding and building inter-personal relationships;
g) it is in fact important for good general practice anywhere;
h) due to lack of mental health care personnel/services in
the country, there is a greater need for generalist
' doctors to take up responsibility in this area;
i) to understand interdepartmental conflicts in medical
colleges!
iii) Regarding the teaching, the suggestions were:
a) to emphasise the oractical aspects;
b) greater exposure during PSi-1 postings in the rural areas;
c) greater exposure through discussions etc,during internship;
o) psychology of people in rural & urban areas to be explored;
■
e) need to be trained to manage different aspects of
alcoholism - physical, social, psychiatric;
f) skills in developing and building relationships with
teachers and colleagues. This would help in team
functioning later.
43
1.6 GENERAL SUGGESTIONS DURING THE PRE-CLTNICAL PHASE included:
i) It was suggested that the fol.lowing general topics
could be covered during the preclinical phase:
a) five or six introductory lectures about the medical
profession;
b) self development exercises;
c) physical training - exercises, yoga;
d) a presentation on student problems.
ii) It was mentioned that involvement of the basic sciences
(Anatomy, Physiology and Biochemistry) in community
studies during the first year rural orientation
programme was a very good experience for the students
in one of the colleges.
iii) It was felt that sessions on medical ethics were
necessary.
iv) It was important to develop healthy attitudes and a
feeling of responsibility towards patients. The
ultimate aim/happiness in the profession was in being
able to help others and should not be measured by
money or professional stature.
44
2. PARACLINICAL PHASE
2.1 PATHOLOGY
i) Several respondents opined that pathology was basic
to an understanding of the clinical subjects.
ii) Subject areas that were considered important were:
a) clinical pathology which should be emphasised more
than systematic pathology;
b) Haematology;
c) An indepth knowledge of immunology and its
relationship to nutrition etc.
d) Several felt that students should be proficient in
preparation of slides and in carrying out routine
investigations in clinical pathology - as lab
diagnostic facilities and pathologists are not
available in rural areas;
e) Doctors should be proficient in blood banking
procedures and should participate in blood donation
camps.
iii) Regarding the teaching, the following suggestion were
given:
a) A detailed study of histopathology of uncommon
diseases is not necessary and could be deleted;
b) The emphasis should be on common diseases and
correlation of pathology with clinical signs;
c) A posting in the Pathology lab. dealing with
hospital specimens could be introduced during final
MBBS and internship;
d) Students should learn to independently carry out
routine investigations;
e) They should be able to send specimens for HPE.
iv) Doctors in PHIs often have the responsibility to support
and supervise technical staff who conduct routine
investigations in hospitals without a pathologist. They
also sometimes have to set up/manage a small lab.
2.2 MICROBIOLOGY
The following corr.ments/suggesticns were made:
i) The teaching could be more practically oriented towards
the acquisition of knowledge and skills which the doctor
car. apply in a rural set-up where services of micro
biologists, pathologists and laboratory facilities are
not available.
45
ii) There were also suggestions by ten doctors that the volume
could be diminished, by reduction of detail (for eg., the
composition of the cell wall of bacteria, the various
descriptions and methods by which staphylococci can be
differentiated, etc.).
iii) It was felt that if unnecessary detail/rare topics which
were studied for the sake of the examination could be
left out or just mentioned,it would be easier to focus on
and remember the essentials and the more common problems.
iv) Sections that were considered to be covered too extensively
and which could be deleted were - micro-organisms,
complicated laboratory techniques, in bacteriology classification and detailed study of serotypes, virology
could be reduced slightly.
v) The clinical importance and aspects are to be stressed.
vi) The subject is very useful in dealing with contagious
bacterial, viral and parasitological problems especially
prevalent in India.
vii) Knowledge of common organisms in different / particular
areas of the country would be useful and types or
organisms more commonly found in certain anatomical areas
would help choice of therapy.
viii) Students should be proficient in examining simple
specimens like sputum, stool, pus, etc., to identify
common pathogens - staining and identification of
organisims should be emphasised especially Grams-stain
sputU.m exam for AFB.
ix) Focus on laboratory tests/simple routine investigations
that can be done in a peripheral situation.
x) Useful to study water borne organisms that commonly
pollute water sources.
xi) Students could be taught to do culture and sensitivity
tests.
xii) Interpretation of tests - their diagnostic value,
reliability etc., to be emphasised.
xiii) Should have postings in the lab dealing with hospital
specimens.
xiv) In summary "greater stress to be on bugs related to day
tc day practice" or common conditions.
xv) Reduce emphasis on culture and culture media.
the use of serology and simpler examinations.
should be studied using clinical specimens.
Strengthen
These
46.
2.3 PHARMACOLOGY
There was a great degree of interest shown in Pharmacology as
is evident from the fact that no one 3aid that it was not
useful or relevant, and there were a very small number (5) of
no comments. There were on the other hand a large number of
comments and suggestions, viz.:
i) Several respondents felt that the coverage was too
exhaustive, too theoretical, going into unnecessary detail
which is most often forgotten, with undue emphasis on
drugs not currently in use, with the making of mixtures
and experimental pharmacology which was "not particularly
useful". Too much of memorization was required which was
not helpful. To quote a respondent "listing all the
adverse effects of every drug, one forgets all". The
latest drugs were not dealt with at all.
ii) It was felt that there could be a change in content, with
emphasis on the following:
a) emphasis on applied clinical pharmacology with practical
work using prescriptions from clinical cases in the
wards/OPDs;
b) indications, contraindications and side effects of drugs;
c) drugs used in different situations eg., pregnancy and
lactation;
d) paediatric dosages;
e) to be taught the rational use of drugs, rational
prescribing or rational drug therapy, focussing also
on cost effective management;
f) drug interactions to be stressed;
g) misuse of drugs;
h) important to give clinical correlation/orientation eg.,
"even though we study that Furesamide is a duretic and
can be given intravenously, a graduate using it
intravenously for the first time has no idea of how
much duresis it will cause or hew much hypotension/
weakness. It is the same with analgesics and other
drugs".
i) sessicnson the latest developments concerning newer
drugs end their advantages;
j) rationale for use of each crug/combination to be
stres.ee. Also the use and misuse of steroids.
k) focus on anti-infectives, anti-infestation drugs,
anti-hypertensives, and anti-diabetics.
iii) Suggestions regarding the teaching were:
a) pharmacology teachers should teach in the wards and
community too;
47
b) reduce pharmacy classes with preparation of mixtures.
Substitute with exercises where prescriptions are
analysed and discussions held on many relevant aspects
(mentioned above);
c) teaching must centre on a firm foundation around the
use of essential drugs as given by WHO;
d) focus on drugs currently used;
e) identification of side effects of drugs in the wards;
f) drug dosages should be made easy to remember or if
necessary a ready reckoner to be used;
g) practical knowledge of some of the common trade names
and the names of good drug companies in India;
h) it was suggested that Lawrence's Textbook of Pharmacology
could be used.
iv) It was felt that pharmacology should be removed from the
para-clinical side to the clinical side with active postings
in the wards.
v) Frequent updates are necessary in the subject because of
rapid developments and changes in drugs available.
2.4 FORENSIC MEDICINE
i) The number of respondents who offered no comment or felt
the subject was not useful was very small (7).
ii) There was in fact a strong plea to enhance the importance
of the subject and comments that it was not stressed
adequately during the present course.
iii) Several respondents felt that the medico-legal aspects
were important.
iv) Important areas identified for study were:
a) management of suicidal consumption of poisons;
b) snakebites, injuries, accidents;
c) examination of wounds, wound certification;
d) toxicology;
e) diagnosis of death, certification of death, declaration
of death;
f) managin, medico legal cases where there are inadequate
facilities and no transport to refer the cases;
g) medico leca] autopsies eg., cases of murder. Practical
difficulties of doing post mortems in rural areas;
h) all medico legal aspects of the doctor-patient
relationship “since patients nowadays no longer
consider doctors as 'Gods' who heal for free";
i) medical ethics to be given greater importance;
48
j) medical jurisprudence to be adequately covered;
k) students should be able to witness court scenes;
1) practicalities of handling different types of medico legal
cases;
m) stress to be given to common social malpractices rather than
going into criminological details;
n) to develop a more human attitudes to dead bodies, the
morgue and the whole set up;
o) identification of common poisons in the field / shops;
p) poisoning / road traffic accidents.
) It was opined that forensic medicine and especially medico legal
aspects are going to be increasingly important in the future
and a better grounding in the subject would make the graduate
more secure and more responsible rather than staying away from
such situations.
49.
3. CLINICAL PHASE
3.1 MEDICINE
i) There were a large number of respondents who felt that
the coverage of the subject was useful, relevant and
adequate.
ii) There were also a large number of comments and suggestions
viz., general suggestions regarding approach which were:
a) students should also be taught how to approach a case
and what to do within the set-up available in a
periferal centre. And more importantly, when to refer
a case to a bigger centre.
b) the subject has been described and taught according
to systems. However, if it was dealt with in terms of
common illnesses and problems it would have been
better;
c) emphasis on clinical skills rather than high tech
diagnosis helps in the field;
d) attention should be given to the management of
illnesses in a periferal centre in the absence of
facilities for investigations and newer/more
expensive antibictics/drugs;
e) the difficulties of adjusting from working in a large
teaching hospital set-up to the taking of decisions/
responsibilities on one's own in a periferal health
institution were voiced by many. The change from a
situation with a range of investigative facilities
available and many colleagues, seniors and other
departments to refer "to manage on one's own was
difficult". Therefore greater involvement as interns
in patient management was considered very important
rather than just writing discharge summaries, getting
investigation results and performing a "clerical"
job. There is a need to build up independent
decision making capacity.
f) both curative and preventive medicine should be
emphasized in Medicine and during internship practical
approaches to general practice in village situations
should be taught.
g) problem oriented medicine and therapeutics needs to
be stressed with greater emphasis on clinical diagnosis
and a rational approach to problems, interpretation of
laboratory investigations, and applied pharmacology
and an overall emphasis on tropical medicine.
h)
if possible the last l-l-; years of study should
contain only medicine, surgery, obstetrics,
gynaecology and paediatrics. The other subjects
should be finished before that.
50
iii) Suggestions regarding areas to be covered/given emphasis
included:
a) need for exposure to diagnosis and treatment in
Emergency Medicine with taking' of responsibility for
such cases during internship eg., priority to be
given to the management of medical emergencies like
Bronchial Asthma, Myocardial Infaration, Variceal
Bleed, etc.
b) Infectious diseases, parasitic infestations, chest
diseases (dermatology and ENT).
c) the relevance of different diseases should be understood.
Diseases more common in the West eg., multiple selerosis
should not get that much importance in the curriculum.
Common medical conditions in our country should be given
more teaching time and importance.
In several of the good text books which are British or
American, diseases with relevance to our conditions may
not be described well.
d) too much attention is given to exotic diseases. Not
enough attention to common problems like tuberculosis. •
e) rational prescribing should be taught and interns given
an opportunity to prescribe independently under the
supervision of seniors.
f) drug therapy should include teaching about cost benefit,
cost efficiency relationships and the use of cheaper
alternatives in the perifery.
iv)
Regarding teaching, the suggestions included:
a) students should be given increased opportunity to
present cases and participate in seminars.
b) theory lectures have a limited value. Students need
more time in the wares with patients. Like nursing
training, the last one year of the MBBS course should be
spent in the wards, like an intern. Students should
take part in admissions, work-up, treatment, discharge
and follow-up. So that internship will be a
continuation and a time for acquiring more detailed
knowledge and perfection without fear of exams, rather
than a period of fresh start in patient management. It
is easier to remember dosages of medicines, type of
complications to look for and their management by
actual doing and seeing rather than memorisation from
book s.
c) instead of the predominant inpatient teaching in wards,
teaching in the out patient department, in mobile
clinics and in genera] practice CPD's should be
incorporated.
c) there should be no routine lectures in large groups.
Teaching should be always in a small group. Senior
students should help the junior students in learning
clinical medicine. The teachers should function as
coordinators (facilitators).
51
e) students should carry out simple investigations in the
side-labs and collect blood samples etc., in hospital
admission cases.
f) periferal institutions could be made use of for the
teaching of clinical subjects as well.
g) More experience in procedures like intubation, starting
of IV lines.
h) should follow up one or two admissions from OPD/
casualty every week - these should be worked up in the
ward and students should be in charge of these patients
till discharge.
i) it was felt that the writing of records in the way it
was being done was mere routine without much meaning
and could be discontinued.
j) the students may be involved in keeping medical records.
For chronic and incurable patients students should be
encouraged to follow them up in the community after
discharge.
k) the teaching should not be according to diseases but
according to symptom based diagnosis.
1) because the system of education is exam-oriented many
important topics from the practical day to day point
of view are missed.
m) this exam orientation should give way to orienting
students towards problems faced in a Primary Health
Centre (this is almost never done).
n) the common problems of medical practice need to be
emphasised during exams eg., gastrointestinal and
respiratory problems and not so much with endocrine
and cardiac problems which are uncommon in PHI practice.
o) some felt that the time period in internship
especially in medicine was inadequate and should be
increased.
p) longer posting during internship in ICU/CCu/emergency
areas (casualty).
q) if the number of forms to be filled during internship
could be reduced and substituted with more teaching
rounds it would be useful.
r) A book of 'Davidsons' standard is adequate for practice
in India.
As with Medicine, Surgery was also found to be very
necessary and relevant for work in periferal health
institutions. This is evident from the extremely small
numbers (2) of "nc comments", and nil "not useful" responses.
community health cell
326i v Moin. 1 Block
Mp'iSo
Bsng^’®
52
ii) There were a very large number of suggestions. The most
corn on among which were that they needed more practical
experience in actually doing certain minor procedures and
in acquiring basic skills.
iii) Important areas identified that need to be covered are:
a) several respondents mentioned that more training is
required in basic suturing techniques, minor surgery and
management of emergencies.
b) similarly, proficiency in proper dressings, cut downs,
and cannulations is essential.
c) emphasis on trauma care and treatment of wounds.
d) management of acute abdomen.
e) stress on common diseases / problems.
f) every doctor should be able to do an appendicectomy and
hernial repair.
g) hand and foot surgery is important since rural occupations
often result in .injury or disease of hands and feet.
h) as so many Indian villages still do not have access to big
medical centres a graduate must be able to manage common
surgical emergencies like appendicities duodenal ulcer,
perforation etc.
i) we should be adept at handling small cases eg., surgical
removal of lymph nodes, lipomas, subcutaneous cysts,
incision and drainage.
j' more practical experience in minor procedures of I & D
biopsies,fistulectomies, suturing cuts.
k) all major surgical procedures should be just mentioned.
Greater emphasis should be on post-operative complications
and rehabilitation, diagnosing common surgical conditions
eg., testicular swellings, Tracheostony on cadavers should
be taught.
1) need to be well versed in pre-operetive preparation and
in managing complications.
m) ability to treat shock.
n) practical dentistry - often a necessity because of lack of
availability of any trained personnel.
iv)
Seme of the problems mentioned were:
Presently the practical training is only 50% of what is
actually required especially in a rural set up - V.hat we
learnt most was to arrange blood; fill forms; suturing
and removal; and not minor surgical procedures.
53.
b) graduates are grossly undertrained to handle minor
surgical problems and do minor surgery. They should
not be "overused" to assist major surgeries •which have
no practical applications in the future unless they are
inclined to do their MS later.
c) inadequate surgical skills acquired - for rural work
expertise in minor surgery is essential.
d) too exam oriented - should be oriented to problems faced
in a PHC.
v) Therefore the teaching should keep in mind the following:
a) the focus of teaching should not be only on the surgical
procedure but on the "complete pre-intra and post-op"
surgeon.
b) to be able to meet the bare minimum surgical situations
in rural hospitals, the graduate should, have acquired
enough skill and confidence by the time he is already in
the situation.
c) that in a periferal set up it is important to know what
is required for the patient, to decide what is not possible
in the centre, when to refer and to give the patient some
idea of what to expect in the future and what would be done.
d) emphasise clinical skills rather than exotic diagnostic
' procedures.
e) increase ability to diagnose acute cases/emergencies and
to do the needful.
f) more opportunities / chances need to be given to do
surcery/practical work.
g) greater involvement of interns in case management is
required rather than doing mainly clerical work.
h) internship posting in surgery is too short.
3.3 OBSTETRICS AND GYNAECOLOGY
i) The question on this subject elicited the greatest response.
There was not a single "no comment" and nobody mentioned
that it was not useful or relevant.
ii) Several mentioned that the subject was very important for
rural practice and one which can cause the most tension to
a doctor.
iii) Several (20) specifically mentioned that greater emphasis
should be given to this subject, especially in the area of
getting practical experience and in acquiring skills.
54
iv) Areas of importance to practice in PHIs that need to be
covered ares
a) ability to provide good antenatal’care.
b) to develop the ability to make a decision as to when
to manage a case in the periferal centre and when to
refer.
c) ability to be able to assess pregnancy, to identify risk
factors and to assess the course of delivery.
d) any doctor who goes to the village should be able to do
a vacuum and forceps extraction and a caesarian section.
e) assessment of pelvis and cephalopelvic disproportion is
very essential.
f) management of Pre-Eclamptic Toxemia and of Post Partum
Haemorrhage.
g) greater stress to be given to the management of emergencies.
h) ability on manage bleeding PV, Dilatation and curettage,
emergency Caesarians.
special
i)
stress to be given to management of abnormal labour,
complications arising therein.
j) A detailed study of ovarian tumours etc, and operative
details of hysterectomies is not required. This should
be replaced by tubectomy, episiotomy, repair of cervical
tears, examination of pregnant mothers, precancerous
condition of the cervix, PAP test etc.
k) sufficient information should be acquired about the effect
of drugs on pregnancy.
1) neonatal care, including recognition of complications at
this stage.
m) practical knowledge relating to family planning was also
necessary.
n) while nost mentioned that Obstetrics was more important
and to be stressed upon during the training, ability to
manage common gynaecological problems was also mentioned.
v) Regarding the teaching - learning process the following points
were made:
a) Teaching should keep in mind the situation and necessities
of treatment in rural primary/periferal health centres,
where they often have to manage complicated cases for which
they have never gained experience during their undergraduate
days.
b) in general more attention should be given to patient oriented
teaching rather than exam oriented theory.
55
c) More experience in per vaginal examination, in assessing
a woman in labour, in the management of deliveries.
d) the need to develop confidence in handling Obstetrical
problems and practical knowledge was repeatedly stated.
This could be acquired through exposure to more cases
and through getting more experience.
e) students must conduct as many normal deliveries as
possible - upto 50 would be better.
f) interns should be allowed to do evacuations and forceps
and vacuum extractiore under the supervision of senior
doctors.
g) Donald's Textbook of Obstetrics was found to be a very e
practical guide during rural practice - it was recommend .d as the standard teaching book.
h) students should also know well what ashould not be
attempted in a rural primary/periferal health centre.
i) "Rather than being taught just to do what one is told
we should be trained to thipk and act".
j) for those who are interested,a longer duration posting
should be given.
k) there was a lone voice that said "for those who are not
keen on it, the labour room requirement in final year may
be made less rigourous" •
vi)
It was mentioned that,"the patients are dealt with as cases
more than as human beings". To overcome this it was felt that
the students should be involved with history .taking- etc.,
of patients in the OPD. This will encourage them, give them
experience as well as rectify the behaviour of hospital staff
towards OPD patients.
o» £
(0 (U
In summary, there is need for greater involvement in patient
management in OPD, casualty and in the ward, with follow up of
certain patients till discharge. The emphasis should be on
ining practical experience. Interns should be allowed to do
ny more procedures.
3.4 PAEDIATRICS
i) Paediatrics was considered important because a large number
of patients seen in. the rural PHIs - upto 60-70% in one case,
were of the paediatric age group. Therefore several of the
respondents felt that it should be emphasized.
ii) A fairly large number (19) felt that the coverage was adequate
and was very useful to work in PHIs and 2 thought it was
excellent. Kot one thought that it was not useful or relevant.
56
ill) Several suggested that the following steps could be taken:
a) more marks need to be allotted to this subject in the
curriculum;
b) it should be made a separate paper;
c) the time allotted to paediatrics should be increased with
longer postings.
iv) The following areas
were important for PHI practice:
a) infectious diseases;
b) immunization schedule, its complications;
c) diarrhoeal disorders, gastrointestinal infections;
d) management/practical treatment of dehydration in detail;
e) neonatology - in relation to obstetrics;
f) pharmacology - rational prescribing of drugs;
g) URTl/respiratory tract infections;
h) convulsions;
i) nutrition;
j) neonatal and paediatric resuscitation should be taught well,
with management of emergencies, practice on cadavers;
k) overall focus to be on common diseases;
1) the understanding and study of the normal child needs
greater emphasis;
m) weightage to be given to social paediatrics rather than
just theoretical/academic aspects;
n) community orientation especially regarding nutrition is
needed;
o) the importance of useful domiciliary measures can be stressed.
This will suit the community better and give the doctor
greater involvement in the given setting.
v) Regarding the teaching, the comments were:
a) they felt the need to be exposed to more cases.
"Those who
are working in villages need to have more experience in this
field. And we must know simple methods of tackling ordinary
problems/common diseases - what one requires is practical
knowledge rather than theory".
b) during the training there was tendency to concentrate on
the more unusual cases like Kephrotic Syndrome, Congenital
Heart Disease etc., while in the PHI most of the patients
needed immunization, nutritional supplementation and
treatment for coughs and colds.
c) students to work in OPDs,carryout simple investigations,
follow up patients in the community.
c) every student must work in a well baby clinic and
participate in immunization programmes.
57
e) each student should follow up 1-2 admissions/week
from OPD and casualty, do the work up in the wards and
be fully in charge of patients till discharge.
f) should learn how to approach a patient within the
set-up available in a peripheral centre and when to
refer a case to a bigger centre.
g) much more ward work with involvement in patient
management.
h) last l=j years to be devoted only to Medicine, Surgery,
Paediatrics and Obstetrics and Gynaecology.
i) small group teaching to be used, with senior students
working with junior students.
j) theory lecturesto be minimized.
k) paediatric hand books of CMC-Vellore are very handy.
1) more practical experience with incubator management/lV
cut downs is essential,as this is often required and
difficult to do.
m) since the internship posting is only for a month it
would be better to be trained in these procedures during
the pre-exam postings.
n) "When we get out after internship we feel so inefficient.
It would be better to train us to think and act rather
than do only what is told".
o) nursery posting should be given to all interns.
p) "Boring teachers. What a difference they make!
3.5 PREVENTIVE AND SOCIAL MEDICINE / COMMUNITY MEDICINE
i) Most respondents felt that the subject was important
particularly for rural practice as well as for the situation
in India, however several (18) felt that the training was
inadequate. The language use also was indicative of a
sense of irritation, about several aspects about the subject/
the training/internshir? etc.
ii) As with the other clinical subjects there was only one
respondent who had "no comment" and one who thought that it
was of no use "since there was not much change in the life
of people".
iii) Areas that were identified as being important were:
a) Need for better coverage of preventive aspects eg.,
immunization.
b) need for better coverage of management aspects.
c) how to organize/actually work out feasible health
programmes in the village.
58.
d) nutrition especially regarding use of local foods available.
e) methods of health education of the public within the time
available when one is practising medicine as well eg., use
of posters, audiovisual equipment etc.
f) school health and the training of school children as health
guides.
a) occupational health.
h) epidemiology and statistics.
i) use of different methods of communication.
. j) to assess the public health problems of a community through
surveys and to be able to evolve a simple practical strategy
for implementation.
k) to be able to identify local health and economic needs and
also to be able to identify and muster resources to help
meet the needs.
1) greater stress to be given on how to organize a community
health centre, how to organize extension programmes, how
to avail of existing facilities under various (government)
programmes etc., rather than having only didactic lectures
on the National Tuberculosis and Malaria control programmes
etc., at the macro level alone.
m) discussion on the common types of problems in community work.
n) community health orientation with the total approach towards
development using health as an entry point to the community.
iv) Comments/suggestions about the teaching were:
a) students should be taught the organizational and
administrative aspects of conducting programmes for
immunization, mother and child health, family planning.
b) students should participate in the training of community
health workers.
c) an emphasis even in PSI’./CM on acquisition of clinical skills
was important with posting of interns to centres where
in-patient facilities are also available.
d) it was felt that it would be better if teaching of the
subject could also give importance to what basic doctor's
could do on their own in their settings.
e) the teaching could be made more interesting with the use
of si ices/films, practical work in the field.
f) there is need for more guidance of interns in the field
during PSM postings.
g) more importance may be given to this subject by sending
students to the villages more frequently and making them
work there. One respondent felt that atleast 1 year may be
given to this subject.
h) it was suggested that the 3 month internship coulc be done
as ar. apprenticeship ir. periferal hospital/health centres sc that "one gets a taste of things to come in the future".
i) exam orientation shoulc be dropped.
j)
there should be a complete reorganization of the present
set up including the system and syllabus which should be
tuned to the needs of the Primary Health Centre medical
officer.
k)
another respondent felt that
"1. lecture classes should be abandoned immediately;
2. the available books are quite insufficient to make
the subject interesting;
3. too much time is spent learning definitions and
reporting, rather than understanding the significance
of programmes;
4. no teacher should be appointed according to University
degrees. They should not be allowed to teach unless
they have concrete experience of work in the field".
1) there should be a minimum of lectures and more of field
work. Greater use of community based teaching is essential
m) it was expressed by several respondents that the subject
should be made more interesting, more practical with more
field work.
n) since students do not seem to respond to present methods
of teaching it was suggested that they could be modified
and they could take up different projects to work on.
o) the present 3 month posting in PSM was considered a waste
by many respondents.
p) it was felt that the subject was made boring due to undue
importance being given to unnecessary lectures on latrines
wells and "other like". Practical demonstrations of these
with a simple visit would be more beneficial.
Innumerable "definitions" weie also considered "a bore".
Instead it was felt that lecture hours could be used for
stucy/practice of management of clinical illness in
relation to the community.
) Other comments / suggestions were:
a) The Departments of Community liedicine should, give the lead
in the community orientation of medical teaching.
The lifestyle and the teachings of the doctors should be
relevant to the community.
b'
it was suggested that there should be a direct contact
between rural service doctors and the PSM/CH Department
with a special cell created to respond to different needs.
c) one of the problems mentioned was that of a single doctor
ir. a hospital with no community health programme and
without availability of basic staff.
c) it was mentioned by one respondent that "the Department
has poorly motivated staff, with stress on the seemingly
useless aspects of FSE (Pseu6o PSI4), with a total lack of
practicality and a lack of basic ethics, so much so that
even interested persons get no motivation".
60
e) the textbook (Park & Park) was suggested by one as a
treatment for insommial
f) it was felt that most of what was studied in the
college is not being carried out in the'field.
g) this was considered "a highly debatable department
which could do a lot but was not able to. If a PSM
teacher was really wanting to, they could influence a
number of students and totally change their attitude
towards "health" and "society".
3.6 PSYCHIATRY
i) Of the 53 respondents, 1 did not undergo a formal training
in psychiatry during the undergraduate course, 6 offered
no comment, 1 said it was not relevant to work in PHIs and
1 felt that training in it could be reduced.
ii) A majority of the other 44 respondents felt that greater
importance needs to b given to the subjects as "50-60% of
patients seen in the peripheral hospital had an associated
psychological problem" and "20-25% of the OPD in any
hospital consists of primary psychiatric/associatea
psychiatric illnesses" etc., i.e. they felt it had great
practical importance to any general practice. Even those
who did not pay attention to it during their student years,
found that it was "extremely important ".
iii) Some of the common problems encountered in rural practice
were:
a) depression - presenting as a physical illness and
accounting for a large percentage of the patients who
attend OPD;
b) alcoholism - need for kncwledge/ability to manage
de-addiction;
c) cases of mania - where practical management is very
important;
c) attempted suicides;
e) neurosis;
f) hysteria;
g) mental retardation - how to manage, what tc do?
h) psychotics ("I-'.adpersons") how to deal with them in the
community.
iv) The suggestions and comments regarding the teaching were
as follows:
a) more working hours need to be allotted to psychiatrya posting of 3 months could be introduced rather than
the present 1 month;
b) a separate paper should be introduced;
61
c) the focus should be on problems likely to be faced
by a Primary Health Centre doctor;
a) it would be better if the posting to the psychiatric
unit is given at a later stage, during the clinical
years of study;
e) this is one of the fields making rapid strides as far
as advancement of medical knowledge is concerned.
Students should be put in touch with modern advances
in this subject rather than undergoing repetitions of
old theories;
f) emphasis should be given to the social implications;
g) because of the psycho-somatic background in a large
proportion of illnesses knowledge about psychiatry is
useful in all clinical settings and in all cases;
h) greater clinical exposure and practical knowledge is
necessary;
i) we should be trained to take psychiatric histories;
j) relevance of different drugs should be taught;
k) students need training in counselling patients;
1) should have regular case presentations followed by
analysis/discussion. Classroom lectures could be
reduced;
m) in its present form, which is very drug oriented, it is
“useless". Students must be taught how to talk to and
to counsel psychiatric patients;
n) need to be able to identify common psychiatric problems
and to have a definite knowledge about some serious
disorders. This will enable doctors to intervene to
help patients, and also to know when to refer;
o) this is an area wherein a young and fresh doctor is not
confident and in which problems are faced very ,often.
The idea that it is a "short-posting" needs to be
removed;
Thus longer and wider exposure to the subject is needed.
3.7 3ERHAT0LCGY
i; Five respondents out of 53 offered "no comments" but not
one said that Dermatology was not useful.
Cf the eight
who mentioned that it was useful/relevant four termed it
as being imocrtant/very very useful/essential ;
ii) Common skin conditions that presentee to the PHIs that
were mentioned by some of them, included:
a} fungal infections;
b) allergic conditions;
c) Hansens Disease;
62
d) nutritional skin problems;
e) STD's ("in keeping with the change in times");
f) scabies;
g) eczema;
h) lice infestation;
i) pyoderma;
j) dandruff;
k) falling hair;
1) cracks in the feet;
iii) Among the suggestions/comments were the following:
a) Several (15) said that the posting should be longer
with more exposure to common disorders since a fair
proportion of the OPD load in peripheral health centres
were dermatological. The present 15 days posting is
inadequate;
b) graduates need to be able to recognise/diagnose common
skin lessons.
They should be able to perform simple tests and to
treat the above;
c) there should be an emphasis on proper therapeutics.
"Blind treatment" is very commonly resorted to with
an ointment containing a combination of steroids,
antibiotics, antifungals for any dermatological condition;
d) proficiency in skin biopsy techniques (for patients
suspected of having leprosy) needs special emphasis
and also in the treatment of Hansen's disease;
e) emphasis should be given to the importance of proper
diagnosis of conditions and deciding when to treat
actually and when not to;
f) common diseases should be covered in sufficient detail,
and students should be able to see adequate number of
cases of each of them;
g) it is not taught adequately. There is no prescribed
textbook-in the curriculum at the MBBS level;
i) again the concept that it is a "short posting" should
be removed
.£ OPHTHALMOLOGY
i) Of the 53 respondents, 5 offered "no comment" 3 felt that
the subject was not useful to practice in periferal health
institutions and a further 6 specified that it was not
very useful as people preferred to co to specialists for
ophthalmic problems.
ii) Cf the remaining 39, 16 felt that the training received
was adequate and 1 thought that it was inadequate.
63.
iii) The following areas should be well covered, with adequate
clinical exposure also ensured:
a) acute conditions, including trauma to the eye, and
removal of foreign bodies;
b) infections, particularly conjunctivitis which are
common;
c) problems relating to the anterior part of the eye;
d) detection of serious conditions at an early stage and
to be able to differentiate them from benign conditions;
e) refraction, evaluation of vision;
f) diagnosis and treatment of cataract, glaucoma, Vitamin k
deficiency and trachoma
iv) Regarding the teaching, the suggestions were:
a) the details of operative procedures could be deleted
or reduced;
b) students should be able to participate in mobile
ophthalmic clinics and camps;
c) students should be taught about the preventive aspects
of ophthalmology such as nutritious diet, prevention
of ophthalmic trauma, and organization of village
outreach programmes for the prevention of blindness;
d) there should be greater emphasis on common problems,
with less importance givento "exam" cases;
e) the respondents suggested that if doctors in rural
medical practice were given adequate training in
retinoscopy and in determination of refractive errors
there would not be a need to refer such cases to the
ophthal rrologist/refraction!st;
f) there was a suggestion that there could be an internship
posting (which was not presently there), keeping in
mind the situation at the PHC level, and the prob]ems
faced by a doctor there;
g) importance in teaching to be given to practical
experience gained from the community and in dealing
with OPE cases rather than theory.
3.9
e.i:,t.
(OTOR:-:i:;cLA.Rn;GOLCGY)
i) Cf the 53 respondents, 8 offered no comments and 3 felt
that the subject was not very useful to practice in a
periferal health institution. Cf these 1 mentioned that
an EPT surgeon managed the cases.
Thirteen respondents felt that the coverage was adequate
and 2 thought it was inadequate.
64 .
iii) Suggestions regarding some important areas to be covered
are:
a) management of epistaxis;
b) removal of foreign bodies and wax;
c) children with ENT problems are seen quite commonly
in daily practice, eg.,
- tonsillitis;
- chronic Suppurative Otitis Media (CSOM);
(discharging ears)
- running nose - upper respiratory tract infections,
rhinitis;
- foreign body.
There was a suggestion that the teaching could be
combined with paediatrics.
d) problem of external ear;
e) giddiness
iv)
Suggestions regarding teaching were:
a) Students need to get more practical experience with
basic procedures like syringing, otoscopy, foreign
body removal. This was presently difficult as the batches
for clinical postings were too large;
b) repair of ear lobes is also important;
c) emphasis on rational therapeutics;
d) students should be taught about preventive aspects;
e) the focus should be on recognition and management of
common problems in a rural setting. The PHC and the
doctor there should be kept in mind;
f) details of operative procedures could be reduced or
deleted;
g) importance to be given to the gaining of practical
experience from working with patients in the OPD, and
in the community, rather than on theory;
h) a few suggested a short posting during internship.
3.10 RADIOLOGY
The suggestions / comments given were as follows:
a) Students should be trained to diagnose common conditions
from X-rays;
b) Students should get adequate experience in the
interpretation of the following types of X-rays:
1)
2)
3)
4)
5)
6)
X-rays of the abdomen;
chest X-rays;
different types of fractures;
barium studies;
some congenilal anomalies - this is more rare;
the importance of the diagnosis of Tuberculosis was
mentioned.
65.
c) Proficiency in the interpretation of chest X-ray films
should be stressed as this is one of the most useful
investigations which may be useful in diagnosing many
conditions.
d) More experience in the reading of plain X-rays is
necessary which should be taught in the context of
patients during clinics or rounds.
e) Most rural health institutions (voluntary sector) are
equipped with X-ray facilities wihtout a technician.
f) An elementary knowledge about taking and developing films
will help the graduate in certain situations.
g) Basic knowledge of handling X-ray equipment (technical
aspects)is useful.
h) Should have compulsory tutorials and postings during
Final MBBS and internship.
i) Reading of X-rays should be part of the training in
different departments.
j) Students and interns presently do not take radiology very
seriously. The importance of the subject needs to be
stressed, particularly in Medicine and Surgery.
k) Six respondents stated that the present coverage was
inadequate and it should be further strengthened by
allotting more working hours/stressing its importance.
1) One respondent felt that they could also be trained to
carry out safe contrast studies.
m) Use of a screening machine should also be taught.
n) Exotic views and sophisticated contrast X-rays and the
rapid developments taking place in the field of imaging
are not so useful in the perifery.
3.11 ANAESTHESIOLOGY
The suggestions/comments given were as follows:
i) The usefulness of periferal/regional/local nerve blocks
in the PHIs was mentioned by several respondents (11).
Most of them suggested that practical training was
necessary in this area which was important to be able to
do minor surgical procedures. It could be taught along
with subjects like Surgery and Orthopaedics. Sometimes
dental cases also have to be handled, therefore
knowledge regarding irandibular nerve blocks etc., are
useful .
ii) Similar was the need for experience in spinal anaesthesia
fcr caeserians/ap: encicectomies, especially in peri feral
hospitals that have an operation theatre but no
anaesthetist/trained nurses to work there. Therefore
experience in doing lumbar punctures is also necessary.
66.
iii) Doctors should be able to administer anaesthesia in
emergency cases.
All resuscitatine measures should be taught properly;
iv) It is necessary to know how to intubate a patient and
how to ventilate a patient if he/she cannot be intubated.
v) Some knowledge/ability to give general anaesthesia as
open drip either/short time IV anaesthesia etc., would
be useful. Knowledge of what drugs to be used,
precautions to be taken etc., should be given;
vi) It is important to teach the complications of spinal
anaesthesia and general anaesthesia.
vii) A few felt that longer exposure, with perhaps a 2 week
posting during internship would be useful;
viii) Only 1 respondent felt that the subject was not needed
at all and should be offered as an elective
3.12 ORTHOPAEDICS
(NOTE: A question on this subject was not included in the
questionnaire given to 10 respondents, therefore
the total number of responses are less).
The suggestions / comments were as follows:
i) Several respondents felt that this was a very important
subject from the point of view of practice in periferal
health institutions and they felt they needed to be
more adequately prepared in it.
To quote:
"I regret that I could not even handle simple Colles
fractures though they were so common (during the mango
season for example when kids fall off trees)".
"These are very very common problems in rural practice
since falls and fractures occur frequently. There are
often no radiological facilities and nc technicians to
apply the plaster of Paris cast".
ii) Emphasis to be given to first aid measures and trauma
care while transferinc patients to referral centres.
iii) Casualty postings should be compulsory to get exposure
to orthopaedic procedures.
iv) A posting in orthopaedics should be a must during
internship - preferably of a month's curation.
v) Severe! respondents mentioned that practical experience
was essential.
"Theory does not help 5% in a rural setting".
vi) Specific areas mentioned in which skills were needed included:
a) diagnosis of fractures, closed reduction of fractures/
dislocations eg., of common reducible fractures, Cones
fractures, dislocation of the shoulder.
67
b) application of a plaster of Paris cast;
c) how to give an intra-articular injection and more
important when to give one;
d) treatment of osteoathritis;
e) bandaging, application of splints;
f) recognition and treatment of complications of
application of plasters;
g) post-operative/post-plaster exercises;
h) to 'know when to refer to a higher centre;
i) to be aware that the complications of certain
therapeutic measures can be more disastious than
the original injury;
j) portions on tumours, detailed operative procedures
could be reduced/deleted.
vii) Several respondents felt that the teaching was inadequate
and mainly exam oriented.
viii) This is also a field in which a fresh graduate is not
confidant and wherein he may face problems very often.
ix) Again the idea that this was a “short posting" and
therefore relatively unimportant should be removed.
3.13 DENTISTRY
i) Several respondents felt that a fair number of patients
came with dental complaints to periferal health
institutions,
Most often there were no trained dentists
available in such situations. The knowledge that a
medical graduate has is toe superficial to do anything.
ii) They therefore suggested that it was necessary to have
some basic knowledge regarding:
a) the scope of dentistry;
b) how to extract teeth;should have more exposure to cases
and chances to extract teeth.- "this can be done with
some training and self confidence". The clinical batches
were toe large. Mere attention needs to be given to
rracticals.
"Theory can always be studied on one's own".
c’ '.-.'hen a tooth extraction can be done by a non-dentist;
c) even if teeth extraction is not done, the doctor should
know when they need to be pulled out, what to expect
= r.d what tc do after they have been pulled out by
somecne else;
e; experience in giving mandibular nerve blocks;
f) management of eruption of last molar;
68
g) treatment of dental caries;
h) treatment of pyorrhoea;
i) treatment of abscesses;
j) when to refer;
iii) One of the respondents took a special training in
dentistry before going to the PHI. He found it very
useful and recommends it to all graduates who opt for
rural practice.
iv) Cne respondent felt that a 15 days posting was adequate
for those who were not going to have to respond to
dental problems.
3.14 SEVERAL OTHER GENERAL SUGGESTIONS INCLUDED
i) Urgent need for training in emergency medicine and
emergency procedures eg.,
venesections, endotracheal intubations, tracheostomies,
management of epistaxis, management of fractures, burns,
pnenomothorax (intercostal tube placement).
ii) The teaching to focus mainly on common diseases, so that
a fresh graduate can recognise them, treat them and know
when to refer them.
iii) A working knowledge about running a pharmacy.
iv) Awareness about the economic situation of the patients
will help in the general management. Linkages w’ith
voluntary/funding/helping agencies can be incorporated
into the hospital.
v) A brief knowledge about the "Alternative systems of
Medicine" particularly Ayurveda and Homeopathy will be
useful. Since these are commonly used in rural areas,
doctors should know more about their advantages and
limitations so that they can educate the people too.
vi) The concept of holistic health needs to be imparted to
students.
vii) The whole of medical education is oriented towards big
hcspital/referral hospital practice, making work in rural
areas very insignificant and not at all glamorous.
Therefore during clinical case discussions and during
internship every case seen or discussed should end with
what can be done for the case management in a rural set
up with only a few basic facilities available. This
should be done in as many cases as possible, like the
last paragraph in most chapters of "Mudaliar Textbook
of Obstetrics".
69.
viii) First Aid to be taught (to 1st EBBS students);
ix) some basic ideas about physiotherapy to be taught;
x)
basic concepts of ultrasonography and CAT-SCAN to be
included with the major subjects;
xi) The importance of leprosy to be highlighted. Even
medically trained persons are reluctant to take this up.
70
4. ADDITIONAL AREAS / SUBJECTS
4.1 MEDICAL ETHICS
The comments / suggestions were as follows:
i) Among those who felt that it was not necessary/relevant
there were some strong reactions:
a) that there were too many unethical doctors around
for the subject to be applicable (though another respon
dent felt
that this same reason justified a need
for medical ethics to be a subject for discussion).
b) that "medical ethics" depends upon a person's
ethics, and a stress on right over wrong was what
was important;
c) the ethical/practices by the management seemed to be
a cause of irritation;
d) this aspect cannot be dealt by theoretical discussion,
but needs to be practised and followed.
ii) Reasons given for its importance/necessity included:
a) A strong and ethical grounding is required to help
a young doctor to be steadfast and not be 'converted',
as one of the first experiences encountered in practice
is that of unethical medical practitioners "who try to
cut you down, while you try your best to stick to
ethical and correct means"
b) the subject is particularly relevant and meaningful
in the present day highly technical, sophisticated
and competitive situation;
c) this is a vital aspect to a good medical approach;
d) one of the respondents said that though the subject
seemed irksome during the undergraduate days, it
provided a very useful background to several
difficult situations in the field;
e) this is particularly relevant in the context of the
general deterioration in values in society, including
those of the medical profession.
Therefore young doctors should be enabled to hold on
to ethical values in medical practice and thus also
to be an example to others;
f) this is essential in the Indian context due to lack
cf legal restrictions.
iii) Suggestions regarding areas to be covered were:
a) It should include aspects like treating the poor,
using rational therapeutics in medical practice,
therefore affecting the type of drugs prescribed, the
choice cf investigations etc.
b) the caring aspect of a doctor-patient relationship.
c) The subject should include the followings
1. having a human approach to patients;
2. right of the patient to get.information and a
proper explanation about the disease;
3. patient to be informed about the progress,
treatment and adverse effects, of treatment;
4, duties towards the patient.
d) the illiteracy and ignorance of people is being
exploited by private practitioners and illegal medical
practitioners using unethical means;
iv) Suggestions regarding the teaching were:
a) the teaching should include greater interaction with
people in practice who know the ethical problems they
face;
b) the issues raised by this subject should be experienced
at the bedside of every patient, by every student while
watching the consultants - through their daily working
attitudes and behaviour;
c) it is essential to discuss the subject during
internship as well;
o) the indepth inculcation of values such as speaking the
truth, not exploiting/cheating patients etc., should
be done through discussions, debates, seminars.
This is especially necessary as several people these
days do not have these values on the basis of religion.
It will go a long way towards influencing the future of
doctors.
4.2 BASIC NURSING PROCEDURES
i) hhile five respondents gsve no comment, not one said that
knowledge and skills regarding basic nursing procedures
were not useful or necessary. On the other hand several (13)
felt that the training was inadequate in this aspect.
The following statement sums up the general feedback
"suddenly during internship the internee is supposed to
have all the skills in basic nursing procedures, without
proper training". There is therefore scope for further
strengthening the course in this respect.
ii) Emphasis to be given to the following aspects:
a) bandaging;
b) starting an IV line and IV fluid administration;
c) aivinc intramuscular and subcutaneous injections;
Z7 i '^C]
C'/V/
,
, ..
COMMUNITY HEALTH CEU
326, V Main; I Block
Korarrmngala
Bangalore-560034
rndia
72
d) giving soap and water enemas and bowel wash;
e) giving steam inhalations;
f) applying traction;
g) care of the unconscious patient;
h) passing a naso-gastric tube;
i) catheterization;
j) doing dressings;
k) effecting the passage of constipated stools at
different age groups;
1) basic running of a CSSD/autoclave.
iii) The general suggestions / comments given were;
a) All nursing procedures ordered by a doctor should be
done by him/her atleast once during their lifetime;
b) these techniques should be learnt by doing the job,
while working in the wards;
c) they should form a regular part of a students duties
throughout the clinical years and should not be taught
just by classes;
o) it should be included in the curriculum;
e) it could be made a separate subject with a 3-6 month
posting in the preclinical years;
f) it is necessary to be confident about these procedures
both to carry them out as well as to give instructions
as and when is required;
g) all nursing procedures useful in periferal centres
should be taught - they should be trained in such a
way as to manage cases without the aid of nursing staff;
h) skills should be acquired during studentship itself
and increased during internship;
i) the nurse-doctor relationship and attitudes need to be
restructured. Medical students often feel that "these
jobs are too low fcr us".
4.3 CCMMUKICATICK SKILLS
i) There were varying opinions on the topic of 'communication1
including a couple of question marks! Fifteen respondents
gave nc comments while two felt it was not necessary.
Thirteen felt it was adequately covered.
ii) The suggestions / comments were as follow’s:
a) the importance of knowing the language should be
emphasised. Language classes to be held;
bi communication with others is very important in small
periferal centres, unlike in a medical college;
73
c) it is a personalised skill that each medical student
should acquire. It helps in the creation of a smooth
working environment and in medical practice;
d) it is necessary for the creation of a repport with
the patient for reassurance, to be told about the
disease etc., all of which helps in treatment
compliance;
e) students should be taught more on how to talk to
patients and develop a good rapport with them, as this
will definitely affect the healing process;
f) it is necessary to communicate with patients relatives
as well;
g) it is important as part of the art of getting along
with colleagues of different age groups;
h) students should be encouraged to talk to patients beyond
mere history taking oriented towards fulfilling
examination requirements;
i) lack of communication skills can handicap a doctor who
may have even been a rank student;
j) over time one develops methods of communication
overcoming barriers of language and culture;
k) communication skills are needed for a doctor to
interact at different levels in work as shown
Colleagues •
Community--doctor—patient/relatives
Nurse ’
1) it is important in community work eg., techniques of
reaching out to a new population group, especially a
hostile one.
Muchdepends on the readiness/willingness to get
involved with the community;
m) need to overcome communication barriers or gaps at all
levels, in every place and cadre;
n) need tc use and develop indigenous forms of communication;
o) need tc understand the effect on the patient of different
styles/modes cf communication eg., what the patient
understands and remembers.
Suggestions / comments were as follows:
i) A basic idea regarding running a small hospital is needed.
This is especially important when working in peripheral
areas when one is often required to make vital decisions.
74 .
ii) This is very much needed as the young doctors were often
incharge of health centres and need
to know how to
manage. It is important for efficient general practice.
iii) Important for the improved running of small hospitals;
iv) Areas that were mentioned were:
a) delegation of work;
b) how to set up evaluation systems;
c) how to buy equipment / purchasing in general;
o) how to run a pharmacy;
e) how to run a small laboratory;
f) how to 1 manage1/deal with supervisors/employees;
g) optimum management of resources at their disposal in small peripheral centres;
h) labour laws;
i) accounting;
j) market policies;
k) personnel management;
v) The subject should be introduced during studentship and
interns should be given more responsibility to develop
this skill.
vi) There should be postings to the Accounts section, Medical
Records Department, Central Sterile Supplies Department, etc.
vii) The subject could be dealt with in respect to the 3
following types of work:
s)
to Dispensaries;
b) to Primary Health Centres;
c) to Hospitals.
viii) It is taught as part of Community Health
TRAIwIMG CF HEALTH WORKERS / OTHER PERSONNEL
i) Though this is not a "regular" part of the undergraduate
medical curriculum it was considered important from the
point of view of community orientation of Medical Education.
Only eleven resoondents showed a lack of interest by not
giving comments.
ii) Comments / suggestions given were as follows:
a) "Ability to train health workers can be useful. V.'e
were not really trained to do so, but made improvisations
on the job".
b) "Undergraduates/interns need to be taught the art
or demonstrated the same, atleast once in a way during
their 3 month rural posting".
75
c) Many health personnel/staff working in PHIs are
untrained or insufficiently trained. They could be
helped by training to perform better and more
confidently.
o) several of the respondents were involved in the
training/on the job continuing education of a variety
of health personnel viz., nurses, laboratory
technicians, multipurpose health workers, village
health workers etc.
e) it was felt that it was very essential to learn about
teaching methodology, the use of audio-visual aids,
the development of course content;
f) exposure to and active participation in such schemes
during internship would be meaningful;
g) this will definitely help in medical outreach programmes;
h) the focus on training health workers should be to
transmit vital information on the preventive aspects
of medicine;
i) it should be taught as a pre-professional placement
i.e., a compulsory 3 month course before a person goes
for their line of choice;
j) another respondent felt that graduates should participate
in these programmes and gain practical experience after
internship;
k) an important aspect should be how to simplify subjects/
health messages;
1) it is also important to learn how to motivate health
workers;
m) one respondent felt that during selection of personnel
for such courses, importance should not be given to
marks as in any other profession,but rather to their
attitudes and motivation towards the community;
n) the respondent also felt that multipurpose workers and
village health workers were being used for hospital
work (nursing) and hostel work (including in the kitchen)
and are not being taught what is necessary in the field.
More teaching should be given on preventive and curative
medicine.
4.6 OTHER SKILLS I.ECESSARY FOR WORK IK PHIs
Several very interesting suggestions were given along with
reemphasis of points raised earlier. These were:
a) Heed to emphasise practical application in all
subj ects;
fields/
b) need to have an orientation for community work "since medical
colleges impart an upper strata type of everything".
c) the most important part of the training was internship.
"This should be preserved and not changed, as it is beginning
to happen now".
76
d) need for training in emergency medicine and emergency
procedures;
e) more exposure to clinical subjects in peripheral settings;
f) more training in Obstetrics;
g) surgical skills;
h) handling of medico legal cases;
i) managerial coaching, basic lessons on hospital administration;
j) problem oriented, practical training;
k) ability to impart health education;
1) ability to explain / organise medical programmes at the
community level;
m) patient management starts with investigations and includes
drugs, procedures, reassurance and proper instructions.
Investigations and drugs are quite costly. This should
repeatedly be given emphasis as there is a tendency to do
things routinely. Instructions too are important or else
everything else done for the patient can be brought to naught.
n) an • introduction/orientation about the problems that can
arise with the hospital managements and about clinical
practice in general in the setting of peripheral health
institutions. A "setting time of 4-6 months" is usually
required for eny fresh graduate when he/she starts practice
for the first time;
c) determination and development of the practical essentials
of a basic doctor;
p) confidence and personality development;
q) A doctor should be a leader in society;
r) skill to deal with politicians, administrators, government
authorities, writing complaints for public health etc.
s) A keen social and political sense;
t) cooking, other outdoor pastimes like trekking, rock climbing.
Any other hobby, sports or anything;
u) any form of self-defence skills! - police are non-existent
in rural areas
77
5. GENERAL ASPECTS OF THE HELICAL CCURSE
5.1 SELECTION PROCESS
i) In the context of work in PHIs, the comments/suggestions
were:
a) More people from backward areas/rural areas w’here there
is a lack of doctors, should be given preference;
b) It is not brilliance that is required but commitment,
dedication and hard work;
c) Students should be older and more mature, probably
after having completed the degree course;
d) Selection should not be
1. money oriented; or b) merit oriented but;
2. aptitude oriented ; service oriented.
e) One should choose the kind of personalities who will
be able to work at the expense of a social life;
f) Strike out the reservation only based on caste and
introduce a reservation for those who want to commit
themselves to work in needy areas of the State for
10 years either with the voluntary sector or the
government sector.
The needy areas should be pre-determined from data
available from the State and preference given to
resident students from that area.
g) For admission, merit should not be the only criteria.
During the written examination and interviews views
of the students regarding society should be elicited,
their reaction to society and preparedness to give
their service to the rural poor;
h) There should be an entrance exam. Ten percent of seats
could be allotted for those who secure the highest
marks. The rest could be selected on an area wise,
quota basis in accordance with the performance at the
entrance exam. Students should sign a bond that they
must serve in rural areas of their home district for
5 years. Five per cent of seats should be reserved for
candidates from other states;
i) Students should be shown the minimum bondages under the
State rules that candidates will have to fulfil under
each degree/diploma course,as their part in reciprocating
the expenditure incurred by the State for their higher
education;
j) After the 12th standard, students should spend some time
in various colleges according to their choice to help
them make a decision about career choice;
k) Rather than arbitrarily selecting candidates with the
best marks or according to caste based or regional
quotas - the selection should be able to identify some
students who would be academics, some teachers, some
good general practitioners and some who will go to
rural areas;
78
1) Aptitude for the subject is a must. In some cases
parents force their children to take up the medical
profession. This makes intelligent students fail
in the field;
m) Selection should avoid much reservation to be of a
uniform standard. It must be merit based apd never
capitation;
n) The selection should be purely on merit
basis of extra-curricular activities;
and on the
o) Equal importance should be given to the interview
and entrance exam;
p) The selection process should include a premedical
examination, an interview, plus psychoanalysis and
personality testing;
q) The selection must be absolutely
favouritism whatsoever;
fair, without any
r) One respondent felt that a little more emphasis needs
to be given to the academic abilities of candidates.
ii) Eighteen gave no comment, 3 said they had no idea of how
it was done and seven felt that the present procedure was
f ine.
5.2 TE.-.C.HTEG METHODOLOGY
i) Twelve respondents gave no comment. Nine felt that the
methodology being used was adequate / good.
ii) Areas of problem related to teaching in which some change
needs to be brought about included:
a) There is need for a lot of improvement, especially in
presentation;
b) There is a need for committed teachers "who bother to
prepare for lectures and to practice presentation";
c) The teaching should not be exam
and it should not be hurried;
and marks oriented
d) Inter-departmental frictions to be reduced as they
affect the student adversely;
e) Teachers should build their careers as teachers primarily
and not as private practitioners.
Persons from, the regular stream cf health services should
not be teachers. The only exception is PSM for which
practical field experience is the best criterion to be
a teacher;
f) "In some departments, we are expected to know everything
in the first class itself, which is absurd".
79
iii) The respondents understood the term "teaching methodology"
in a broader sense and did not confine it only to pedagogy.
Suggestions/comnents were;
a) Several respondents felt that the number of lectures
could be reduced;
b) It was expressed by many that studying a subject would
become easier and more interesting if audiovisual aids
are used;
c) Similarly, greater use of practical demonstrations would
be useful;
d) The entire approach should be more practical rather than
theoretical - with emphasis on the "practising part of
a doctor's work";
e) Teaching should be problem oriented not disease oriented;
f) Need for greater coordination between the curricula of
the pre, para and clinical sections, eg., "by the time
the student sees his first hernia, he has forgotten the
anatomy of the inguinal region - as during anatomy he
was also preoccupied with the structures under the
gluteus maximus and thought they were all equally
important" ;
g) Combined (integrated) teaching on issues. Anatomy,
Physiology and Biochemistry teachers could take joint
sessions on a particular topic eg.. Respiration. A
total interaction of all subjects around patients would
help the learning process so much more, eg., if Anatomy,
Physiology and the clinical teachers could teach their
respective subjects in relation to a ten year old male
child with Rheumatic Heart Disease - Mitral Stenosis in
congestive heart failure;
h) Clinical orientation with emphasis on practical management
is required especially in the pre and para clinical
sections;
i) There needs to be an orientation of the teachers themselves
towards the Primary Health Centre and their problems;
j) There should be more ward work. Medical students need
to learn practical work in the wards like student
nurses do;
k) A useful combination of theory and practicals with greater
emphasis on clinics would be helpful;
1) Instead of being taught to "present cases" only, the
stress should be on a coordinated way of assessing the
history, the symptoms, findings on examination and the
investications and arriving at an understanding of the
systems involved ir. a diagnosis;
r) Students should spend much more time in the wards from
the first year onwards. They should be part of the
units and take responsibility for patient care. The
present trend is to attend the wards to pass exams.
Very' few students come to the wards to learn to be good
basic doctors;
80
n) The teaching should be directed towards:
1. what is expected of the graduate at
the end of the
course;
2. to stimulate and awaken an interest in the course.
o) More time should be spent in the basic clinical
facilities and less in the super-specialities;
p) Basics should be emphasised;
q) Common ailments and common problems of India like
Hansen's Disease and Tuberculosis should be given greater
importance rather than vague, rare diseases;
r) During ward work students should be incharge of patients,
their treatment and progress and thus develop a "feel"
for patient management".
“These days ward work only consists of clinics on exam
cases. Few students know twhat is happening to the
patient";
s) The stress should be on the independent management of
common diseases with the use of minimal investigative
facilities;
iv) One respondent felt that it was heartening that the present
generation of teachers are able to understand, communicate
and guide properly.
5.3 CURRICULUM STRUCTURE / TIME FRAMEWORK / SEMESTER BREAK-UP etc
i) Eighteen respondents offered no comments to this question.
Nine respondents felt that the present system was adequate;
ii) Suggestions and comments regarding the pre and para
clinical phases are as follows:
a) The present semester system in the pre and para-clinical
years is too subject oriented and does not appear to be
an integrated part of the overall medical education;
b) There is no relationship and no interaction between
the pre, para and clinical phases. Hence each subject
loses its importance and applicability;
c) Several respondents mentioned that Anatomy, Physiology
and Biochemistry should be allotted a shorter time
period than what was being given at present;
d) The semester break up for Anatomy and Physiology should
be for 2 semesters only;
e) The present time framework of classes for the pre and
para clinical subjects can be reduced by atleast one
third. This can be used more meaningfully for clinical
postings and pathology;
f) The entire pre-clinical phase could be reduced to 1 year
and taught as an integrated course of Human Biology;
g) The pre clinical and clinical subjects can be taught
simultaneously to facilitate a better understanding;
81
h) There should be a review of the pre-clinical subjects
during the clinical years.
Theory classes should be for 1’hour and practical
classes for 4 hours;
iii) A range of alternate forms of curriculum structure were
suggested which are as follows:
a) Alternate structure - 1
Anatomy
- 6 Weeks
Physiology/Biochemistry - 6 months
Pharmacology
I
Pathology
I
Microbiology
I- 1^ years
Forensic Medicine }
Preventive and
I
Social Medicine I
Clinical Subjects
- 1^ years.
b) Alternate structure - 2
Preclinical subjects
- 1
year
Paraclinical subjects - 1^ year
Clinical subjects
- 2 Years.
c) Alternate structure - 3
Anatomy, Physiology, Biochemistry - 1 year
Nursing procedures. Psychology,
Sociology, Management
- 3 months
Pharmacology, Pathology,
Microbiology
- l-i years
Clinical subjects
q)
- the
remaining period, but
reduce Gynaecology to 3 months
and add Psychiatry.
Alternate structure - 4
During the first six months:
- Vernacular and English language classes especially
medical terminology;
- Introduction to all the topics/subjects which would
be covered later;
- Methodology of how to learn, etc.
During the next 4 years:
Integrated systemwise teaching of Anatomy, Physiology,
clinical subjects, etc.
e) The first MEBS course should be reduced to 1 year,
Following this, students should join the clinical side as
part cf the treating: team and be involved in patient
management at the lowest rung. They should learn basic
nursing skills along with clinical subjects.
82
f) One respondent felt that each semester could be of a
6 month duration. All subjects presently taught over
l*j years could be divided into 3 parts. There should
be an examination after each semester and also after
all 3 semesters. It should be completely compulsory
to pass all exams.
g) Another suggestion was that there should not be any
time limit for the MBBS course or for subjects.
Frequent University exams could be held once in 3-4
months. Students can take the exams at their own
pace when they are prepared. They could then spend
less time in subjects they are not interested and more
time in areas of their special interest.
h) Yet another suggestion was that a graded system could
be introduced with a 5 year medical course that
includes a 1^ year period of internship. Following this
2 years rural service in India should be made compulsory,
for all graduates. Post graduation should be made
possible after that.
iv) Suggestions regarding clinical subjects were:
a) Final year subjects need to be broken up. Minor subjects
(ENT/Ophthalmology/Orthopaedics) should be completed 6
months earlier to reduce the load and increase the
importance of major subjects.
b) The last one or one and a half year of the course should
be utilised only for the study of Medicine, Surgery,
Obstetrics and Gynaecology and Paediatrics with practical
work like an intern.
c) Greater weightage to paediatrics, dermatology and
community medicine is needed in the curriculum time.
d) The internship training is a mcst useful part of the
curriculum and should involve a lot of hard work, and
practical training.
v) General suggestions were:
a) The teaching should be integrated with teachers from
various Departments dealing with their respective
fields.
b) Several felt that the semester system' of teaching was
good.
c) The present system: "breeds only exam-oriented students".
A six monthly semester break up with continuous
assessment would be better.
5.4 El'lAMlY.ATICi: SYSTEM
i) Fourteen respondents cave no comment on the examination
system. Twelve felt that the system was adequate out of
which three felt that it was good.
83
ii) The majority of comments about the examination system
were net very complimentory. This aspect of the
undergraduate medical course has attracted the most
negative comments. However there are also several
suggestions. A summary of comments is given, including
some in the original language of the respondents to
indicate the depth cf feeling.
iii) The comments regarding the present system were:
a) The examination system is very subjective, unreliable
and outdated.
b) There are many prejudiced examiners and the system is
often unethical.
c) Some examiners even come drunk to the
examination.
d) The examiners should be assessed before examining others.
e) The present system should be banned - there is too much
examiner bias.
f) The exams are totally irrelevant to actual medical
practice, especially in peripheral health centres. For
example, the cases given in medicine are mainly those
with cardiac-endocrine problems etc., which one hardly
comes across in peripheral practice. The cases given
in Surgery are these that are most often beyond care.
The exams should be more problem oriented regarding
common diseases and problems, how one would respond in
emergencies, etc.
g) The trend of trying to elicit what the student does not
know,rather than what he knows should be corrected.
h) "Ke are getting more and more exam oriented, while the
exams are getting less and less patient oriented".
i) "The percentage of results in some cases are prefixed
and the average and little above average are pulled down
sc as tc pass influential students, or those who have
given a bribe or those who belong to a particular
community".
j) "In some colleges, caste and community play an important
part. Sanghas of particular groups exist and even
Professors and staff belonging to the particular group
gc for meetings. This plays a role even during the
exams".
k) The system, of marks, awards, rewards was felt to be too
individualistic needing reorganization.
"There is too
much emphasis or. marks right from the entrance exam
onwards. All the prizes and awards to to those who do
well in exams and the ethers are discouraged".
1) "Final MEBS is a test of nerves more than anything else!
But nerves is what one needs for rural service!".
rr.) "Exams seem to be an indestructible and necessary evil".
n) Time limitation plays an important part in exams which
does not occur in practice.
84
iv) Suggestions for change included:
a) The focus should be to assess whether the student has
acquired the necessary knowledge and skill;
b) Several respondents felt that a system of continuous
assessment should be introduced - a cummulative/monthly,
honest working system, with assessment in the ward;
c) Multiple choice questions to be used for theory
exams;
d) Long essay type questions should not be given, objective
type questions to be used;
e) Practicals should be used to assess skillfthat are
absolutely necessary. Clinical practicals should be
only problem oriented;
f) Instead of being given one long case end two short cases,
students could be given 10-15 small cases, each with
discussion on some particular points;
g) Ethical viva exams with greater allotment of marks than
for theory were suggested;
h) Greater importance to be given to the approach and
management of patients rather than primarily to the
final diagnosis;
i) In general,exams should be problem oriented;
j) The practical application of clinical medicine should
be tested rather than only text-book knowledge;
v) Suggestions of a more general nature were:
a) A uniform examination system should be evolved for the
entire country;
b) The basic attitude towards the examinee as being
"ignorant of all" and the examiner as "knowing all" or
as an "almighty" should be broken;
c) "The holes through which corruption enters should be
sought and removed. There should be a separate
movement to stop corruption at exams".
.5 INTERNSHIP TRAINING
i) Eleven respondents gave no comments. Two felt that it
was adequate and two others that their internship experience
was good - excellent.
ii) Suggestions/corments of a general nature regarding
internship were:
"There should be less of chart care and moreof patient
care";
b) Several respondents felt that the "clerical" aspects
of an intern's work eg., copying out orders, writing
investigation slips and getting the results, writing
discharge summaries should net fill up most of the
intern's time. however there was a mention by one that
much depends on the interest taken by the interns in
learning also;
85
c) Severel respondents mentioned that internship is a
very important period of the draining, during which
confidence is built up, by taking responsibility for
patient care and taking decisions'regarding the
management under the guidance of the PG's/SUO1s/staff.
These aspects seem to be declining and therefore need
strengthening;
d) A credit system of marking could be introduced, based
on acquisition of practical skills;
e) There should be special emphasis and orientation given
towards orientation to work in a PHC;
f) If what the interns do presently is done during
studentship then the interns could be made to take
definite decisions in responsibilities for patient
management and be taught various procedures. These skills
and attitudes are necessary to be able to work effectively
in a rural hospital;
c) Interns should be trained in all aspects of preventive
and curative medicine to run a family practice;
h) Interns should acquire basic nursing skills.
iii) More specific suggestions regarding the postings to the
primary clinical and other departments were:
a) There is a need to increase emphasis on the management
of common medical and surgical emergencies especially
the technical and practical aspects. These have been
mentioned in detail under each subject heading. Also
to have discussions on decision making in emergencies,
eg., when to manage, when to refer etc.
b) It is desirable if the Medicine posting could be the
first or one of the early postings, though the logistic
problems involved in this were appreciated;
c) A posting in Dermatology is important and could be part
of the Medicine or the Community Medicine posting;
c) There should be a posting of longer duration (1 month or
15 cays) in the casualty for at least 8 hours a day;
e) A posting in orthopaedics is necessary for practical
experience for upto 1 month - this could be part of the
surgical posting;
f) There was a suggestion that urology should also be a
pert of the major surgical posting;
c) Acquiring practical skills in Obstetrics and Gynaecology
and these related to Family Planning, especially
management at the levels cf peripheral health institutions;
h; Compulsory postings in Radiology:
i) A posting in Paediatrics;
j) In departments like E’CT, Opthalmology and Rnesthesiology
the oostinc. should be atleast a month's duration;
66.
k) Posting in Dentistry;
1) There should be a posting in Pathology (clinical path
lab and blood bank);
m) Posting in Medical Records Department and Accounts
section;
n) Sessions/ciscussions on Medical Ethics to be held,
during internship.
iv) There were several suggestions, some of them differing from
each other, regarding the 3 month rural posting/posting
in community health:
a) It should be in more than one and more than one type
of centre so that they can gain a wider sphere of
experj ence;
b) This 3 month posting could be organised in established
rural peripheral/mission/voluntary sector hospitals.
Or else it could be given to the major specialities;
c) Decrease rural posting to 2 months;
d) Increase it to 4 months, but work in rural hospitals;
e) Two weeks of this to be spent in dermatology;
f) The present postings were considered a waste.
v) Regarding postings in super specialities there were
differing opinions, viz.,
a) Cut out all superspeciality electives and concentrate
on the basics;
b) There should be one month postings in each super
speciality with an increase in the duration of the
internship by 1 year;
c) A choice of a 2-4 week posting in a super speciality
should be the intern's prerogative.
vi) Several suggestions were given regarding the duration/
alternative structuring of internship postings:
a) The postings in Medicine, Surgery, Obstetrics &
Gynaecology and Paediatrics are not sufficient for
doctors to work independently in the periphery. Besides
quantitative changes mentioned above and elsewhere in
the report, the duration of the posting could also be
increased;
b) There was a suggestion that internship could be for two
years with four months each in Obstetrics & Gynaecology,
Surgery, Medicine, Paediatrics, Dermatology and
Orthopaedics;
c) The entire medical course could be 6^ years after PUC,
with atleast 1^ years spent for internship;
d) After 9 months of internship - in the major departments,
the doctor could decide/choose which of the following
87
streams they could like to opt for viz.,
- Postgradvation in a clinical speciality;
- work in a government PHC/post graduation in community
medicine;
- general practice;
- work in the voluntary sector;
Depending upon their choice, a 3 month pre-placement or
prepatory training could be given.
vii) A few mentioned that the present duration was adequate and
with qualitative change they could be more prepared for
rural work.
5.6 METHODS TO ENHANCE SOCIAL / EMOTIONAL PREPAREDNESS OF GRADUATES
FOR
WORK TN PHIs
i) This question was asked to 43 respondents only, of which
seventeen cave no comments.
ii) The suggestions ano comments given by the other 26 were
as follows:
a) There should be plenty of community based experience,
"introduce exposure to community life style, during
each year of study- and not just in the first year.
The concept should sink in well";
b) Before going tc work in the peripheral health institution,
there could be an orientation regarding the common
problems freed, including those with the administration;
c) During the first 6 months after internship the young
graduate is usually a little insecure and may want to
leave or change institutions etc. At this time they
could be given reassurance, support etc.
d} Graduates who have already worked in peripheral health
institutions, should share their experience with
under-graduates to encourage them to do the same;
e) Undergraduates during their internship may be posted in
rural health centres/peripheral health institutions;
f) Specialists/cthers from the medical colleges must make
frequent visits to the peripheral health institutions
where the graduates are working;
g) Throughout the course it should be emphasised that
doctors should not give importance to making money alone,
but tc the service of people, especially those
underprivileged who form the majority of trie Indian
population;
h' It is better to have some experience curing one’s
uncer-gracuaue days and internship of managing cases/
working in peripheral hospitals. This is better than
just seeing patients in a mobile clinic on an CPD basis;
i) "our training is hardly relevant to a village setting.
he are left loose to work in villages without basic
guidelines about what is the minimum expected of us";
86
j) Rural medical work is a trying experience fcr a single
doctor. Teams of 2 or 3 could work together for it to
be beneficial;
k) Could something be done (by the medical college) at
the level of the peripheral health institution also to
change certain attitudes/approach of the people
working there;
1) A good training in the local language where one is to
be posted/basics in all South Indian languages would be
very useful for medical work;
m) A career guidance cell in the medical college would
help graduates to make better options and help them
to prepare themselves better for village service;
n) Graduates (opting for work in PEIs) should be encouraged
especially during internship tc take more responsibility
for their patients and to give suggestions for better
care "Unnecessary running around should be curtailed as
much es possible";
o' Graduates should be prepared to work under someone who
is not always fair, reasonable and understanding. There
will be no more spoonfeeding. "You will probably enter
a big cruel world and meet many frustrated people";
p) Rural service should be presented as a challenge that
should be enjoyed. "If you dread it, it becomes a
horrible burden that can 'break' people";
q) "A few tips to people opting for work in PHIs:
1. Take a radio/transister along. It helps to keep
contact with the world outside;
2. Keep in touch with the latest through medical journals";
r) Just and fair rules, equal for all, should be laid down;
s) In the peripheral setting a graduate should not try tc
experiment with anything without the knowledge of the
patient by using their illiteracy.
cc.'iiekts on
Airy other aspects of content,
process,
environment
OR BASE Or TEACHING
Most comments have been given in the words of the respondents.
a) The environment is unhealthy.
for oneself and grow;
One is not allowed tc think
b) The teacher-student relationship is often lacking;
c) Most medical colleges are located in cities with western
style hosted and hospitals. In the training,stress is given
to a western style of practice with sophisticated lab-tests
etc., eg., MBBS students talk of blood gas studies, lipid
profiles etc., for simple problems.
Therefore "even a student coming from the remotest area of
India will become a western oriented, style loving doctor,
dreaming of city life with all its luxuries when he finishes
MBES. So then, how do you think you can send him back to the
village, when his aim is for America?"
89
c) Greater emphasis should be given right through, from the
selection process to the internship, to community orientation;
e) The role of social and political factors to be taken into
account in the community orientation;
f) Special topics to be taken on different religions/scriptures
and their positive features regarding health eg., Gita and
Health, Koran and Health etc.;
g) “One uses only a fraction of what one learns in common practice,
one alsc invents/discovers several things not taught. Learning
is a continuous process, Medical school is just a start. We
cannot be too critical".
h) Rules are poorly plannee, often unfair and not in the best
interests of students;
i) Teachers should be good role models and should establish a good
work ethos in the campus;
j) The fee structure in (Private) medical colleges is "crazy;1
GRADUATE
FEEDBACK
-from
Peripheral health institution (Ru ts)
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