MEDICAL EDUCATION PROJECT
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- Title
- MEDICAL EDUCATION PROJECT
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RF_MP_8_B_SUDHA
Selection Methods—Utility & Validity
by
L.
Monteiro,
Dean, St. Johns Medical College, Bangalore
K. N. Sharma,
Chairman & Prof of Physiology, Si. John's Medical College, Bangalore
V. Kumaraiah,
Res. Officer, Med. Education Research Cell, St.John’s Medical CoD Bangalore
W. T. V. Adiseshiah,
Prof of Psychology, Meston Training College, Madras-14.
Of recent years, the problem of proper
selection of students to medical colleges has
aroused considerable concern among medical
educators and health administrators (*, ’).
This is particularly true in the Indian context.
where variability in standards and diversity of
school education is confounded with the availa
bility of limited resources: these resources have
to be -utilized to the fullest extent with the
least wastage, failure and under achievement.
Somehow the efforts of the admission com
mittee in most of the colleges have been
directed largely towards selection of candida
tes who will become academically successful
during the medical course. These committees
have been generally unconcerned with the
actual needs and performances of their gra
duates in practice (’). The applicants are
selected largely on the basis of previous
scholastic records. This strategy of selecting
applicants on these basis as predictors of
medical college success has yielded disappoin
ting results, as at most they predict only the
early phase of medical education
A
second strategy has involved the use of tests for
personality, interest and motivation, as well as
several other non-intellectual tests (values,
attitudes, etc), as predictors of medical college
performance. Here again, the results have not
been very encouraging but certain promising
relationships have been reported (’,6,’). It
appears that psychological tests, when used in
combination with selection criteria, do a more
efficient job of predicting medical college
success (10)
The aim of medical education is to produce
the best possible physicians and medical
scientists to serve the society. The basic
purpose of selection should be to choose, as far
as possible, the kind of men and .women who
will be a success in the profession and who
possess the right mixture of scientific knowledge
and human qualities—compassionate, scienti
fically astute, selfless, dedicated, responsible,
and with an urge to grow through self learning
throughout the professional career. It is easier to
train applicants with desirable personality traits
that would go to make a good physician rather
than those who have to be reshaped during their
course. Admission committees have, therefore,
not tc- restrict their selections only to the
students with superior intellectual ability as
reflected by their academic records in science
and related subjects.
Keeping this in mind, £>t. John’s Medical
College is currently engaged in a longitudinal
research project (since April 1968), with the
support of I.C.M.R., to determine the utility
and validity of selection methods in force at
this college since 1963.
This research project mainly aims at:
Analysis of selection methods in predicting
medical college success;
Value of rating scales—self rating, peer
rating and faculty rating, in assessing
medical training course ;
iii.
Analysis of medical training wastage in
terms of failures and personal problems;
iv.
Analysis of selection methods, medical
examination marks and rating scales in
predicting professional success.
i.
ii.
THE INDIAN JOURNAL OF MEDICAL EDUCATION
2.
Materials and methods used :
VOL. XII
NOS. 3 & 4
knowledge and insights. For this reason,
Achievement Tests of the multiple choice
type were constructed in preclinical, paraclinical and clinical subjects, and adminis
tered to students during the I M.B.,
II M.B., and III M.B. courses respecti
vely.
For the assessment of medical skills, the
following three criteria measures have
been developed and used.
i. Subjects: All the 260 students, admitted
to St. John’s Medical College during the
years 1963-67, form the subjects of this
study.
ii. Predictive variables: This study is mainly
concerned with the value of the psycholo C.
gical tests in predicting academic success
throughout the under-graduate medical
college years. The predictive variables
included:
<z) Self-rating scales, for I M.B.B.S. students
(consists of 30 items), and for final
A. Intelligence tests B. Personality ^sts
M.B.B.S. students (consists of 70 items),
and C. Group situation tests.
were developed and used to study their
These tests were pretested and standar
attitudes and interests. The question
dised. (Details of the psychological tests
naires, amongst other factors, covered the
are given in U.G.C. financed Research
following areas:
Reports No. 64402 (1963), 64411 (1964),
(i) Personal and background information
65415 (1965), 67420 (1966), and 67425
of medical students, (ii) medical course
(1967), entitled ‘ Psychological criteria for
and the students’ reaction to it (study
selection of medical students ’).
habits, opportunities provided to develop
In addition to psychological tests, two other
medical skills, evaluation of course and
predictive variables, namely Pre-University
achievement etc.), and (iii) career aims
examination marks and Entrance Examination
(future plans, doubts, career choice, etc.).
marks, were used for comparative purposes.
(6) Peer rating scale (P.R.S.) consisting of 36
items and covering areas like medical
Hi. Criterion variables:
knowledge, medical skill and interpersonal
A. University examinations : Marks obtained by
relations, has been administered to the
students at different stages of the M.B.,B.S.
final M.B.B.S. students. The students
course have been taken as the criterion,
were asked to assess the performance of
since examination success or failure is
their own classmates during the medical
regarded, for practical purposes, as the
course.
index of an individual’s proficiency or
(c\
Faculty rating scales (F.R.S.) were used by
deficiency. The seven criterion variables
faculty members to assess the progress of
(first six are immediate criterion and the
students. One of the F.R.S.—Behavioural
last one is intermediate criterion) are:
Rating Scale (B.R.S.) consists of 40 items
a) Pre-professional course (P.P.C.)
and covers traits such as practical common
sense, clearness in grasping, verbal expres
b) I M.B., B.S. Examination (I.M.B.)
sion, critical thinking, ability to influence
c) II M.B., B.S. Part I
others, cooperativeness, emotional stabi
Examination (II M.B-1)
lity, self-confidence, steadiness of purpose,
ti) II M.B., B.S. Part 2
caution and vigilance, helpfulness, initia
•
Examination (II M.B-2)
tiveness, regularity, manual skills, etc.
e) II M.B., B.S. Part 3
The other F.R.S.—(Evaluation of Stu
Examination (II M.B-3)
dents’ Medical Achievement (E.S.M.A.)—
consists of 26 items and covers areas like
f) III M.B., B.S. Examination (III M.B.)
knowledge
of medical information, ability
g) M.B., B.S. Cumulative marks (M.B-cum)
to gain and maintain patient’s confidence,
B. Internal academic assessment. The gain in
skills in observation and clinical judge
proficiency during the medical course is
ment, diagnostic ability, desire to learn
capable of being assessed not only with
and cooperate, etc. Each student is rated
reference to examination marks, but also
by three independent assessors before the
by considering day to day improvement in
scores are pooled.
SELECTION METHODS—UTILITY & VALIDITY
JULY-DECEMBER, 1973
TABLE 1
Validity Coefficients between Predictive and Criterion Measures (1963—67)
Predictive variables
Criterion measures
University
Exams
during
M. B.B.S.
P. P. C.
(N = 259)
P.U. C.
Ent
rance
Exami
nation
**
0.22
**
.0.28
**
0.22
**
0.24
Psychological test scores
Group
situa
tion
Intelli
gence
Person
ality
0.03 NS
0.12 NS
**
0.27
Final
I M. B.
(N = 244)
0.12 NS
0.09 NS
0.13 NS
**
0.23
**
0.22
II M. B.-l
(N = 169)
0.03 NS
*
0.17
**
0.26
0.14 NS
0.14 NS
0.14 NS
II M. B. -2
(N = 164)
0.08 NS .
0.11 NS
0.06 NS
*
0.21
**
0.24
**
0.22
II M. B.-2
(N = 164)
**
0.22
0.13 NS
0.05 NS
**
0.-31
0.16 NS
0.03 N
(II M. B. As
a whole)
(N = 1.68)
0.11 NS
0.06 NS
0.12 NS
'
*
0.24
0.18 NS
0.11 NS
0.03 NS
0.09 NS
0.17 NS
**
0.27
0.08 NS
0.06 NS
0.05 NS
**
0.29
0.12 NS
0.13 NS
III M. B.
(N = 104)
Cumulative
(N = 121)
0 03 NS
0.02 NS
N.
=
S.
Not significant
•
=
Significant at 0.05 level
•»
=
Significant at 0.01 level
turned out to be academically successful in the
Results:
medical education, whereas those who perfor
i.
Significance of psychological tests in predicting med badly on psychological tests but were
admitted to the course turned out to be
medical college success.
academically
poor. As compared
to
psychological
tests,
the
validity
Table I indicates that the predicative vali the
dity of psychological tests (final scores) is coefficients of P.U.C. and Entrance Examina
significantly high. Those who performed well tion marks significantly low in predicting aca
jn psychological tests at the time of selection demic success. Out of seven correlation
3.
VOL. XI/
THE INDIAN JOURNAL OF MEDICAL EDUCATION
coefficients tested in each of P.U.C. and
Entrance Examination, only 3 are significant
(with P.P.C., I M.B., and II M.B-2). These
results thus reveal two important facts, viz.,
that PUC and Entrance Exam marks are (i)
assessing the some common factors (like scho
lastic achievement), and (ii) at best predict
academic achievement in earlier phases of
medical course. Another important factor
emerging from this table is that the final scores
on Psychological tests do reveal a consistently
high and statistically significant correlation
with medical course examination marks,
although the scores on individual tests do not
show high correction (II).
The battery of tests, as originally designed
for administration to students seeking admis
sion to St. John’s Medical College, was a
‘three pronged’ approach and included
measures of intelligence, personality and social
interaction. Different tests were accorded
NOS. 3 S’ 4
appropriate weightages in working out the
final score, and the students were ranked and
graded accordingly. In the light of regression
values obtained for 1963, 1964, 1965, and 1966
batches, it appears justifiable to apply ‘cut off’
at 50% of the final score in the psychological
tests. Candidates following below this level
would be potentially unsuitable for the medical
course.
Scores on Achievement Tests were correla
ted with P.U.C. Entrarce Examination marks
and Psychological tests scores in order to find
out which of these three measures is the best
predictor of the high level of achievement.
The results are shown in Table 2.
Correction in respect of P.U.C. and Entrance
Examination marks are not significant, whereas
correlations of psychological tests scores with
Achievement Tests are highly significant.
TABLE 2
Predictive Variables and Achievement tests in Preclinical,
Paraclinical and Clinical Subjects in Medicine
Achievement
Test
Batch
__________Predictive variables
Entrance
PUC
Exam marks
Marks
Psychological
Test scores
1967
N=53
Preclinical subjects:
Anatomy
Physiology
Biochemistry
-0.07
0.06
0.08
0.25
-0.09
0.17
0.59
**
**
0.52
**
0.57
1966
N=38
Paraclinical subjects:
Pathology &
Microbiology
Pharmacology
Forensic Med.
-0.04
0.02
0.08
-0.10
-0.01
0.06
0.34 •
0.41’*
0.27
Clinical subjects
Medicine.
Obst. & Gynaecol.
Prev. & Soc. Med.
Surgery
0.06
-0.Q8
0.08
-0.01
-0.09
-0.13
-0.03
0.11
0.33
0.52”
0. 3*
*
0.40
1966
N=33
•
==
Significant at 0.05 level;
••
=
Significant at 0.01 leyel,
JULY - DECEMBER, 1973
SELECTION METHODS—UTILITY & VALIDITY
ii.
Vaule of rating scales in assessing medical techniques, and observation to be sufficient,
training course and attitudes of students although they had very little clinical responsi
towards Medical course.
bility for the care of the patient; (g) they
experienced no difficulty in establishing con
A. Self rating scales:
tact with patients in the hospital, but not in
The important findings are (a) students in the home setting; (h) hospital practice was
the first year who took the decision to do the preferred to private practice; (i) with regard
medical course because of persona] interest had to areas of specialisation, the favourites were
no doubts regarding medical career, whereas, surgery and medicine whereas Dermatology
those who took the medical course at the promp and Pharmaceutical industry were least attrac
ting of their parents or teachers expressed tive; (j) more than 75% of the students intend
some doubts regarding the wisdom of their to settle in India, but nearly half the respon
choice; (b) those who had developed regular dents wished to go abroad for further studies
study habits devoted more time to continuous (12, 13, 14).
study as compared to those who worked by fits
and start; (c) with regard to teaching methods,
the general drift of opinion was that practical B. Faculty and Peer ratings :
Scores on the two rating scales—B.R.S., and
classes, reading text books and demonstrations
S.M.A.,
were correlated with M.B. cumula
are of great value; (d) internal assessment is E.
preferred to University examinations; (e) tive marks. The correlation for the 1963,
need for guidance was felt by the majority of 1964, 1965 and 1966 batches, which have now
students (f) they considered facilities for clini completed the M.B.B.S. course are shown in
cal work, practice of routine laboratory the Table 3.
TABLE 3
Faculty and Peer Ratings Correlated with Medical Examination
Cumulative Marks (1963 to 1966 Batches).
Batch
Peer
Rating
Scale
Behaviour
Rating
Scale
Medical
Achievement
Rating Scale
1963
1964
1965
1966
0.19 NS
0.04 NS
0.23 NS
0.34 NS
0.54 **
0.49 **
0.61 ••
0.28 NS
0.67 **
0.42 **
0.51 **
0.63 **
NS = not significant
** = significant at
0.01 level
On B.R.S. and E.S.M.A. all values (except faculty members, a significant correlation was
in B.R.S. with 1966 batch) are statistically established at levels varying between 0.75 and
80.
significant at the 99% level confidence. This 0.
goes to show that faculty ratings are good pre
dictors of examination success, and that they Hi. Medical training wastage.
confirm the evaluations based on psychological
tests administered at the time of admission.
Regarding Medical training wastage, four
The Peer Rating Scale, used by students for aspects were studied (11,15). (A) What are
making evaluations on one another, has not the rates of failures at different stages in medi
led to any conclusive findings, on account of cal education? (B) Is there any relationship
wide difference in evaluation.
between wastage in terms of failures and
In order to assess the relationship between gradings based on psychological test scores,
faculty ratings and students’ ratings, correla administered at the time of selection for the
course?
(6) What are the factors contributing
tions were worked out between the rating
scales. The correlation between P.RS. and to the medical training failure? (D) What is
R.S.
F.
was not sigi ificant. Between the two the value of selection procedures in predicting
■ratings scales (B.R.S. and E.S.M.A.) used by the ‘Problem’ students?
VOL. XII
THE INDIAN JOURNAL OF MEDICAL EDUCATION
NOS. 3 & 4
TABLE 4
A Medical Training wastage, Stage wise
Stages in medical
education
Total no. of
students
No. of
failures
Percentage
of failure
260
260
200
150
29
61
63
84
11.2
23.5
31.5
56.0
P. P. c.
I. M. B.
II M. B.
Ill M. B.
It will be evident from the Table 4 that casualty rates are highest at the final M.B.B.S. stage.
Of every 100 candidates admitted, 44 go through the M.B.B.S. course unscathed at any stage
and the remaining 56 have to take the examination more than once at some stage or the other.
Table 5 indicates the additional attempts taken by the failed candidates at each stage of the
medical course.
TABLE 5
Stages in
med. edn.
No. of failed
candidates
P. P. c.
I M. B.
II M. B.
Ill M.B.
29
61
63
84
Additional Attempts
two
One
No.
23
41
26
61
four
three
%
No.
%
No.
%
No.
%
79.3
67.2
41.5
72.6
4
16
22
12
13.8
26.2
34.9
14.3
2
1
5
1
6.9
1.6
7.9
1.9
0
3
10
10
4.9
15.8
11.9
0
As is evident from the Table 5, 12 to 16% of the students took more than four attempts to
pass II M.B. and III M.B. Examinations.
B. Medical training waste, gradewise on psychological tests.
Wastage in terms of failure rates during the medical course is shown in Table 6 against the
various grades obtained by pooling the psychological tests scored at the time of admission.
TABLE 6
Gradings &
score range
Total no.
admitted
Failures
Percentage
I (60% & above)
II (50-59%)
III (40-49%)
IV (30-39%)
V (Below 30%)
37
145
69
9
nil
14
63
33
8
nil
37.8
42.8
47.8
88.8
nil
'
3ULY-DECa\tBER, 1973
SELECTION METHODS—UTILITY & VALIDITY
. In case of those placed in the higher gra?‘n8s (above 40%) the failure rate varied
between 38 and 48%, whereas the failure rates
jn the case of those placed in lower gradings
(below 40%) was as high as 89%. Further, dis
criminate analysis of psychological tests indi
cates that the lower gradings on intelligence
terts were found among failed students at
F.P.C. and preclinical stage, whereas lower
gradings on personality and social interaction
tests was found among failed students at paraclinical and clinical stages.
D.
Value of selection procedures in predicting
problem students:
In a separate cross-sectional study, attempts
were made to determine the value of selection
procedures in predicting ‘ problem ’ as well as
‘model’ students (11). It was found that
psychological tests, but not either P.U.C. or
entrance examination marks, significantly pre
dict these criterion measures. The ‘ problem ’
students usually labour under- emotional stress,
inferiority feelings, antisocial tendencies, with
strong inclinations towards withdrawal. Fur
C.
Factors contributing to medical training wastage ther, academic performance is poor and they
create difficulties for themselves inside and
The following nine factors were identified outside the college.
after analysing data collected on psychological
tests and specially designed questionnaire for 4. Findings
the purpose.
i. The predictive validity of psychological
tests administered to candidates seeking
a)
Age: Older students show a much higher
admission to St. John’s Medical College,
wastage than the younger students.
Bangalore, is significantly high. As com’ pared to the psychological tests, the P.U.C.
b)
Sex: Men have higher’ attrition rate than
and Entrance Examination marks have a
women.
poor predictive value.
c)
Socio-economic background of students is not
ii.
Scores
of psychological tests correlated
a contributing factor.
significantly with achievement test scores
d)
Health : 20% of students showing irregular
in preclinical, paraclinical and clinical
progress, reported health problems. Emotional
subjects. This was not found to be so in
difficulties were encountered more by unsuc
the case of P.U.C. and Entrance Examina
cessful students. It was not clear however whe
tion marks.
ther these difficulties were the cause of the result
iii.
The faculty ratings based on the Behavi
of their lack of success.
oural rating and the medical achievement
e)
Study habits did not have a consistent
rating scales have greater predictive vali
relationship to success or failure.
dity. Peer ratings, on the other hand,
did not correlate significantly.
f)
Inadequate intellectual capacity has contri
iv. Medical training wastage rates are highest
buted substantially towards wastage, particu
at the final M.B.B.S. stage and lower at
larly at P.P.C. and preclinical stages.
the earlier stages. 89% of medical training
g} Personality: On Edwards Personal Pre
wastage was found in students obtaining
ference Record failed candidates were
lower gradings (below 40%) on psycholo
found to be below the norms on achieve
gical tests, administered at the time of
ment need and were less aggressive. On
selection.
the other hand, they showed significantly
v. Main factors responsible for medical
more deference and a higher need for
training wastage are (a) inadequate in
order.
tellectual capacity (b) poor adjustment
h) Adjustment: On Bell’s Inventory, failed
and (c) lack of interest and motivation.
candidates were inferior in general adjust
ment, particularly in emotional adjust 5. Summary
ment.
The findings of follow-up of medical students
i) Interest and motivation : On self rating scale admitted to St. John’s Medical College,
7 the failed candidates showed poor interest Bangalore indicates that the predictive validity
and lack of motivation in medicine.
of psychological tests is significantly high in
JULY-DECEMBER, 1973
SELECTION METHODS—UTILITY & VALIDITY
forecasting (i) academic success and (2) training
wastage.
Those who performed well in
psychological tests at the time of selection
turned out to be academically successful in the
medical course, whereas those who performed
badly in psychological tests but were admitted
to the course, turned out to be academically
poor. As compared to the psychological tests
the validity of P.U.C. and Entrance Examina
tion marks were significantly low in predicting
academic success. It is an important finding
and should be seriously taken into consideration
since it is not infrequent that great weightage
is given only to candidates ’ Scholastic record at
the time of admission to the medical course.
The results also bring forth the necessity of
reliance not only on the university examina
tions, but emphasise [he necessity of giving
higher weightage to internal assessment and
faculty rating of the candidates. It should,
however, be pointed out that the present con
clusions arc applicable to medical course. It
will be necessary to determine the role of these
factors in predicting professional success in an
objective and quantitative method, when the
medical graduates enter upon career—the
ultimate justification of this project.
8
3.
Price, P.B., Lewis, E.G., Lough Miller,
C.,
G.
Nelson, D.W. Murray, S.L. and
Taylor, C.W: Attributes of a good practising
physician. J. Med. Educ. 1971, 4(j:
229-237.
4.
Gough, H.G: Non-intelleclual factors in the
selection and evaluation of medical students.
J. Med. Educ. 1967, 42 : 642-650.
5.
Hutchins, E.B: The A.A.M.C. Longitudinal
study: implications for medical education.
J. Med. Educ. 1964, 39 : 265-277.
6.
Korman, M., Stubblefield, R.L.: and
Martin, L.W. Patterns of success in medical
school and their correlates, J. Med. Educ.
1968, 43: 405-411.
7.
Gough, G.H., Hall, W.B., and Harris,
R.E: Admission procedures as forcaslers of
performance in medical training, f. Med.
Educ. 1963, 38: 983-998.
8.
Solkoff, N: The use of personality and
altitude tests in predicting the academic success
of medical and law students. J. Med. Educ.
1968, 43: 1250-1253.
References
9.
Beiser, H.R: Personality factors influencing
1. Frankenstein, D.H: Current medical school
medical school achievement: A follow-up
admissions'. The problems and proposal.
study. J. Med. Educ. 1967,42 : 1087-1095.
J. Med. Educ. 1971, 45, 497-509.
Gotthiel, E and Michtel, C.M: Perdiclor
2. Weisman, R.A., Weinberg, P.O., &Win- 10.
variables employed in a research on the
stel, J.W: On achieving greater uniformity in
selection of medical students. J. Med. Educ.
admissions committee decisions. J. Med Educ.
1972, 46: 593-602.
1957, 32: 131-147
Mg?
KEEPING TRACK------------
ffedical Education is a topic that would be very difficult
to 'keep track' off since there is so much available literature
in the fields However, for all those readers who are keen to
know more about the new trends and experiments as well as the
main issues of debate the following list would be helpful, tfe
hope that the contents of issues 97—S 5 have stimulated interest
in this important area. Readers are requested to keep us
informed about their ideas
and experiences. The selection is
made on the basis that most of these would be available in any
medical college library.
1
HEALTH AND THE DEVELOPING WORLD
John Bryant, Cornell University Press, Ithaca, London, 1971.
Thia book has two relevant chapters on the education
of the
health team and the economise of medical education.
2
DOCTORS FOR THE VILLAGES
Carl Taylor at al. Asia Publishing House, 1976.
A study of rural internship in Seven Indian Medical Colleges.
Possibly the only planned evaluation study on one aspect of
medical education in India. Its findings highlight the
•feasibility of employing physicians in rural areas, the
conditions under which they might agree to work and the
structural and organisational changes needed to improve
rural health care
*
and the physicians own training performance
2
keeping track....contd......
3
2
AN ALTERNATIVE SYSTEM OF HEALTH CARE SERVICES IN INDIA S SOME PROPOSALS
□ P Naik. Allied Publishers, ICSSR, 1977.
Includes recommendations from the Srivastava Report and a report
□n tho Kottayam experiment on training Community Based Doctors.
4
HEALTH FOR ALL - AN ALTERNATIVE STRATEGY :
ICFIR/ICSSR, 1981.
An interesting chapter on the type of Personnel and Training
required for an alternative model of health care in India.
5
PREPARATION OF THE PHYSICIAN FOR GENERAL PRACTICE
WHO Public Health paper hlo.20.
One of the earliest public health papers of WHO which discusses
many aspects of the early experiments in training of doctors
in social medicine and for general practice. The paper on the
"Psychological basis for Education of the Physician" is
particularly thought provoking.
6
ASPECTS OF MEDICAL EDUCATION IN DEVELOPING COUNTRIES
WHO Public Health Paper No.47.
Its various chapters discuss objectives, student evaluation,
integrated teaching, social medicine and some of the newer
developments in the field.
7
EDUCATIONAL STRATEGIES FOR THE HEALTH PROFESSION
WHO Public Health Paper No.61.
Summarises the newer concepts of curriculum theory, evaluation,
examination and decision making, dynamics of learning groups
eind evaluation of teachers and teaching effectiveness apart
from other issues.
.3
keeping track contd,
8
3
PERSONNEL, FOR HEALTH CARE - CASE STUDIES OF EDUCATIONAL PROGRAMMES
WHO Public Health Papers No.70 and 71.
These tut) volumes highlight the main experiments in medical
education and curriculum development all over the world. The
experiments in Nepal, Thailand^ Phillipines and
are particularly relevant to our situation.
lO
FOR FURTHER READING ON THIS SUBJECT FROM RFC SOURCES CONSULT
INDEX OF 100 ISSUES (BULLETIN Nofl. 100-101).
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/ Importance of Economics of Healing in Medical Education and
a Simple Way to Impart it
S. V. Nadkaml
Frofeiroe of Surgery, LTM Medical College. Sion, Bombay-400 022-
Medicine is an art based on a scientific foot
ing. This basis is mainly the chemical and
physical processes involved in the physio
pathology of the body. The materialistic and
western influenced attitudes plus the advance
in modern technology have made a medical
teacher and a student feel that these are the
only important sciences to be taught and
learnt, to become a successful doctor. He is
thus being taught more and more details of
the physico-chemical processes, or what may
be termed as ‘organic' changes, more and
more of the detailed investigative approaches
involving the great technological advances and
is taught to plan his treatment on the ‘Sound
Basis' of these scientific facts. In terms of
the best results, 1 have myself no doubt that
some of these, if not all, have vitally contribu
ted to the quality of the results of medical
treatment. And yet, this is the most impor
tant reason, in my opinion, for the education
becoming unoriented to the practical needs of
the medical graduates, in our country.
being little aware of his own ignorance that
what he has not learnt in the college covers
much wider field than what he has.
The present set up of full-time 'non-practis
ing' teachers and free treatment to all patients
in the teaching hospitals makes this deficiency
in teaching even more glaring. For the entire
cost of hospital, equipment and the treatment
is borne by the Government or some autono
mous bodies, while neither the teacher, the
student nor the patient become aware at all of
the actual costs incurred in the whole process.
This results in growing dissatisfaction among
all with demands for ever-increasing equip
ments and facilities, which more often than
not. contribute so little to the qualitative or
quantitative improvement in the results.
Rarely though they do happen to be the most
valuable modernities without which real pro
gress would not be achieved. In short, neither
the teacher, nor the taught and least of all the
patient, ever even think about the cost involv
ed in the so called modern methods and the
For medicine in its fuller concept is nn art relative benefit derived out of this added ex
based on the above-mentioned scientific footing. penditure. In actual practice as soon as the
In actual practice, many other factors come medical graduate goes out of the college, he
into play in determining the care of the pa is confronted, at every minute, with the cost
tient. The social factor, psychological factors, involved and its relative or comparative bene
environmental studies, the religious biases, fit to his patient. This makes him unable to
etc. But the most important and vital barrier take decisions, especially
the ‘cheaper
to the effective practice of the knowledge decisions’.
learnt in the present way, is the knowledge of
Economics of healing. In practice what to do
Ultimately, some may learn, by themselves,
and what should be ignored, which investiga the relative economic and medical values, but,
tions are necessary and which can be avoided. many swing to the opposite side and think
and with what material difference, which that science taught in the medical college is
equipments to buy and which would become meant to be forgotten and everything in
burdensome, the choice between the best drug practice is Art. This way the word Art
and the cheap drug, everything is determined becomes synonymous with nure commerciali
by the socio-economic factors rather than any sation. cheating and fraud. Some of the
thing else But the graduate full ol knowledge graduates who are too good in their science
of physico-chemical processes often lacks in and fail to learn by themselves the real art, i .e.
the knowledge of the economic influences on the moulding of medical practice to these
the medical practice and fails to satisfy his socio-economic factors, return back to the fullpatients and thus gets rapidly frustrated. He time job seeking and in turn, not only .conti
tends to blame the masses for their ignorance. nue to teach the pure science but fully ridicule
/As \
/t-v
.» DecEn&£K 1973
y
IMPORTANCE OF ECONOMICS OF HBALtNO IN MEDICAL ..
tny practical dilutions in practice (ridiculing
• the scientific aspects of ART, if I may say so).
20
tions are the mainstay, but there Is not
single column or a confidential referene
regarding the candidate's ability to treat an.
trach R.esult—unnecessary and elaborat
modern investigations on the poor, advancer
cascs-long hospital stays, often at the cost o
essential early treatment—all for the sake o
research and publications—for the sake o
promotions—expensive non-productive medi
cale ducation.
Thus, the whole cycle of wrong emphasis
leads to wrong choice of teachers, further
•emphasis on modernity and the society pays
more and more, to receive less and less benefit
in the poorer countries. The doctors trained
by our college become progressively ineffective
in treating our people, because they (the
people) cannot afford such
treatment.
But it is a difficult task, for which time
Strangely, the richer countries, already
advanced, even in their countries in such -must be spent. But ease is preferred to effort
technologies and the relatively affluent people and the new graduate becomes dependent or
there can afford them. This mutual satisfac equipments than his own senses and judge
tion between those masses and our doctors ments. Clinicians who could teach, what I air.
seems to be one of the most important factors, advocating, are available in plenty, but >hev
why ‘scientific doctors' are draining to the seek direct rewards in practice and would not
west. Are we not training them for their turn to full-time teaching jobs, which become
needs, and not ours?
unrewarding both monetarily as well as jobsatisfaction-wise as such a person is usually
Clinical Emphasis : Secondly, the present condemned as a ‘non-scientific teacher', a
pattern of'modern or technologecal’ approach dilutor, non-research-minded, non-progrc.sive
is leading to ‘Office-type Doctors’ with a etc. And yet, some objective method ought
progressive deterioration of clinical judgement. to be found to find out, retain, encourage and
which is being substituted by investigative promote such ‘clinical’ teachers, who treit
procedures. I emphasize that investigative well and yet economically. Such teachers
approach is used to substitute and not to aid automatically will teach students the art of
clinical judgement. Again the result being clinical judgement. Today, there seems to be
same quality to the patient at a higher cost no way. for the Deans, Administrators. Or
and the cause being non-economy-oriented Service Commissions to sort out such types of
medical education. My personal experience, teachers. Can we find a way out?
after having worked in newer and smaller
colleges and slowly shifting to the City of
The answer is not simple but a simple
Bombay, shows me clearly that by conscious beginning can be made in this direction, which
efforts, clinical judgements can be improved can expand later to cover the problems that I
and managements economised to half or even have posed. And the simplest way to start
one-fourth.
would be ‘to bill the patient’. Every oatient,
The quality of clinical material available in who is admitted to a medical college hospital,
the hospital is also a direct reflection of lack should receive a bill of expenses, at the time
of understanding of the economic influences. of discharge, irrespective of whether he pays
Advanced cases, inaccessible for follow-up, for it or not. This bill must be given to him
from the poorest strata make it relatively through the consultant teacher by the resident.
easy for the senior medical staff to be relatvely so that all concerned would have seen it. Tlje
indifferent (and irresponsible). It is necessary conception of the bill, for the present, is fir
to draw a more health con'-ious middle class medical education and hence the charges
and skilled labour to teaching hospitals, to evolved can be only crudely accurate and
make medical education worthwhile. Other need not be commercially accurate. They will
wise, today, it is only lecturing, without give a comparative picture of the money spent
actual observation, about early signs and over each patient, over each disease, and
would help to statistically evolve the compa
better treatments.
rative benefit derived to the patients or 'he
The present mode of selection of senior mas'es through additional expenses for moder
teachers by the Public Service Commissions nities. For a 600 bedded hospital with
again shows the same lack of importance to 12,0'10 admissions a year, this involves
'clinicians' as teachers, and indifference to making about 40 bills a day and the total
medical economics. Research and publica extra establishment would not be much.
Vl
IMPORTANCE Or ECONOMICS OT mALVHO IN MED t CAL ..
THE INDIAN JOURNAL OF MEDICAL EDUCATION
. /Ouch a scheme will automatically make all
money-conscious. The impact or additional
'Space, personnel or equipment will be imme
diately reflected in the bill and the teacher and
the taught would necessarily ponder over it.
whether this was essential or not. Some
may now substitute clinical judyemems to
investigations bringing the costs down. It
w'ould now be possible to sort out a better
Clinician as one who gives better results with
tester costs, and attempts could be made to
retain and promote him or encourage him by
offering larger responsibilities and/or mone
tary incentives. It would be necessary for
making the scheme more educative, to arrange
regular forums for discussions, seminars, mon
thly meetings etc. where clinical results would
be evaluated with the bills of expenditure.
The positive concept of health is essentially
due to the economic influences in the modern
society. The need to keep productive, money
earning population is not, only not-ill but fit,
fit for skills and possibly fitter than before,
through the medical progress is a pure product
of understanding of economic influences in
modern society. Unfortunately, it is becoming
necessary in our country to teach the medical
profession, especially in medical colleges to
distinguish between essential treatments for
positive concept of health. For after such
isolation, it will be correct and scientifically
appropriate to charge fully for the latter and
increase the direct income to the medical
colleges, independent of the State or public
money. Such accrue! of direct wealth could
make for a self-expanding medical education
system and only such self-expanding medical
education system and only such self-expanding
colleges are likely to retain permanently their
utilitarian character. Again the beginning is
in inlroduction of medical economics and the
first step is billing the patient and critical
evaluation in periodical discussions, seminars
etc.
20
POL. XIV NO. 2.
more (discuss is the euphemistic word), because
that is what some of the teachers do. He can
not decide, without multitudes of reports,
because that is what he sees. He fails ns a
house-surgeon, to talk and explain to his
patients about the nature of illness and details
of treatment and show sincere sympathies, but
merely replaces them by efficient ‘Organic and
technological' approach, because that is what
he sees in the hospital.
This would be only a beginning to give a
social bias and practicality to our education
system. Other aspects like social, religious,
psychological, environmental, (rural and urban)
factors, also might have to be brought home to
the new students’ notice. Such an expansion
of teaching of Art, will necessarily restrict the
horizons in the knowledge of science and
modern technology. A hue and cry would
develop, that our students thus would be
unable to compete with others in the Western
World, and would be found to be unfit there.
It is for the educators here to decide, would it
be better for the country or worse. It is for
us to decide whether we train our students for
foreign fitness or for internal fitness. This is
what I call, ‘Indianization ’ of Medicine.
Another common argument put forth is
that these things need not be taught, and
students would learn them automatically, when
they go out in society, I have myself conceded
this fact in the case of many. But it is at the
expense of many more years, but more discom
forting is the fact that a progressively larger
number of students fail to learn this or accept
and adapt to it, without a sense of guilt or
shame. Secondly, it is leading to wrong
choice of clinical teachers. Let us also
remember that commerce, business manage
ment, teaching, and politics arc also being
taught today and with advantage. Were not
the former generations practising them and
learning by themselves ? Lack of natural in
heritance in the new students in all fields
The answer is not that simple of course and today makes it imperative to include such
involves many more basic changes in the aspects in the formal education.
system. While a lot of discussion centres
I urge that these things should not be
round the content of medical education, extre
mely little time is spent over the need to select brushed aside, as politics, trade unionisms, or
proper teachers, and still less to medical and purely non-educative subjects, for they, more
hospital organisation in the utilitarian way. than the paper-definition of the contents of
It is easily forgotten that the student learns education, will determine the progress of medi
from what he sees and not what he hears. cal education in India and its usefulness to
Today, he is learning to do less and argue the Indians.
Low-Costs Systems of Visual Aids in
Medical Education
&
by David Morley, Senior Lecturer in Tropical Child Health, Institute of Child Health,
University of London
Cassette television, or television piped from a satellite,
is still many years away for the medical teacher in
developing countries and yet he needs help here and
now to assist him in teaching more effectively with
visual aids.
Teaching Aids at Low Cost (TALC) is a non-profit
making organization set up to meet the needs of
medical teachers, particularly those working in the
field of child health. Keeping down costs is essential,
*s most of these teachers are working in situations
Where they have to provide any visual aids they need
from their own pockets. In some parts of the world, one
Kodachrome colour film may cost the medical teacher
between 5% and 10% of his month's Government
salary, and in these circumstances he is unlikely to be
preparing his own transparencies for use in teaching.
Most of the work of TALC is concentrated on the use
of transparencies, as the colour transparency, with either
a written script or a tape recording, is the most econ
omical and practical way of making visual aids available
forteaching in a developing country.
conveniently stored in a single sheet in a standard filing
cabinet. (Fig. 1). Similarly, to achieve standardization,
only horizontal transparencies are used. The limitation
to 24 slides is not serious. Experience has shown that
the format of the majority of slides leaves a large area
of the slide unused and that it is possible to join slides
together to make a more effective teaching aid. For
example, one of the more recent sets made available
through TALC on Leprosy in Childhood is made up of
47 transparencies, although there are only 24 frames.
The horizontal format allows the cardboard mounts
all to be printed with a mark which indicates how they
have to be placed in a projector. This again is necessary.
as many of those using this material are unaccustomed
to using slide projectors. A simple method cf numbering
every transparency has been evolved, so that those
listening to the tape, or reading the script, can be sure
that they are looking at the correct slide.
Difficulties of black-out
Medical teachers and others have failed to communicate
effectively to architects to ensure that adequate space
Low cost
A strip of 24 transparencies, if mass-produced, will cost
around 20p. To this must be added the cost of the
script, which is printed using a lithographic method and
which costs 5p. Strong self-sealing cardboard mounts,
if ordered in large numbers, prove to be quite inexpen
sive. The packing and despatch of the parcel of trans
parencies, mounts and script is undertaken by married
Women working from their own homes, which again
reduces overheads to a minimum. In this way, TALC is
able to send out 24 colour transparencies, with a script
of five or six pages, post free, by surface mail, anywhere
in the world, for 60p.
Our efforts to bring down the cost of this form of
teaching aid have met a tremendous demand. Currently
between 3,000 and 4,000 sets are being sent out each
year, and the organization has just sold its quarter
millionth transparency.
Standardization
In order to simplify the production of this teaching
material, it was necessary to standardize the length of
each set to 24 transparencies. This number of slides fits
easily into a transparent foolscap sheet and can also be
252
Fig. 1 : These plastic, combined slide and cassette holders
are supplied ready to hang in a 15" .. 20" (39 ■ 24cm.)
hanging film cabinet.
Reproduced from Educational Broadcasting International _5
252
with grateful thanks to the Editor C.E.D.O. Tavistock House, London WC1H 2LL
is available to allow visual aids to be projected in a cool
atmosphere. The majority of lecture theatres in develop
ing countries are still not easily blacked out. Although
there is no reason why it should not be as cool as the
shade temperature, the blacking-out of a lecture hall
usually reduces the air flow; it is not long before the
temperature rises and teaching becomes steadily less
effective. Air conditioning is prohibitively expensive for
'arge lecture theatres and should not be necessary if
sufficient care has been taken in their design.
Because of this difficulty in the use of visual aids,
during the last three years TALC has been developing
a simple system by which the transparencies may be
studied by individual students, preferably in a library.
Slide-Tape Tutor
The Slide-Tape Tutor (Fig. 2) has been developed as a
simple answer to the use of this material by individual
students. It consists of a standard cassette player, a
slide viewer and a transformer, so that both of these
may be run from the mains. This is all mounted on a
strong board and placed in a box (not shown in the
figure) which can be locked to the library table, so that
it cannot be removed and does not have to be locked
away when not in use.
The student obtains from the librarian a plastic sheet
containing 24 slides, and in the pocket at the back a
cassette on which is recorded the lecture. The lecture
Fig. 2.
may have been recorded anywhere in the world and
the student should be looking at transparencies which
have been expertly prepared. The recorded lecture
quotes each slide number and then gives a carefullyprepared description of each slide. On the reverse side
of the tape are recorded a series of questions and
answers, so that the student may check for himself
whether he has gained the information that the slide is
attempting to teach him. When he has finished thfl
student returns the plastic sheet and the librarian can
see at once that all 24 slides are present, together with
the cassette.
Discussion
The demand for low-cost material of the type described
here has been most encouraging and suggests one way
in which the more fortunate industrialized countriss can
assist the developing areas of the world. It gives
considerable satisfaction to those who take trouble to
prepare effective teaching aids to know that these can
be widely distributed and used by teachers in universities
and medical schools which do not as yet have effective
departments of medical illustration. Although this
method and system was designed primarily for
developing countries, there has been considerable
interest in it in Europe and North America as one which
is simple to instal and maintain and can be extremely
versatile.
253
.
»C’- Ct
•'■ jloi<? (C,C'—V.)« -1
.I/.1 j
. ..n::.;
6'i-.idicus Colley hr.hwc been invited to participfite
ir- the project
*
through
yroup .support <.nd Hnsnaen. tzc-i. hsa
........ ?■'.,.\C
C.’C-'1..'
•Hra?Kiell>’ but hive. uvy
od Vrlncipal/Vice Principal </'•••.-V -sod
iinei' i-hemas
~?C for the peer aroup ptocesa.
: ba
*
also
u;.»h interest
have
"Ms . tssoc.’i-V -roif^sfcor of
.•edici no', for the peer
iinivos# Prof •’o-.u;uxtssent of Ccesounity •reulclne <snd
.
'.'fticr.wi ■■eacher -/raining-ill
Interact with the project teara
* 2)
tr.sort ;-'roc;a»g to,
r ayeloctgc-ntB
:hc Medical Education -rojact is expKct«-'r; to be Mtr^ z«.Krx«ry/
*
cos.1-’! 15501’tary to the ♦new’ /f' ‘ongoing
*
effort® of
«s«:.vts
ef the X'K'-netiork.
•••?vcr ,1» Ht'u of th® n’&sitive ttevaic/^nts in
the • ursjf.'o Vnivs&rslty, giving ;/.>.«■)', the yxeen signal tc di-veiup the
arperlioental parallel cr«c^ by »h
*ly
FfS1.!* tl-se < ;■€ tc®sj (>c. :•..
®n<S
c ..:...i r">ncls
*
ir
v-reiacharian («
* ’••/) beve a^rnuS tr-- -a three-etei:
asport process tc
staff as they evolve the definitive
Qarriculu®. ,’hatc step®, arei1) .Reflective M’viw anu collation of trasBeworX of.
course fro® all the axiatlng’ plans/ren-oris and
papers of < . £-»i. Faculty on the .Course
*
(Ey JJ'.'C ''.'©ars, E>&n jalcre)
2
s.
11; • orkshtn wi.-- .3-'.. cere tsw of i-catt of
C:.C-L in 'r»ar..:; adore elu-c ^ith ..■/r;./e < afd :<•
*.
ill; . w& wc-.-k cu!r> 1 %<;■' *
.-evdC ’ .-^cct sxerclwith
rcocci«» at CS ••;..,
•
I ' '.
. \.. ■ ■ ■■ ■
■-.:. ■ '■ •.. ■ . ■ ■.
■
of the
Ct;."-it
ne-4”?.i; in sc-liv-arlty.
.. ■
The three main project objectives ^©rs then reviewed.
It w««; felt that this cbjsrtivc ;.-ore th-ihe others would erew
rest uthe ChC
-rice,. •-? ■•
cjre'ct-ivity of the teaw-»
"■ .
'- ilK
■
'.
:
! ■:.
i) :«?ns itlr-ation h-.- .tv'd
..’ctors/cwfirounlty
■Orients!.■ i s?- -for CCWUnlty VOjrk»
li. Aswaeft-Berst ;..f tb,r •vitsbility of the student
for ccix-u»ity orjudical educatier..
ill;- --reparation for u it' direc tax.; study and other
learning ski 1 Is ?jn a fcoesunity crlenicd
>;■' us t corse
*
it was felt o;-.6t it would toe Iwi^ortant to rork cut the ‘.■•varcll
•ihiloSOyZiy f,snh the cc.-.'tent «snd
of SUCb a course
also
'»lnliKjr.< Lit • fr.-jsb <wrk rc':-di«;nseet. the cc’.;r&e
objectives,
I. - ■ h. .-i ■■-• -. ■ • ..•' C t\- •• . . • ■:. ;
:...: U - r t-ChlVi'
accord!sj<; to local feasibility
; re#-.',
ha®
; giver to the fetur© ©£ the rtudente who ct»plet» the couree
*
but do not get selected to the medical course.
Vc-rlo-js i.ce? <srl©» <’:■
.-me' ’.<111 e.’^rge in the coming
years, fhe course
srii'ul." keep these in minds
i; .?.e ffiv-.-'icai colic-.c ’.-ay 11:;?. the fobneation
course tc- e .:; c
-c1»s;<csb course (1 s‘eax.;
in * sr’-'ree collefje/univerulty.
:owver since
university suluollrwa-s m«y uut conditions such »$>
1 a shculi Itusi to
c or ..-...’t. there chculd be
one /.rin ant’ t«o anelllery o.bjects etc., thu
flexibility of the courtc with •■-dau.uat© time for
fi«ld work jr«y g®t cuxtui.l®<;,
c,^. c:.<.~7 is ti-Kj-lorin f,-..-ch s course, link with
adr®s«
**
Ecc11} The course could be linked tc> ®. school of social
work, who ray he »x>re att-aitt-d to twetterts such as
fiei--- plac■■-•nr-sts, c->se studies etc
,
*
ill) The coup’s® could be inccrr.br®ted in full or In
parts into the existing sGOblcal courso during
cei;wRxnity .:rl©ntatlsr j>rogr®?n.t9&, field, nlacc.
*
end block postings.
3
■
3.
iv)
radical
could d-.; fit specific
3-.: ryontns or s»r« for such ■.-> eourte
as ac’-liticml to the <Kisti«»j’cwarae
durativi' <3c? re'd reteeuts•
_■ t *
as sc-<,-;'4te&
s;/>ut one third ci the total taecie. -x fcducstir
project year shoul-? be spent wor?-l’?-y vr. this .'ourv-'etiot. Cours
.
*
ths tcaifiici- experience :>£ the voluntary sector in >': alt'?: and
dcveXc: ■ --c-nt fields vc>d€ he ^ra'-ci a-pon aa resource for this course
it rbetter tv ;.len this co.-rse Jctnr In th
*
project after a
v<.view t.* th
*
pxiatinv. -.ftotto of medical colleges in this ores.
It wa
*
diacujssed that •:■...-
h th
.-.
.
'
•. )
driest tl
Li
cf
:?.c-.d t-ducatlon ;•<■•.;• bcs-’.'i
sf-d- -■ tv he rd.c.- : n«:..e- ?j. te by
< jfcs t <:
■?t'•
:•.-.. vhV4‘V7::M?ns rclicy •statements, U«« hs-ve been
■ -■
.'? ■ -v.it,’. ...:,
•-■; - ,- -..7 ■'
:■
.
■ '
"
.'. '6.J.V .,
:.
have Peer. intend idy ;.■ vhXl»r:--s.: er ;.'co ..vented. "iXte.- experiences
need tc be callatd ar.; mid -:.vei I
to all those vho are trying
t» iriiwate within oxisvinv ce-nutreisjts
*
. f.c<s:t fr«Joc4?w;Gt'i v.j
■ ;n.<j?i
*
■■ .cs-t. syMeoti over svai;'/ jrcdic-jl
C-.Aiejv ..c,■•irtr.t.,tf' -.-.i
t: :■
)„•:•.,? r-r<>-ct
could
eclvct
1;' i;’.‘13.7 ■■..■ icr -n - •.•■.c- • .efc- lid.
s
•-.:
:n
;. ,
.. , ...
...
•• '
. .: . •• t.5 '.•cerr?.;
■-■■. / . ■ ;
• ■.
■ , . ,./
7 -i .. . : ' ‘7 . . ./.yc: ■■:
' j- '.-. ;
fsetsrs That v.-re •?•.'<;• .tiw 3^ the tlm: . f innovation? ©val^ntlofi
of t’;-: jitterr.-v.-ts if <.■-y
so or-. . he vort-s of ■.■tvW v.er ■- uelci
fncur.rts' e; r.ovl.; r-ni/cv/^us-ity -■■ricnf.Atic-. ex.;
r-ith -ySvigory servJ
; J.nt.uv.tcn.ev. ■ •>- Viscni■^ratene?
'-ontj.'.;..■- in hh--- v .'cnity?
■ vr' »
si' on.
s;><del effort ■..vu’.1.'. he ??;-><•<■■■ io f.kx'i.nfrnt Vue rv.-sJl-. z, lessor
.-...: v ■•.7.-' -. .' ■■-•/.•. ,.jh\ 1. : .k?7. cc i. .i ■ „
. .
help tv- critiGU.ll.; vvalv-jy: &.?-« of
more cc.-wcr-- <>n? koowu
rhe cc«r«R?ittee ievlews^i the llvt of radical coll& ...Iven in tnv
project prc-;.:osal
-~5). It >-.-? felt th..st teEi'd-:
which function relatively autoneMoesly it wul<5 air be useful to
look
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"
MEDICAL
MAKING
EDUCATION
RELEVANT
TO
A
OF
NEEDS
THE
STUDENTS
SOCIETY"-
OF
POINT
VIEW
B Y
NARAYAN,
DR.
RAVI
ST.
JOHN’S
REGISTRAR.
MEDICAL
COLLEGE,
BANGALORE.
Paper
Conference
Read
at
XI
Annual
Association
of
the
Advancement
Held
at
Armed
Forces
Medical
February 26th, 1972, at
the
of
of
India
Medical
College,
Students
Education.
Poona
Seminar.
on
INTRODUCTION
The history of Indian Medical Education reaching down over the decades - for
over 100 years, has seen no major changes in its pattern, structure or adaptation
to the changing needs of Indian Society,
The health needs of India are varied.
Side by side we have existing tho bullock-cart age where primitive practices of
sanitation and hygiene result in a mortality of over 3C$ in the rural areas;
we have the jet age in our big
and
cities where cancer, hypertension Diabetes, Mental
illnesses and other so called diseases of civilisation are taking a heavy toll.
In addition even after over two decades of Independence and National planning the
problem of uneven distribution of Medical personnel i.e, 20^ of
where 80/“ of the population resides, still continues.
Doctors in areas
This is irrespective of
the increase in number of medical colleges from 25 in 1947 to 97 in 1971 and the
annual admissions from 2000 to 12000,
Since our Medical Colleges continue to be
located in the urban areas the needs of the rural population Jias been sadly
neglected and in addition the concept of community health even in our urban areas
has not been adequate stressed by these colleges.
Therefore the greatest need in
India today is 1.
2,
A.
To make Medical Education more community oriented.
To reorient clinical training to prepare our young doctors for
work in Rural areas.
"BASIC DOCTOR"
The present system of Medical Education serves admirably to train our young
graduates for work in our large city hospitals moddelled on the British and
American pattern and not in our rural and semi-rural community centres.
in a rural area are very different from those in an urban society.
The needs
"In the urban
areas one can accept the responsibility for a limited group of people knowing well
that others can seek and obtain equivalent advise and care elsewhere but in rural
areas a doctor must accept responsibility for a large number of people often quite
beyond the possibility of his own personal management acknowledging that if he
2
declines this responsibility he deprives them of all sources of medical help”.
In
order to work in a rural area therefore a doctor must be what the Government of India
defines as a "Basic Doctor" - i.e.s "one who is well conversant with day to day
problems of urban and rural communities and is able to play an effective role in the
curative as well as preventive and promotive aspects of regional and national health
problems."
SHORT COMINGS IN THE PRESENT SYSTEM
The present system makes the young medical graduate ’professionally incompetent’
and 'emotionally unprepared’ to face his new role in the community because of the
following shortcomings:
1. Education js not community oriented :
Medical Education in India is very hospital oriented and not community oriented.
The doctor does not learn to treat his patient within the context of his life of
society but on the basis of brief encounters in the wards.
He loses sight of the
fact that the stress and strain of everyday life affects the patient both in health
and disease and if this is not taken into consideration the treatment becomes one
sidecU
2. Academic Environment of Inatitutiona
The environment in nearly all the teaching institutions is highly academic where
each person endeavours to work in as narrow a field as possible.
This stress on
specialisation leads to the fragmentation of a patient making medicine more organcentred.
The student therefore prefers to specialise rather than take up general
practice.
3.
stress on cnrat-jva JWcim. »
Too much stress is laid in our teaching hospitals on curative medicine and
little or no stress on the preventive and social aspects.
A student studies these
aspects through a course of didactic lectures but no attempt is made to make these
concepts a practical reality with reference to the cases in the ward.
3
4.
Foreign Bins in Medical EducMlOJl »
The textbooks we study are all written by foreign authors whose experience is
based on cases and facilities present in their hospitals.
The student thus develops a
foreign bias and is not able to reorientate his knowledge to suit the special needs in
our rural areas or even in our smaller urban communities.
COMMUNITY ORIENTED MEDICAL EDUCATION
TO make our system relevant to the needs of our society certain changes have to be
introduced in our present, patterns of training.
In this paper the changes are
suggested in order, from the pre-professional year to the period of internship.
Many
of them have been suggested in other papers on this subject in the last few years and
the repetition is unavoidable.
All these suggestions have been discussed with students
and all of them have been found to acceptable to them.
For Medical Education to be more community oriented the earliest change must be s
a)
Prfr-profesa.tonal Student Counselling All high school and pre-univ»rsity students planning to take up medicine as a
profession roust be counselled :i)
ii)
to make them aware of their responsibility : to.-society,
to prepare theta to meet the special demands of the long medical course.
This measure will prevent wastage of potential medical personnel due to
chronic failures caused by disinterest and emotional inadequacy.
Also
for girls who do not plan to pursue their profession after marriage this
counselling would help them to choose other less demanding professions.
b)
Pro-professional Courqe -
The prosent pre-professional course is to a large extent an unnecessary
repetition of the higher secondary or preuniversity course.
All the subjects
taught are not adequately medically oriented :
1) In Botany or Zoology the stress should be on understanding the basic
principles of humam anatomy and physiology by a study of similar structure
and function in plants and animals.
ii) In Physics and Chemistry - various aspects of so-called Biophysics and
Biochemistry should be stressed.
4
iii)
The student should be prepared for his role in society through lectures
in certain aspects of sociology, anthropology, elements of economics,
statistics and biomathematics even at this stage.
c)
Pxe-CljMcal Course. 1) Anatomy and Physiology from the basis of our medical education and the content
of these courses cannot be radically altered except that the teaching should
The student must be
be less cadaver-oriented and more clinically oriented.
exposed to clinical material to help him understand better the normal anatomy
and physiology of an individual and the changes in them which constitute disease.
2) The introduction of Preventive & Social Medicine at this stage is very welcome.
The student must be taught about nutrition, Environmental, Industrial and
personal Hygiene, Population Dynamics and National Health problems and programmes.
A systematic course in the social sciences i.e. : in Sociology and Psychology
at this period of training will make the student aware of certain duties towards
the community which arc overlooked during the hospital training.
d)
Clinical. Course -
It is during this period of training that medical students can be made most
community and ’rural' conscious.
Though the hospital is the centre of his training
an attempt should be made with the help of a well organised community health department
to shift the emphasis of training and research from the hospital to the whole community
in which the hospital resides.
This can be done by :
1) Clinical bed-side teaching must take into account the preventive and social
aspects of diseases encountered in the wards and the student should be
encouraged to study these aspects in each case. e.g.: In a case of T.B.
i)
ii)
a follow up of the patients contacts must be made,
at the time of discharge the patient and his family must be educated on the
health measures to bo taken to prevent spread of the disease,
iii) a study of the socio economic circumstances in which the patient developed T.B
should be made.
This will help students to understand and appreciate all
aspects of a disease and its treatment.
2) Throughout the course in addition to the ward training the students, in batches
must be made responsible for the primary health of organised groups in society like
school and colleger students, children in orphanages, inmates of destitute homes,
rehabilitations centres, prisons and in the big
cities even of localised slums.
stress should be on primary health aare and mass screening.
The
After his first clinical
5
year?student will ba in a position to taka keen interest in such activities.
One of the criticisms of hospital training is that the students are not given enough
responsibility in the treatment of the patients.
The above scheme would help them to
shoulder this responsibility and make them more conscious of their usefulness in societj
Recently the Bangladesh Refugee problem gave many of our interns and students an
opportunity to voluntarily accept the responsibility of a large number of people for
a certain time and this has been a very rewarding experience.
□
io n e cc-jocui y
j)yRural orientation^ tn order to prepare a student for work with rural conditions,
culture and traditions ,and the psychology of villagers.
i)
This can be done by
a study of an Indian Textbook which should be prepared on the lines
of the book "Medical care in Developing countries - a symposium from
Makerere - Nairobi which is based on African rural conditions.
ii)
Practical training in rural areas for upto 6 months during the
clinical years and 5-6 months during the period of internship.
4) The Preventive & Social Medicine Department which would also be a Public Health
or community health department has a very important role during the clinical years.
In addition to the coordinated activities suggested above students should be helped
to conduct surveys and studies in the field-work areas in nutrition, infant care
maternal welfare and in diseases like TB, Cancer, Malnutrition and Diabetes.
The
students could also be posted in this department for 1-2 months for participating
in the above schemes.
e)
Internship
Finally it is during the period of internship that the young
medical graduate will be able to determine how well oriented he is for work in the
rural areas - if he is posted in a Primary health 'centre for 5 - 6 months.
In the
company of a senior doctor and his colleagues he will get a first hand impression
of the type of work in Rural Medical Centres, which will give him a background for
possible village work after internship.
Each Medical college could take over a few
primary health centres or start its own rural health centres where such training
could be imparted.
This programme could be planned out with the Government District
Health officer so as to prevent too much overlapping in the health care of particular
6
villages.
In this connection the government achene of supplying 50 bedded nobile
hospitals yb medical colleges to provide opportunity for rural work in very welcome.
f)
Posteraduatjon.
According to latest estimates at least 50 $ of Medical graduates
go in for higher studies either in the country or abroad.
One of the main reasons
is that young doctors who qualify have to complete with their seniors who are already
well established in the urban areas.
Therefore to enter this highly competitive
field they feel the need of a postgraduate degree of specialization.
If at this
stage however the government offers certain incentives like "jjood living and working
conditions, vehicle for field work, visits to specialised institutions in the
country and abroad and opportunities for professional advancement by way of admission
to postgraduate courses after completion of 2 - 3 years in rural areas”.
I am
with the added background of rural orientation during the medical course the
majority of our young doctors will opt for the rural areas.
In conclusion it can be said that the crying need of the moment in the
field of medical education is to widen the horizon of the student from a
severely clinical~pat:.ent oriented outlook to a wider, socially conscious—
community outlook and a student symposium such as this is a very constructive
step in this direction.
sure
BIBLIOGRAPHY
1.
Reorientation of Medical Education for Community Health Services
by : B.P. Patel - Secretary Minister of Health & Family Planning.
2.
Indian Journal of Medical Education - April and May 1970. Volume IX - 4 & 5 Conference issue. The Role of teaching hospitals. Non-teaching
hospitals, health centres and other health services in Medical
educatioh.
3.
Indian Journal of Medical Education - Volume IX Oct, 1970 issue.
i)
Medical Education for India - Dr. K.K. Shah
ii)
Utilisation of Health services for undergraduate medical
education - Dr. B.G. Prasad.
iii)
Problems of Medical Education - Dr, B. Mukhopadhyaya.
4.
Medical Care in Developing Countries - A symposium from Makers re.
Edited by Maurice King (Oxford publication)
5.
A Review of the nature and uses of examinations in Medical education WHO Public Health Paper No. 36.
6.
Preparation of the Physician for General practice - WHO Public Health
paper No. 20.
7.
Proceedings of the 1st World conference on Medical Education London - 1953
(Oxford University Prase 1954).
8.
Bharat Medical Journal - Volume 3 - No. 2, April 1971.
i) Teaching Preventive and Social Medicine to undergraduates Dr. B.G. Prasad and Dr. J.K. Bhatnagar.
ii) Changing Horizons in Medical Education - B. Mahadevan.
iii)
9.
Research and Service aspects of Teaching Preventive & Social
Medicine.
Background papers of U.G.C. Institute for teaching Social Sciences in
Medical Colleges.
i) Changing needs of Medical Education - K.N. Rao
ii) Social Science content in Undergraduate teaching of Community
Health - D. Banneriee.
Rural Health problems and preparation of physician H.S. Takulia.
iv)
A case for Integration of social sciences and medicine and
medicine and medicare - Hair Vaishnara.
v)
Doctors as a Modernising elite - T.N. Madan.
iii)
me?
Students' Seminar
MAKING MEDICAL EDUCATION RELEVANT TQ
THE NEEDS OF THE SOCIETY;
A STUDENT’S POINT OF VIEW—PAPER I
by
Ravi Narayan
Jakrx. A. }M1 Medical College, ^eogpbre.
The system of medical education in our country is a legacy of lie pgsl,
not materially changed for many Arcades.
Ils str#cture and ppfierp type
Primarily evolved to tram doctors for working in large city hospitlas, this system is#ol suited do prepare
doctors for serving rural or semi-rural communities. Its major shortcomings are:
(a)
It is not community oriented.
-(■b) Because it is hospital oriented, too great an emphasis is .laid on specialisation.
(c)
Too much stress is laid on curative medicine and .liiffe or na#c,on preventive apd socj^l affects.
(d)
Il has a foreign bias.
To make-medical education -relevant to the needs of our society, it must be commupily .prjcnlql. fit order
to achieve this godl, the fallowing suggestions are made,:
•(a) djuidance and-counselling of pre-university students desiring to take up medicine as a profession
with a view to making them aware of their responsibility to the society.
(b)
During the pre-professional course, elements of sociology, anthropology, economics, statistics, and
biomalhemalics should .be introduced. Also -at this stage, Jh‘ ts.tpdy of science gybjects, .namely, physicse
chemistry, botany and zoology should be relevant to their .application io rthe related fields, in. medicine.
(d) 'Thepre-dlinicdl course should be clmeidlly oriented rather than ,cadaver oriented as.it is ^tlpresent.
Thcpre-clinical trainingperiod would be the -proper -stage for itbe 'teaching -of -nutrition, environmental
sanitation, industrial .-health and .personal hygiene, population dynamics, national health problems agd
programmes.
(d) During the clinical course, concerted efforts must be made-lo impart ..community prjented trjWWIff
Emphasis shotlld Shift from the' hospital-centred training, io,-tpe training for fpe provision,pf .comprehensive
■bealth'eare loithe •eommmiity. Familiarisation of the sludents with .rural conditions, -rural culture and
traditions, and with the psychology of:the village-folk should form an integralfart of the curriculum
during the clinical-period.
(e)
.During.their.internship,-the fresh graduates should serve Jor 3. to 6 months inp^tjigpry .hfqllh
centre under the guidance pf-fenior and experienced.doctors.
THE INDIAN JOURNAL OV MEDICAL EDUCATION
Introduction
VOL. XL
NO. ? & 3
“Basic Doctor
i.e : “one who is well con.,
versant with day-to-day problems of urban
and rural communities and is able to play an
effective role in the curative as well as preven
tive and promotive aspects of regional and
national health problems.' ”
’“The history of Indian Medical Education
reaching down over the decades-for over 100
years, has seen no major changes in its pattern,
structure or adaptation to the changing needs
of Indian Society. The health needs of India
are varied. Side by side we have the existing
bullockcart age where primitive practices of Shortcomings In The Present System
sanitation and hygiene result in a mortality of
The present system makes the young medical
over 30% in the rural areas; and we have the graduate ‘ professionally incompetent ’ and
jet age in our big cities where cancer, hyper emotionally unprepared ’ to face his new role
tension, diabetes, mental illnesses and other so in the community because of the following
called diseases of civilisation are taking a heavy shortcomings:
toll. In addition even after over two decades
of independence and national planning the 1. Education is not community oriented:
problem of uneven distribution of medical
Medical education in India is very hospital
personnel i.e. 20% of doctors in areas where
80% of the population resides, still continues. oriented and not community oriented. The
This is irrespective of the increase in number. doctor does not learn to treat his patient with
of medical colleges from 25 in 1947 to 97 in in the context of his life in society but on the
1971 and the annual admissions from 2000 to basis of brief encounters in the wards. He
12000. Since our medical colleges continue loses sight of the fact that the stress and strain
to be located in the urban areas the needs of of everyday life affects the patient both in
the rural population have been sadly neglected health and disease and if this is not taken
and in addition the concept of community into consideration the treatment becomes
health even in o.ur urban areas has not been one-sided.
adequately stressed by these colleges. There
2. Academic Environment of Institutions
fore the greatest need in India today is—
1. To make medical education more com The environment in nearly all the teaching
institutions is highly academic where each
munity oriented.
person endeavours to work in as narrow a field
2. To reorient clinical training to prepare as possible. This stress on specialization leads
our young doctors for work in rural to the fragmentation of a patient making medi
areas.
cine more organ-cci.trcd. The student there
fore prefers to specialise rather than take up
general practice.
A “Basic Doctor ”
The present system of medical education
serves admirably to train our young graduates
for work in our large city hospital modelled on
the British and American pattern and not
in our rural and semi-rural community centres.
The needs in a rural area arc very different
from those in an urban society. “ In the urban
areas one can accept the responsibility for a
limited group of people knowing well that
others can seek and obtain equivalent advice
and care elsewhere but in rural areas a doctor
must accept responsibility for a large number
of people often quite beyond the possibility of
his own personal management acknowledging
that if he declines this responsibility he deprives
them of all sources of medical help ”, In order
' to work in a rural area therefore a doctor must
be what the Government of India defines as a
3.
Stress on Curative Medicine
Too much stress is laid in our teaching
hospitals on curative medicine and little or
no stress on the preventive and social aspects. A
student studies these aspects through a course
of didactic lectures but no attempt is made to
make these concepts a practical reality with
reference to the cases in the ward.
4.
Foreign Bias in Medical Education
The textbooks we study are all written by
foreign authors whose experience is based on
cases and facilities present in their hospitals.
The student thus develops a foreign bias and is
not able to reorientate his knowledge to suit
the special nceds'ih our rural areas or even in
our smaller urban communities.
APRIL-SEPTEMBER, 1972
MEDICAL EDUCATION AND THE NEEDS OF THE SOCIETY
Community oriented Medical Education
To make our system relevant to the needs of
our society certain changes have to be introdu
ced in our present patterns of training. In this
paper the changes are suggested in order, from
.the pre-professional year to the period of in
ternship. Many of them have been suggested
in other papers on this subject in the last few
years and the repetition is unavoidable. All
' these suggestions have been discussed with
students and all of them have been found to be
acceptable to them.
For medical education to be more commu
nity' oriented the earliest change must be:
(c)
3
Pre-Clinical Course:
1. Anatomy and Physiology form the basis
of our medical education and the content of
these courses cannot be radically altered except
that the teaching should be less cadaver-orien
ted and more clinically oriented. The student
must be exposed to clinical material to help
him understand better the normal anatomy
and physiology of an individual and the changed
in them which consitute disease.
2. The introduction of Preventive and
Social Medicine at this stage is very welcome.
The student must be taught about Nutrition,
Environmental, Industrial
and Personal
Hygiene, Population Dynamics and national
: (a) Pre-Professional Student Counselling :
health problems and programmes. A systema. All high school and pre-university students matic course in the social sciences i.e., in Socio
planning to take up medicine as a profession logy and Psychology at this period of training
will make the student aware of certain duties
must be counselled:
towards the community which are overlooked
(i) to make them aware of their responsibi during the hospital training.
lity to society;
(ii) to prepare them to meet the special (d) Clinical Course:
demands of the long medical course.
It is during this period of training that medi
This measure will prevent wastage of
potential medical personnel due to cal students can be made most community and
chronic failures caused by lack of interest 'rural’ conscious. Though the hospital is the
centre
of his training an attempt should be
and emotional inadequacy. Also for
girls who do not plan to pursue their made with the help of a well organised com
profession after marriage this counselling munity health department to shift the emphasis
would help them to choose other less of training and research from the hospital to
the whole community in which the hospital
demanding professions.
resides. This can be done by:
; (b) Pre-professional Course :
1. Clinical bed-side teaching must take
The present preprofessional course is to a into account the preventive and social aspects
large -extent an unnecessary repetition of the of diseases encountered in the wards and the
higher secondary or pre-university course. All student should be encouraged to study these
the subjects taught are not adequately medi aspects in each case, e.g : In a case of T B—
cally oriented:
(i) a follow-up of the patient’s contacts must
1. In Botany or Zoology the stress should '
be made,
be on understanding the basic principles of
(ii)
At the time of discharge the patient and
human anatomy and physiology by a study of
his family must be educated on the public
similar structure and function in plants and
health measures to be taken to prevent
animals.
spread of the disease,
2. In Physics
and . Chemistry-varipus
(iii) A study of the social economic circums
aspects of so-called Biophysics and Biochemis
tances in which the patient developed TB
try should be stressed.
should be made. This will help students
3. The student should be prepared for his
to understand and appreciate all aspects
role in society through lectures in certain
of a disease and its treatment.
aspects of sociology, anthropology, elements of
economics, statistics and biomathematics even
2. Throughout the course in addition to
• at this stage.
the ward-training the students, in batches must
tHft iMJIAN JOURNAL OF MfcbtGAL fiOOUATtON
4
be made responsible for thfe priftiaty health 6f
| organised groups in society like school and
College student!, children in orphanages, in| mates of destitute homes, rehabilitation centres,
prisons and in the bjg cities even of localised
slums. The stress should, fee oh primary health
care and mass screening. After his'first clinical
year every student wiTbe ln a position to take
keen interest in such ■ activities. ,t)ne of the
\ criticisms of hospital training is that the Students
are not given enough responsibility in the
treatnSSft of ths pAtients. The above kchetne
wOWd help them ro shonMct this respbhsibiiity
awd WM
*
tftm more Wiwciotis of their useftilhfers tn society. Recently the Bangladesh
Refttgee problem :gave many nfowr Interns and
students ati opportunity tt> votantAriiy accept
the WspOnsfbility of ■ a large number of people
for :a Certain 'time 'And tfeft has been a very
rt Warding •ttcpdriewtfc.
*3. Rural briefitStiont th'Order Vo prepare
a s'udent for work ’fit the YCiral areas he riittst
: be familiarised during his course . with .rural
' conditions, rural culture and tra'ditiWIS ti'hd the
i psychology of villagers. This can be done
j
[
*(i-) a •'study Of all Iwfilan tPeWbdOk Which
'should be prepared dn The Ijihes Of the
book ’‘‘MeditsItafiftto’DewilcqAig cwm'fries—n 'siympbSirffA 'ftWn Wakerwe—
‘Nairobi Whiifh ft 'based On'Afritfan 'Hirai
<conditioKb.
(ii) Practical training in rural areas for upto
6 months during ’-the -clinical .years and
, -8—■€-months-during-the,period-of-intern
ship.
*4.
The PSM’Department'wliich ’wodia rilso
I be’"a Public Health dr ‘tOmrrrtlrfity 'health
department has a v.erv -important role during
I the clinical years. Tn addition 'to the coordi■ nated activities suggested above Students should
I be ‘helped to conduct -surveys land-studies>in
| -iBe.tfield woifc Jareds-in Nutrition, drifartt care
: maternal ‘welfare -and >in -diseases like TB,
Cancer, Malnutrition -and Didbotes. The
students could also be posted in this depart: merit'for T-5 ‘months Tot 'participating in-the
'aboVe■sdhdntis. "
, ;;•
VOL. XL
NO. 2 & 3
(e)
Interfithip :
Finally it is during the period of internship
that the young medical graduate will be able
to determine now well oriented he is for work
in the rural areas—if he is posted in a Primary
Health CentreTor 3—6 months. In the comp
any of a senior doctor and his colleagues he
will get a first hand impression of the type of
work in Rural Medical Centres, which will
give him a background for possible village
wortc after internship. Each medical college
could take over a few primary health centres
or start its own mral health centres where nch
training could be imparted. This programme
could be planned out with the Government
District -Health officer so -as to prevent too
much overlapping in the health care of parti
cular villages. In this connection the govern
ment scheme of supplying 50 bedded mobile
hospitals to medical colleges to provide opportu
nity -for -rural work is very welcome. (f)
Poslgraduation :
According to latest, estimates at least 30% of
medical 'graduates go in for higher -studies
either in the country 'or abroad. One of the
htain Teasorrs is "that yotmg doctors who -qualify
have To -compete -with Their seniors who are
Steady well tsrablKhed tn die -urban areas.
ThtereForeto enterrtiis’Highly competitive field
ihtty feel The-need'of'a-postgraduate -degree of
specialization. If at this stage, ’however, the
'government offers certain innerrtrvesffike'-“good
living and working conditions, vehicle for field
work, visits to specialised institutions m the
country -and abroad umd opportunities .for
professional -advancement -by way of.admission
topostgraduate-courses -after completion .of'2-3
years in ‘rural .areas
1 am .sure -with the
added background of rural orientation-during
the medical course the majority of our .young
Sectors will'bpt for the rural-.areas.
• - In -Conclusion it -can be .said that the .crying
need of the moment in the field of medical
education’is to widen the horizon of thcjtudent
from a severely clinical patient oriented out'ludktto a -witter, ’socially conscious'commuriity
UUtlpdk 'Hr.d -a student ■aymposium'sudh as'this
is a very constructive step'in»th>s direction.
*********************************************************** * ******* ***
Discussion
Chapter
of
A dissertation
TRAINING DOCTORS for
Health Services
-
on
Community
Trends in
Under-graduate Medical Education
in India
London University
(D.T.P.H. 1973)
By
Dr Ravi
Narayan
Dept of Community Medicine
St. John’s Medical College
Bangalore - 560 034
For further details, rest of dissertation and
references list contact author at
326, Sth Main, 1st Block,
Koramangala, Bangalore-560 034.
DISCUSSION
Medical education
in India is at the crossreads.
A time has come for a radical appraisal of the entire system and an
assessment whether we are progressing in the right direction.
The post-independence burst of energy lead to a remarkable
growth
in medical education which was, however, quantative rather
than quailfive.
The aims and objectives were exalted from the very
beginning, and the translation into performance would have been possible
only if all the medical educators and students had been paragons of
dedication.
By the end of the first decade, it was discovered that
the doctor in India would have to be very community oriented and that
the hospital oriented system with a dichotomy of preventive and cura
tive services, which we had inherited, would never produce the type
of ‘basic doctor' we required.
A reorientation of the system was,
therefore, necessary.
Like the medical profession all over the world we, in India, were
still ‘traditionalists' and resistant to change, and so the measures
taken towards this reorientation were half-hearted and indicate only
a partial solution.
Volumes of papers and hundreds of speeches were
made on the health needs of the village communities, and the need
based changes required in the medical curriculum but "imitation of
western patterns and anxiety to reach standards acceptable by the
western institutions resulted in a blurring of vision tocreate and
develop an educational pattern that would fulfill the expectations
and needs of the rural societies.'7
Most universities decided that adding a course in preventive and
social medicine and providing time in rural health centres would be
adequate measures to give students the required community health
orientation. Many departments of preventive and social medicine,
however, made pioneering attempts in evolving new concepts
of community
health training, discussed in a previous chapter, which helped to
improve the status of the subject, in the eyes of the students and
staff.
The clinical departments were alow to respond and many con-
tinued to give the students and.narrow hospital orientation, in the
mistaken belief that the community health orientation of the student
...2
2
was the sole responsibility of the preventive and social medicine
department. The specialists continued to load the student with
unnecessary details of their specialities, patterns of research followed
the fashionable and sophisticated pathways of medical research in
developing countries and, therefore, the medical colleges continued
to produce doctors who preferred the organised and protective health
systems of the heopitals, to the challenging task of rural service.
Planners and educators appeared surprised at the reluctance of doctors
to man the health services in the rural area, and it took them quite
a time to realise that the fault was in the educational system, that
neither trained nor prepared them for the task and often, actually,
interferred with the development of self reliance and confidence
required to meet the challenges of rural health centre
service in
India.
It would interest educators in India to know that the protected
development of the undergraduate has gone so far in the British system
that the TODD report (1968) made the following interesting obser
vation. "Every doctor who wishes to exercise a substantial measure
of independent clinical judgement will be required to have a sub«
stantial meaaeaje-e-f independent eiinieal- judgement will postgraduate
professional training, and the aim of the undergraduate course should
be to produce not a finished doctor, but a broadly educated man who
become^ a doctor by further training".
It is a moot point, therefore,
to consider that having adopted the British system, with subsequent
minor alterations, whether we could afford to produce such 'broadly
educated men' who could serve the community only after years of further
training - for this is the observed result of our present system.
Another interesting question that needs to be answered is whether we
should reduce the largely futile dependence on expensive over-trained
physicians, and experiement with new grades of medical workers.
In
its approach to the Fifth five-year plan, the planning Commission
(1972) states that "The emphasis in rural health will have to be on
prevention, family planning, nutrition and detection of early morbidity
with adequate arrangements for referral of serious cases to the district
hospital. Such a multi-tier system cannot be buil<£on a national scale
on the basis of the present expensive system of prolonged medical
education.
In order to provide an adequate number of doctors for the
Fifth plan programme, and as an advance preparation for a more intensive
coverage later, it would be necessary to consider the revival of the
3-year medical diploma. Indigenous systems of medicine will also have
to be utilised for the purpose."
3
3
The Government has, therefore, aclearly indicated that the training
of a new type of doctor through a shorter course is inunindent in India.
Though the details of such a course are outside the scope of this
dissertation, it would bd worthwhile to discuss a few principles that
could be applied in planning such a course:
1.
The most
important principle is that the proposed 3- year
diploma course should not be a revival of the earlier- licentiate
course which we abolished at the time of Independence.
Since
then the medical profession in India has been highly suspicious
of attempts to r2vieve condensed M.B.B.S. courses and training
of of what are often known as ’near doctors' or 'subprofessionals1.
The object of the
course should be to produce a doctor who is so
specifically trained for rural health centre service that he becomes
more qualified for that job than the average graduate M.B.B.S.
In
fact, the 3 - year course should lead to a Bachelor's degree in
rural medicine, and not be underrated by calling it a diploma,
and Snaking it appear to be a lower qualification.
2.
The training of the new cadre of doctors should follow the
principles suggested by ROSA (1964):
i)
Approach based on local problems
ii)
Maximum use of community self help
iii)
Training must be in the svironment where his future job will be
)(Rural health centre)
iv)
Broad perspective of rural problems.
v)
Efficiency in mass methods of treatment, vaccination and so on.
vi)
Appreciation of economy
vii)
Strong basis in maternal and child health and principles and
practice of health education.
viii)
Training should be very practical and realistic.
In fact
ideally it should be two-thirds practical, and one-third theory.
3.
The training of this new cadre should be reqionalised and specifi
cally oriented to meet the needs of the peripheral health services
in each state. Close cooperation between the medical colleges of
the state and the government health services especially the primary
health centres and district hospitals should be encouraged.
4.
The findings cf the Rural Health Research project at Narangwal
and the long experiences of many departments of preventive and
social medicine in the country, in the organisation and problems of
training in a rural health centre setting should be closely studied
4
- before evolving the new diploma course.
5.
Such locally - oriented cadres of Jnedical workers have been trained all
over the world, and the experience of educators of feldshers in U.S.S.R.
peasant doctors in China, physician assistants in U.S.A. (DUKE UNIVER
SITY SCHEME) and medical assistants or Health Officers in Fiji, Tanganfia
Malawi, Sudan, Uganda, Ethiopia, Kenya and Nigeria should be consulted
in the planning of the new course.
6.
These are described in FENDALL (1972)
Selection of students for this course should be carefully done.
Stress
should be on a rural background, a command of the local language, a
familiarity wijsh the people and a commitment to return to the rural
area for work.
Stipends should be
made available to these students
during their training, and on completion they must get jobs as close
as possible to the areas from which they were selected. The village
panchayats could also help in the selection of the right type of students
7.
The content of the course should be practical and realistic.
The
training must prepare the rural doctor for the three vital functions.
i)
To act in a screening capacity and refer to more highly trained profes
sionals, patients in need of greater dLiagnostic acumen and skills.
ii)
To treat visible sickness and cater to simple health requirements such
as routine Midwifery, simple sanitation, water and housing improvement.
Lii) To render emergency medical care.
8)
The teaching staff on such a course should consist mainly of health
officers and teachers who, themselves, have a personal experience of
rural health centre services.
The challenge,
put bluntly, is that health services and systems of
education must be organised for the good of the people, and not to meet the
personal needs of a certain cadre of doctors for material gain or scientific
satisfaction and if a shorter course producing a new type of medical worker
specifically trained for the rural areas is the answer, then we must have
the courage and commitment to go through with the changes required.
Only
when the needs of the rural areas are met can the claims for'Social Justice
*
within our constitution be validated.
5
5
It must, however, be remembered In India that the decision to con
sider a revival of a shorter training course for doctors does not mean
that the existing M.B.B.S. course be allkwed to containue to develop
along western trends. The decision to reorient this course to meet
the needs of our expanding community health services, taken many years
back, has resulted in many healthy trends attempting to make the course
more relevant to our local needs, and this must continue.
The product
of the system whether he wants to be a general practitioner, public
health officer,
specialist, teacher or research worker, must be made
aware of the local needs of his country, the economic limitations, the
sociocultural factors that determine health trends, and the need to
develop local knowledge, local technology and local expertise.
He must
be made to realise that "no matter how useful a heart surgeon may be in
the right situation, he is of little value in a country where thousands
of infants still succumb every year to infectious diarrhoeas, and it
would be far better if his talents had been turned towards a more useful
if less spectacular, direction".
The process of making the existing medical education in India more
relevant to the country's needs is well under way as described in Chapter
4,
but unless these new programmes and methods of teaching ace introduced
with a degree of urgency into every medical college, the effect of the
reorientation will be difficult, to assess. It must be remembered that
for such an orientation to be successfull we need staff trained in pre
ventive and social medicine and in the expanding field of community
health, and there is an acute sh ortage of such a cadre. Certain
principles to be followed in this continuing reorientation should be
stressed here.
1.
University involvement in health care
Bryant (1971) has said that systems of health care are inseparably
linked to the education of health personnel, and these systems cannot
change without corresponding changes in education.
What is needed in
India today is a strong commitment of universities and medical colleges
to health care in the surrounding.communities.
A medical college must
not consider itself a purely academic institution, but must be actively
involved
in the health of the community.
A first step towards this
commitment should be the allotment of a primary health centre, and its
subcentres to each medical college in India.
The college should not
,6
„
only use the centre for teaching, but also be responsible for its
administration and for the delivery of comprehensive health care to the
villages; thus teaching and service become closely linked.
Greater
involvement in health projects in urban areas like urban slum health
schemes, school health services, health of specialised groups in
societies such as destitutes, prisoners, industrial workers, could b
also be initiated. Finally, a medical college situated in an urban area
could be responsible for the total medica care of that region, both
urban and the surrounding rural areas.
2.
Improvement of standards of teaching and teachers
In India, as in
all developing countries, there are acute shortanges
of wall trained medical teachers.
Most teachers take up teaching be
cause they have been unsuccessful in private practice, or as specialists
they feel that contact or association with a medical college improves
their status and prestige.
Teaching is thus seldom taken up as a voca
tion. This is unfortunate, since the teacher is a key-figure in the
educational precess.
1.Teachers must be given a training in the basic principles of education
and must know how to produce effective results with the available facilities.
2.
They should be full-timd so that teaching becomes the main responsibility
and not a side issue.
3.
In order to get good teachers, the salaries must be improved, and their
social status raised.
Even the most dedicated teachers can be put off
by the present salaries offered in India.
4.
The teacher must be, acutely concerned with problems of health care
and delivery in India.
He cannot pass on a social concern to the medical
students he teaches, unless he, himself, is so motivated.
3.
Documentation of local knowledge and needs and development of
local technology
Any system of education which continues to follow textbooks, primarily
written for, and dealing with the needs of a western community, cannot
hope to produce students aware of local needs and disease conditions.
Textbooks of medicines specially geared to features of disease and
measures for treatment prevention and control available in the country
are, therefore, urgently required. An Indian medical student, especially
if he is expected to serve in the rural areas, must, surely, know more
...7
7
■> about Hookworm Anemia, Amoebiasis, Malaria, Tuberculosis, Leprosy and
Malnutrition, than the information given in the textbook of medicine
by DAVIDSON. At the same time he need not study, in detail, diseases
such as Disseminated Sclerosis or Pernicious Anemia which he seldom
sees. A special textbook or manual of medicine to prepare him for
rural health centre service on the lines of
would be very welcome.
Attempts to develop local technology to design and produce medical
apparatus and equipment suited to our local needs, budgets and climatic
conditions should also be encouraged.
4.
Appreciation of economy and effective utilisation of available
services and resources
Health is only one of the many priorities in socio-economic development
and hence the financial resources available for health care, education
and developnebt are limited.
In/a developing country, like ours, appreciation of economy and effort
to initiate biiilding constructions, and health programme which are
realistic, must be stressed.
Often due to social and political pressures
we are tempted to build large medical colleges and hospitals purely along
western standards and designs.
Very often these prove to be ’white
elephants’ which are difficult to staff and administer, but more often
not the building takes up the entire budget and so remains unutilised
due to shortage of running expenditure.
This situation has occurred so
often in India that there is an urgent need to ban any further investment
on such projects. Ina country where the need is great, the quality and
extent of care provided is far more important than the aesthetics or
size of the institution through which it is given.
"For a proper an d effective utilization of the available resources,
it would be necessary to coordinate the activities of the various health
institutions in
ful expenditure
a region. In this way, duplication of effort and waste
on personnell and equipment could be avoided". This also
means greater utilization a of esisting private and public non-teaching
hospitals and medical institutions clinics and dispensary in medical
education.
5.
General practitioners and General practice.
TO meet the health needs in India, there should be a much greater empasis
on the production of general practitioners rather than specialists.
This can be done by;
8
8
i) Introducing general practice units in hospital out patients,
as suggested in Chapter 4.
*
ii) Involvement of general practitioners of the area in the teaching
and training programmes of medical colleges.
iii)
Starting of gener al practice speciality or department is every medical
college which cou Id coordinate (i) and (ii) and also provide training
for all medical graduates interested in taking up general practice.
6.
Evaluation
It is necessary to determine the efficacy of many of the earlier
suggested changes in the curriculum, on the reorientation of students
towards community medicine. Unless these programmes are subjected
to wall-planned evaluation studies, the effect they have on a student
can never be determined.
The only known study carried out on rural
internship, for instance, is that by. The study revealed that 71%
of the interns que stioned thought the rural experience was useful,
69% developed
an ability to establish rapport with the villagers,
57% learned to get along with other professional colleagues and auxi
liaries, 56% got en understanding of the socio-economic factors in
disease, and 50% got a favourable idea of rural life after the three
month programme.
7.
Motivation of the Medical Profession
all over the world there has been a gradually increasing materialistic
orientation of the medical profession. The ideals of service and dedica tion are becoming rarer among the doctors. The outward manifesta
tions of this change are reflected by the shortage of doctors willing
to work in
rural areas all over the world, by the shortage of doctors
willing to work in spedilities like geriatrics, psychiatry, or any
field which requires a certain amount of dedication and also in the
development of hea 1th care system such as in the US.where the treatment
one receives depends entirely on how much one can pay; thus a time
ha s come when the medical profession must reappraise its own position
in society.
The young medical stu dent plans his career in the image
of his teachers an d
elders in th e profession and unless their moti
vation changes, the hope of produc ing community oriented .doctors
remains idealistic.
However, it is important to keep in mind that
the motivation of doctors to work for society in different countries
is closely
related to the
political systems and, therefore, a parti
cular experiment works in a country only if the political system
favours it.
Finally, it must be remembered that health care and
9
9
medical education are only one of the many aspects of the entire life
of a country, and the more commensurate they are with the countr's
ec onomic, cultural, social and other conditions, the more likely
they are to succeed.
They also stand a better change of influencing
favourably those other conditions.
A village health centre is no
longer a curative dispensary but a centre providing comprehensive
health care which include curative, preventive and rehabilitative
measures, environmental health, improved nutrition, housing and
recreation; in
other words it is a centre involved in the overall
imporvement of the life
of a community.
Therefore, a doctor
trained not only to the the head of a health team but must be pre
pared to be a member of a larger developmental team of, admini
strators, farmers, engineers, teachers and so on, united together in
an effort to improve the conditions of Rural India.
Medical Colleges in India do not prepare medicos for the
emotional and professional challenges of rural health care.
For many it is their first experience ofthe harsh realities oflife
and the inadequacies of our health care system.
The Devadasans, a doctor couple, both graduates of the
1980’s reflect on their experience in the light oftheir medical
education.
A View From The Periphery
Dr. Roopa Devadasan
Dr. N. Devadasan
(Accord, Gudalur)
Frankly, sometimes we wonder
what prompted us to take the decisiontwo fresh MBBS graduates with a
year’s experience after internship and
training in CMC-Vellore, with a
romantic idea of working in a remote,
rural area. It is not easy to remember
and relive those first few months in
Gudalur, but some scenes are etched
forever in one’s memory.
Like, walking up to Theppakadu
village, a Bettakurumba hamlet next to
the tourist lodge in Mudumalai
sanctuary. A series of three blackened
and broken down bamboo huts. We
ask what “happened”. The women
Tlied in childbirth last year, we are told,
and custom demands that their
dwelling should be burnt after their
death. Three maternal deaths in the
space of one year !
Like, riding on the back of a bike at
one A.M. through elephant infested
forest, soaking wet and bone weary
after a village meeting to chose a health
worker. Wondering why? Commu
nities can only meet at night and we
live 35 km away. And a year later, that
same health worker brings to our
house at nine p.m. a young woman in
obstructed labour. She needs a
caesarian section to save her life. What
hospital can we take her to ? A night of
coaxing and cajoling the Government
hospital staff and exhilaration as at
3.30 a.m. after surgery both mother
and child are saved. A deep sigh of
relief aswetransportherhomelO days
later; two post operative Caesarian
deaths have occurred that month due
to sepsis.
A second referral to the same
hospital, a young boy of 6 years with
probably meningitis. We stand by
helplessly while he gets antibiotics to
tickle the bacteria - totally inadequate
doses. How does one tell a very senior
doctor that the dose won’t touch him ?
Or a nurse, that shouting does not
improve a patient’s comprehension ?
When we decide to transfer him out
and take total responsibility, it is too
late. Going back to the village with his
mortal remains. The tribals are right -.
only the dead return from hospital.
Our first year was a series ofshocks.
Medical college did not prepare us for
a town which did not have a
laboratory to do a cerebrospinal fluid
examination, and whose four drug
shops do not stock medicines to fight
tuberculosis.
Sometimes we had to visit three of
the four shops to obtain a complete
course of antibiotics. We did not wai
to duplicate government and existin
medical services; so we doggedl
worked at cooperating. But no one ha
prepared us for the total apathy an
greed around.
— a poor tribal to undergo a belo’
knee amputation is told to pa
Rs. 60-00 for a blade for hi
surgery.
— the nursing assistant won’t chang
a soaked dressing until he is pai<
for his evening booze.
— a young woman has a rupture o
the uterus after her thin
pregnancy, because of careles
management. She has no living
children and will never have oni
now.
— a District Health Officer whc
insists that the ifnmunizatior
coverage in our area is 150% ? Sc
what if we know whole tribal
villages are left out ?
We roped in our old classmate
studying for his Master of Surgery in
neighbourihg Mysore, to help us with
surgeries. He told us everywhere it was
the same; he had seen in his hospital
emergency surgery refused, because
the party could not pay.
Health Action June 1991 • 2
Slowly the scales began to fall from
our eyes.
Today we have 36 trained village
level health workers. The budget runs
into thousands. That is when we start
fumbling and cursing. No one taught
us administrative skills, budgeting,
time and personnel management. How
does one work in isolation in the field
of health which is so linked up with all
other aspects of life, particularly the
economic ? Can a patient really pay for
his drugs ? Therapeutics in college did
not include costs, the absolute bottom Over eight thousand people, a large
line as far as the patient goes. The few
ideas we have on the “political” number of them tribal people on a
implications of health are through an protest march to the Sardar Sarovar
rmal friends circle, the MFC, and dam were stopped at Ferkuva and
prevented from proceeding to the dam.
:r experience.
On the positive side, for medical The march called the “Jan Vikas
college, they did give us a fair amount Sangarsha Yatra” (March for
of skill in medical and obstetric care. People-Oriented Development) set
We managed what we could and out from Rajghat on the banks of the
when referral was impossible we river Narmada last Christmas day,
prayed! The very fact that we plunged reached the border on the 31st
into a community health project gives December, 1990; and are camping
credit to our training in that sphere - there ever since. Since 4th January,
planning, executing, monitoring came seven people including Ms. Medha
easilv because WE HAD DONE IT Patkar of the Narmada Bachao
ALL BEFORE, DURING OUR Andolan (Movement To Save
STUDENT DAYS. I only feel sorry Narmada) are on an indefinite fast.
jeep mechanics was not included in the The anti-dam marchers are demanding
a comprehensive review of the project
course !
and a stay on the construction pending
Finally, a lot of people ask us — do
you miss not having done a such a review.
Renowned social worker Dr. Baba
postgraduation yet ? In all honesty, I
Amte, recipient of the Magsasay and
^kt say Yes because we don’t have a
cOTrse which makes one jack of all Tempelton Awards for his work
trades. A course in general practice, among leprosy patients, who is
knowing a little of all branches of accompanying the march is also on an
medicine to manage all kinds of indefinite protest sit-in at the Gujarat
problems. General practice or Family border.
The Sangarsha Yatra began with
Medicine is the only useful subject
worth a postgraduation if you are around 2,500 people, including a large
working on your own in a rural area. number of women from the villages to
Our predominantly rural country does be submerged by the Sardar Sarovar
not have the course. Specialisation 'project at Rajghat in Madhya Pradesh
tends to erase basic knowledge of on 25th December last year. Amidst
managing simple cases. Not all of us the clanging of bells, blowing of conch
shells the marchers took a pledge not
are meant for teaching hospitals.
Unless they modify the under to return home till they had achieved
graduate course. Anyone listening their objective of stopping the dam.
Over hundred representatives of mass
out there?
organisations and NGO s from all over
The Battle for the Narmada
Anti-dam Marchers Camped
At Gujarat Border
»
28 • Health Action June 1991
the country were with the march. A
four member delegation from the
Friends of the Earth, Japan also joined
the Yatra.
Travelling on an average of 20 km
per day, carrying their own food and
fuel the marchers camped during the
nights in villages on their way. They
held meeting to explain their demands
and werejoined by many more people.
The Yatra had swelled to about 4000
people by the time they reached
Alirajpur on the 29th December,
about 24 km from the border and
120 km from the dam site.
The Yatra received a rousing
welcome from the residents of the
town Alirajpur. Over 1000 tribal
people from the areas to be submerged
by the dam in Madhya Pradesh,
Maharashtra and Gujarat, who had
trekked over 200 km of rough hilly
terrain joined the Yatra. Several more
representatives of mass organisations
from all over the country also joined
the march at Alirajpur.
In the face of threats from the
Gujarat government and the fact that a
massive rally organised by the pro
dam people across the border had
threatened to form a human chain and
prevent the anti-dam Yatra from
entering Gujarat. The Yatra set out the
next day and reached Ferkuva, on the
inter-state border between Gujarat and
Madhya Pradesh on the morning of
31st December, to be stopped by
armed police and para-military forces.
A small group of pro-dam rally was
also present to shout abuses at the
marchers.
Me-pgfe -
Chapter - 7.
DISCUSSION'.
Medical education in India is at the crossroads.
A time
has cane for a radical appraisal of the entire system and an assessment
whether we are progressing in the right direction.
The post-independence burst of energy lead to a remarkable growth
in medical education which was, however, quantative rather than
qualitive.
The aims and objectives were exalted from the very beginning,
and the translation into performance would have been possible, only
if all the medical educators and students had been paragons of
dedication . (TAYLOR, 1970).
By the end of the first decade, it was
discovered that the doctor in India would have to be very cocununityoriented and that the hospital, oriented system with a dichotomy of
preventive and curative services, which we had inherited, would never
produce the type of ’basic doctor’ we required.
A reorientation of the
system was, therefore, necessary.
Like the medical profession all over the world we, in India, were
still ’traditionalists’ and resistant to change, and so the measures
taken towards this reorientation were half-hearted and indicate only a
partial solution.
Volumes of papers and hundreds of speeches were made on
the health needs of the village communities, and the need based changes
required in the medical curriculum but "imitation of western patterns and
anxiety to reach standards acceptable by tiro western institutions resulted
in a blurring of vision to create and develop an educational pattern that
would fulfill the expectations and needs of the rural societies (!A0, 1966c).
Most universities decided that adding a course in preventive and
social medicine and providing time in rural health centres would be
adequate measures to give students the required community health
orientation.
Many departments of preventive and social medicine,
however, made pioneering attempts in evolving new concepts of community
health training, discussed in a previous chapter, which helped to
improve the status of the subject, in the eyes of the students and staff.
The clinical departments were slow to respond and many continued to
give the students a narrow hospital orientation, in the mistaken belief
that the community health orientation of the student was the sole
responsibility of the preventive and social medicine department.
The
specialists continued to load the student with unnecessary details of
their specialities, patterns of research followed the fashionable and
sophisticated pathways of medical research in developing countries and,
therefore, the medical colleges continued to produce doctors who preferred
the organised and protective health systems of the hospitals, to the
challenging task of rural service.
Planners and educators appeared
surprised at the reluctance of doctors to man the health services in the
rural area, and it took them quite a time to realise that the fault was
in -file educational system, that neither trained nor prepared them for
the task and often, actually, interferred with the development of self
reliance and confidence required to meet the challenges of rural health
centre service in Indin.
It would interest educators in India to know that the
protected development of the undergraduate has gone so far in the
British Systran that the TODD report (1968) made the following
interesting observation. " Every doctor who wishes to exercise a
substantial measure of independent clinical judgement will be required
to have a substantial postgraduate professional training, and the
aim of the undergraduate course should be to produce not a finished
doctor, but a broadly educated man who can become a doctor by further
training" .
It is a moot point, therefore, to consider that having
adopted the British system, with subsequent minor alterations,
whether we could afford to produce such ’broadly educated men' who
could serve the community only after years of further training - for
this is the observed result of our present system.
Another interesting
question tliat needs to be answered is whether we should reduce the
largely futile dependence on expensive over-trained physicians, and
exp eriment with new grades of medical workers.
In its approach to
the Fifth five-year plan, the Planning Commission (1972) states that
"The emphasis in rural health will have to be on prevention, family
planning, nutrition and detection of early morbidity with adequate
arrangements for referral of serious cases to the district hospital.
Such a multi-tier system cannot be built on a national scale on the
basis of the present expensive system of prolonged medical education.
In order to provide an adequate number of doctors for the Fifth plan
programme, and as an advance preparation for a more intensive coverage
later, it would be necessary to consider the revival of the 3-year
medical diploma.
Indigenous systems of medicine will also have to be
utilised for the purpose."
The Government has, therefore, clearly indicated that the training
of a new type of doctor through a shorter course is inmindent in India.
Though the details of such a course are outside the scope of this
dissertation, it would be worthwhile to discuss a few principles that
could be applied in planning such a course:
The most important principle is that the proposed 3 - year
1.
diploma course should not be a revival of the earlier licentiate
course which we abolished at the time of Independence.
Since
then the medical profession in India has been highly suspicious
of attempts to revieve condensed M.B.B.S. courses and training of
what are often known as ’near doctors’ or ’subprofessionals'.
The object of the course should be to produce a doctor who is so
specifically trained for rural health centre service that he
becomes more qualified for that job than the average graduate M.B.B.S.
In fact, the 3 - year course should lead to a Bachelor’s degree
in rural medicine, and not be underrated by calling it a diploma,
and making it appear to be a lower qualification.
The training of the new cadre of doctors should fbllow the
2.
principles suggested by ROSA (1964):
i)
Approach based on local problems.
ii)
Maximum use of community self help.
iii)
Training must be in the environment where his future job will be
(Rural health centre)
iv)
Broad perspective of rural problems.
v)
Efficiency in mass methods of treatment, vaccination and so on.
vi)
Appreciation of economy.
-.vii) Strong basis in maternal and child health and principles and
practice of health education.
viii) Training should be very practical and realistic .
In fact
ideally it should be two-thirds practical, and one-third theory.
3.
The training of this new cadre should be rogionalisod and
specifically oriented to meet the needs of the peripheral
health services in each state,
dose cooperation between
the medical colleges of the state and the government health
services especially the primary health centres and district
hospitals should be encouraged.
4.
The findings of the Rural Health Research project at
Narangwal (TAKULIA et al, 1967) and the long experiences
of many departments of preventive and social medicine in the
country, in the organisation and problems of training in a
rural health centre setting should be closely studied before
evolving the new diploma course.
5.
Suoh locally- oriented cadres of medical workers have been
trained all over the v.orld, and the experience of educators
of feldshers in U.S.S.R. peasant doctors in China, physician
assistants in U.S.A. (DUKE UNIVERSITY SCHEME) and medical
assistants or Health Officers in Fiji, Tanzania, Malawi,
Sudan, Uganda, Ethiopia, Kenya and Nigeria should be
consulted in the planning of the new course.
These are
described in F0JDALL (1972) GISH (ed),1971), KING (1966)
BRYANT (1969) TITMUSS (1964) and WADDY (1963).
6.
Selection of students for this course should be carefully
done.
Stress should be on a rural background, a command of the local
language, a familiarity with the people and a commitment to
return to the rural area for work.
Stipends should be made
available to these students during their training, and on
completion they must get jobs as close as possible to the areas
from which they were selected.
The village panohayats could
also help in the selection of the right type of students.
7»
The content of the course should be practical and realistic.
The training must prepare the rural doctor for tire three vital
functions (FENDALL, 1971):
i)
To act in a screening capacity and refer to more highly
trained professionals, patients in need of greater diagnostic
acumen and skills.
ii)
To treat visible sickness and cater to simple health require
ments such as routine midwifery, simple sanitation, water and
housing improvement.
iii)
8.
To render emergency medical care.
The teaching staff on such a course should consist mainly of health
officers and teachers who, themselves, have a personal experience
of rural health centre services.
The challenge, put bluntly, is that health services and systems of
education must be organised for the good of the people, and not to meet the
personal needs of a certain cadre of doctors for material gain or scientific
satisfaction (TAYLOR 1970) and if a shorter course producing a new type of
medical worker specifically trained for the rural areas is the answer, then
we must have the courage and commitment to go through with the changes required.
folly when the needs of the rural areas are met can the claims for Social
*
Justice
within our constitution be Validated.
It must, however, be remembered in India that the decision to consider a
revival of a shorter training course for doctors does not mean that the exi-ting
M.B.B.S. course be allowed to continue to develop along western trends.
The
decision to reorient this course to meet the needs of our expanding community
health services, taken many years back, has resulted in many healthy trends
attempting to make the course more relevant to our local needs, and this must
^^ntinue.
The product of the system whether he wants to be a general practitioner,
public health officer, specialist, teacher or research worker, must be made
aware of the local needs of his country, the economic limitations, the sociocuktural factors that determine health trends, and the need to develop local know
ledge, local technology and local expertise.
He must be made to realise that
"no matter how useful a heart surgeon may be in the right situation, he is of
I little value in a country where thousands of infants still succumb every year to
infectious diarrhoeas, and it would be far better if his talents had been turned
towards a more useful, if less spectacular, direction". (MAB&UILES, 1966).
The process of making the existing medical education in India more relevant
^o the country’s needs is well under way as described in Chapter 4, but unless
i these new programmes and methods of teaching are introduced with a degree of
! urgency into every medical college, the effect of the reorientation will be difficult
■ to assess.
I
Ib must be remembered that for such an orientation to be successful
we need staff trained in preventive and social medicine and in the expanding field
of community health, and there is an acute shortage of such a cadre.
Certain
| principles to be followed in this continuing reorientation should be stressed here.
5A.
1.
University involvement in health pare
Bryant (1971) has said that systems of health care are inseparably
linked to the education of health personnel, and these systems
cannot change without corresponding changes in education.
What
is needed in India today is a strong commitment of universities
and medical colleges to health care in the surrounding
communities.
A medical college must not consider itself a purely
academic institution, but must be actively involved in the health
of the community.
A first step towards this commitment should be
the allotment of a primary health centre, and its subcentres to
each medical college in India.
The college should not only use
the centre for teaching, but also be responsible for its adminis
tration and for the delivery of comprehensive health care to the
villages;
thus teaching and service become closely linked.
Greater involvement in health projects in urban areas like
urban slum health schemes, school health services, health of
specialised groups in societies such as destitutes, prisoners,
industrial workers, could also be initiated.
Finally, a medical
college situated in an urban area could be responsible for the
total nodical cnre <t>f that region, both urban and the surrounding
rural areas.
2.
Improvement of standards of teaching and teachers
In India, as in all developing countries, there are acute
shortages of well trained medical teachers.
Most teachers
take up teaching because they have been unsuccessful in private
practice, or as specialists they feel that contact or
association with a medical college improves their status and
prestige.
Teaching is thus seldom taken up as a vocation.
This is unfortunate, since the teacher is a key-figure in the
educational process.
Medical teaching in India can be improved, only if the following
measures are taken:
1. Teachers must be given a training in the basic principles
of education and must know how to produce effective re suits
with the available facilities.
2. They should be full-time so that teaching becomes the main
responsibility and not a side issue.
J. In order to get good teachers, the salaries must be improved,
and their social status raised.
Even the most dedicated teachers
can be put off by the present salaries offered in India.
4. The teacher must be, himself, aware of the needs of the
community, and must be acutely concerned with problems of
health care and delivery in India.
He cannot pass on a social
concern to the medical studsits ho teaches, unless he, himself,
is so motivated.
. tffi.-’-,CI'
3«
Documentation of local knowledge and needs
and development of local technologyAny system of education which continues to follow textbooks,
primarily written for, and dealing with the needs of a western
community, cannot hope to produce students aware of local needs
and disease conditions.
Textbooks of medicines specially geared
to features of disease and measures for treatment prevention nnd
control available in the country are, therefore, urgently required.
An Indian medical student, especially if he is expected to serve
in the rural areas, must, surely, know more about Hookworm Anemia,
Amoebiasis, Malaria, Tuberculosis, Leprosy and Malnutrition, than
the information given in the textbook of medicine by DAVIDSON.
At
the same time he need not study, in detail, diseases such as
Disseminated Sclerosis or Pernicious Anemia which he seldom sees.
A special textbook or manual of medicine to prepare him fbr rural
health centre service on the lines of KING (1966) would be very
welcome.
Attempts to develop local technology to design and
produce medical apparatus and equipment suited to our local needs,
budgets and climatic conditions should also be encouraged.
4.
Appreciation of economy and effective utilisation
of available services and resources.
Health is only one of the many priorities in socio-economic develop
ment and hence the financial resources available for health care,
education and development are limited.
In a developing country, like ours, appreciation of economy and
and effort to initiate building constructions, and health
programme which are realistic, must be stressed.
Often due to
social and political pressures we are tempted to build large medical
colleges and hospitals purely along western standards and designs.
Very often these prove to be 'white elephants' which are difficult
to staff and administer, but more often than not the building takes
up the entire budget and so remains unutilised due to shortage of
running expenditure.
This situation has occurred so often in India
that there is an urgent need to ban any further investment on such
projects.
In a country where the need is great, the auality and
extent of care provided is far more important than the aesthetics or
size of the institution through which it is given.
"For a proper and effective utilization of the available resources,
it would be necessary to coordinate the activities of the various
health institutions in a region.
In this way, duplication of effort
and wasteful expenditure on personnel! and equipment could be avoided
(HOMTEIRO, 1970).
This also means greater utilization of existing
private and public non-teaching hospitals and medical institutions,
clinics and dispensary in medical education.
General Practitioners and General Practice.
5*
To meet the health needs in India, there should be a much
greater emphasis on the production of general practitioners
rather than specialists.
i)
This can be done by:
Introducing general practice units in hospital out
patients, as suggested in Chapter 4«
ii)
Involvement of general practitioners of the area in
the teaching and training programmes of medical colleges.
(MOOTKERO, 1970).
iii)
Starting of a general practice speciality or department
in every medical college which could coordinate (i) and (ii)
and also provide training for all medical graduates interested
in taking up general practice.
6.
Evaluation
It is necessary to determine the efficacy of many of the earlier
suggested changes in the curriculum, on the reorientation of
students towards community medicine.
Unless these programmes are
subjected to well-planned evaluation studies, the effect they
have on a student can never be determined.
The only known study
carried out on rural internship, for instance, is that by
TAYLOR (1966).
The study revealed that 71% of the interns
questioned thought the rural experience ms useful, 69% developed
an ability to establish rapport with the villagers, 57% learned
to get along with other professional colleagues and auxiliaries,
56% got an understanding of the socio-economic factors in disease
and
got a favourable idea of rural life after the three month
programme.
7•
Motivation of the Medical Profession
All over the world there has been a gradually increasing
materialistic orientation of the medical profession.
The
ideals of service and dedication are becoming rarer among
the doctors.
The outward manifestations of this change are
reflected by the shortage of doctors willing to work in rural
areas all over the world, by the shortage of doctors willing
to work in specialities like geriatrics, psychiatry, or any
field which requires a certain amount of dedication and also
in the development of health care systems such as in the U.S.
where the treatment one receives depends entirely on how much
one can pay;
thus a time has come when the medical profession
must reappraise its own position in society.
The young medical
student plans his career in the image of Iris teachers and elders
in the profession and upless their motivation changes, the hope
of producing community oriented doctors remains idealistic.
However, it is important to keep in mind that tie motivation of
doctors to work for society in different countries is closely
related to the political systems and, therefore, a particular
experiment works in a country only if the political system favours it.
Finally, it must be remembered that health care and medical education
are only one of the many aspects of the entire life of a country,
and tlie more commensurate they are with the country
*
s economic,
cultural, social and other conditions, the more likely
they are to succeed.
They also stand a better chance of
influencing favourably those other conditions.
A village
health centre is no longer a curative dispensary but a centre
providing comprehensive health care which includes curative,
preventive and rehabilitative measures, environmental health,
improved nutrition, housing and recreation;
in other words
it is a centre involved in the overall improvement of the life
of a community.
Therefore, a doctor' trained not only to be
the head of a health team but must be prepared to be a member
of a larger developmental team of, administrators, farmers,
engineers, teachers and so on, united together in an effort to
improve the conditions of Rural India.
JOURNAL OF THE
INDIAN MEDICAL ASSOCIATION
CALCUTTA, JUNE 16, 1971
Profile of Filariasis Problem
Now that phenomenal success has been attained
in the conquest of malaria, filariasis remains as the
insect-borne disease of major public importance.
Unlike the epidemic explosions occurring dramati
cally due to spectacular diseases like smallpox,
cholera, etc., filariasis seldom shoots up to the ban
ner headline of newspapers. This lack of journa
listic value or dramatic flavour, however, seems to
be more than compensated by its relentlessly crip
pling design as a mass producer of incapacity and
disabilities, thus exacting a devastating economic
toll in areas where it is endemic.
Stoll' in 1947 considered one third of world
population filaria infested. According to a recent
estimate’, about one billion people in tropical and
subtropical countries are exposed to risk of exposure,
and at least 200 million people bear filarial stig
mata of varying grades of severity including grotes
que deformities. About 122 million people in India
live exposed to active transmission of the disease, as
revealed by a national survey3 carried out more
than a decade ago. There is every reason to suspect
that the situation is worse today. Newer foci of
filarial infection in India are being disclosed as
suggested by the survey report4*published elsewhere
in this issue of the Journal. It is, indeed, disquiet
ing that global filariasis is on the increase at a
disturbing rate defying obstinately all that we could
do to cry a halt. Measures and resources at our
disposal proved inadequate in quality as well as in
quantity to match the magnitude of the problem.
Spread of the disease in recent years has been fur
ther accelerated by rapid and indiscriminate
urbanisation with scant regard for environmental
sanitation in many of the developing countries.
Filariasis continues to be a formidable challenge
with many of its facets remaining only ill under
stood. There is much to be desired in our under
standing of the causative organisms and their patho
genic potential, the vectors and their efficiency in
transmitting the infection, the hosts and their
susceptibility to acquire the infection, and above
‘Stoll, N. R.—J. Parasit., 33: 1, 1947.
’Sasa, M.—Proc. Third S.E.A. Regional Meetings on
Parasitology and Tropical Diseases, 1968, Singapore.
4 National Filaria Control Programme—Annual Re
port (1964-65), Director, N.I.C.D., New Delhi.
‘Rahman, N. M. I. and Bhattacharyya, M. N.—
J. Indian M. A., 56 : 363, 1971.
585
all, the dynamic interaction of the triumvirate.
Mechanism of disease-production requiring clearer
elucidation, onset of disease, its course and severity
in the infected individuals remain uncertain and
unpredictable. Clinical expression of Glariasis will
not be explained satisfactorily until we can define
and quantitate host reaction in response to filarial
infection, particularly the nature and extent of
immune. response which would seem to influence
the resultant morbidity. Want of suitable experi
mental model in laboratory animals, specially with
regards to bancroftial filariasis, has severely restric
ted the progress of study in this field. It has not
been possible to pinpoint the factors that operate
alone, or in combination to determine vulnerability
of man to the infection and development of morbid
changes in consequence. However, increasing
amount of evidences recorded in recent years make
it distinctly possible that acquired immune status
in individuals and in communities plays a pivotal
role in shaping to a large extent the spectrum of clini
cal events and the impact of filariasis in the popula
tion. It is now reasonable to suspect that patho
genesis of the disease has a basis of immuno-allergic
mechanism. The nature of morbidity and its re
current character tend to suggest a selective res
ponse of sensitised host tissue to immunogenic insult
of repetitive kind. Observations are on record’-6*
to show that immune response in the host runs
parallel to an increase in mast cell population, hista,mine content and eosinophilic assemblage in the
affected tissue. In vitro experiments3 suggested that
adhesion of eosinophilic leucocytes around infec
tive filarial larvae is probably mediated through
immune mechanism. Occult filariasis causing tropi
cal eosinophilia provides a classical example, which
represents a state of immunologic intolerance to
wards unadapted or incompletely adapted parasites
or immune hypersensitive reaction in a sensitised
host following repeated exposure to assault from an
adapted parasite8. The phenomenon of immune
hypersensitivity may indeed be of great importance
in pathogenesis of filariasis. However, immune
reactions in response of filarial infection are yet to
be characterised fully and we do not precisely know
when and under what circumstances these occur,
when the peak is reached and how long do these
last. Far less is known about the degree of protec
tion, if at all, immune reactions are able to induce
• Bhattacharya, N., C., Chowdhury. A. B. and
Sengupta, P. C.—Bull. Calcutta School Trap. Med., 11:
96, 1963.
‘Idem—Ibid., 12 : 6, 1964.
' Higashi, G. I. and Chowdhury, A. B.—Immuno
logy, 19: 65, 1970.
‘ Chowdhury, A. B. — Presidential Address, 54th
Indian Science Congress, Section of Medical and Veteri
nary Sciences, 1961, Hyderabad.
386
J. INDIAN M. A., VOL. 56, NO. 12, JUNE 16. 1971
against re-infection. Higher antibody level was
detected0 with the help of fluorescent antibody test
in patients with advanced stage of filariasis and
without microfilariaemia compared with that in sub
jects showing microfilariae in peripheral blood and
without gross clinical signs.
Diagnosis of filariasis still remains only a clini
cal assumption in the absence of demonstrable
microfilariaemia. Immunobiological tests employed
so far ar& not free from limitations. Source of errors
lies primarily with the quality of antigens used,
whose sensitivity and specificity could not be con
sidered unassailable. Possibility of cross reaction in
individuals with multiple helminthic infections,
present or past, complicates the situation. Antigen
prepared from homologous source has been found
superior to that from heterologous sources for
immunodiagnosis of filariasis10. Quantitative stu
dies11 on immunoglobulins, IgG, IgA, and IgM did
not suggest diagnostic increase of any of these in
patients with different stages of filariasis. The need
for a dependable diagnostic method, therefore, can
not be overemphasised. Nevertheless, active efforts
put and progress made in recent years hold a
reasonable hope of success at a future not far off.
Treatment of filariasis is less than satisfactory.
None of the drugs available is adequate for the
purpose. Despite remarkable antimicrofilarial pro
perties the drug, diethylcarbamazine is of doubtful
value to ensure a clinical cure. Expected microfilarial. clearance with this drug is incomplete at times
even after adequate treatment, when residual micro
filariaemia continues to show drug indifference
regardless of the amount of drug used. Opportunities
of re-infection occurring with great ease in endemic
areas pose a serious problem in the absence of any
drug able to prevent it. Firmly established tissue
changes in filariasis are more often than not irrever
sible and found refractory to all known therapeutic
agents. Drugs have been used in filariasis whose
toxicity outweighs their usefulness.
Most disappointing is the outcome of our
endeavour so far to control filariasis and prevent
its spread. Needless to mention, the task is unlike
ly to be accomplished until effective remedies are
available to counter the parasites and vectors in all
stages of their development. It will however be
necessary to understand transmission dynamics of
the infection operating in an area, before the stra
tegy can be formulated aiming to interrupt the
transmission. Knowledge about bionomics of in’ Chowdhury, A. B. and Schiller, E. L. — Bull.
Calcutta School Trap. Med.. 10: 97, 1962.
•" Higashi. G. I. and Chowdhury, A. B.—Proc. Sth
rm Congress on Trop. Med. Malaria. 1968. Tehran.
1 "'"1%%-Wian J. Med. Res.. 59: 382, 1971.
volved vectors is of paramount importance for this
purpose.
Necessary information about vector
population should include their taxonomy, genetics,
susceptibility to infection, ability to support or pro
mote parasitic development, mortality, resistance to
insecticides, etc. Studies on infection and infecti
vity rates in vectors along with vector and biting
densities will disclose the expected risk of
human exposure. It is only obvious that transmis
sion success depends in no small measure on pre
valence and density of microfilaria in the popula
tion which reflect the status of endemicity in an
area. Here again the role of immune status in
regulating the level of microfilariaemia remains to
be known. It has also been suggested that state of
microfilariaemia in the population is not unrelated
to distribution of age and sex12.
Attempts have been made to develop quantita
tive model on the basis of microfilarial density in.
the population that can serve as a measure to com
pare extent of endemicity in two different areas or
in the same area at different times13. On the basis
of observation14,13 a useful formula for this purpose
has been suggested that the frequency distribution
of microfilarial counts of the positive cases were
roughly lognormal, and that there always existed
linear regressions between the probits of cumulative
percentages of the positive cases plotted on y-a-xis
and the logarithms of microfilarial counts on x-axis.
Epidemiological investigation provides basic infor
mation necessary for control measures to be formu
lated. It is trite to mention that epidemiological
studies without a quantitative approach and rigid
adherence to standard methodology do not permit
any valid inference16. What is more, information
however well drawn will cease to be meaningful
with the changes in ecological circumstances. Epi
demiological deduction for a given area will, there
fore, be in need of revision in the light of changes
occurring in human ecology and vector bionomics
with the passage of time. Continued system of
evaluation may also suggest necessary changes in
the choice of epidemiologic tools and methods.
It is important to realise that while with better
application of what we already know our success
may be greater than we have achieved so far in the
control of filariasis. ultimate success is only possible
through our efforts to know what we do not yet
know.
A. B. Chowdhury
15 Chatterjee, Arati and Chowdhury, A. B.—Bull.
Calcutta School Trop. Med.. 12: 3, 1964.
’’Kessel, J. F—Bull. W.H.O.. 16: 633. 1957.
“Sasa, M.—Progr. Med. Parasit. (Japan), 3: I. 1966.
” Idem—.Bull. W.H.O.. 37: 629. 1967.
“Editorial—J. Indian M. A., 48 : 446, 1976.
ME? & (2) REORIENTING. OF MEDICAL EDUCATION FOR COMMUNITY
HEALTH SERVICES (from Medical Education Committee
Report 1970)
a p patel
Secretary, Ministry of Health & Family Planning,
Government of India, New Delhi
Recommendations
1.
Definition of 'Basic Doctor ’ : see mfc bulletin 97-9&.
2.
Measures to encourage doctors to goto --illagesx
i.
provision of adequate, living and working
accommod ~tion in --illages with modern
sanitary facilities
ii.
supply of vehicles to PHC ’
iii.
prescription of minimum ser-ice.in rural areas
before crossing efficiency ■ bar or grant of
promotions
i-. special medical allowance for service'in difficult
areas
v. opportunities for refresher and advanced training'
in India and abroad
vi. professional contacts through --isits of specialists
to such centres.
3.
NO revival of licentiate or diploma course.
4.
Entrance qualifications;
i.
13 years prior education before MBB.S course
ii.
Premedical course should comprise Physics, Chemistry,
Biology, Basic Mathematics in relation to Physics
language, and. social Sciences. Atleast 2 years.
iii.
course should be science colleges affiliated.to
universities.
5.
Admission requirements; universities in a state
should, e-ol-e a common and uniform qualifying
examination for entry into medical college^.
6.
A study to suggest a balanced supply of basic
doctors arid specialists within the limitations
of finances to meet our needs.
7.
Duration and curriculum of MBBS Course.
a)
4% years - 18 months preclinical and 36 months
paraclinical and clinical instruction to be
followed by compulsory internship for one year—
atleast 3 months in rural surroundings.
b)
Improve quality of teaching by using suggested
curriculum, methods of assessment and
examination, encouragement of research and
teaching methods.
2
B P Patel..
8.
c)
Emphasise teaching of health promotion, growth
and development, nutrition immunization, health
education, family planning, school health services,
routine check ups and environmental sanitation.
d)
PS-1 should form integral part of MBBS and marks
obtained in this discipline ranked equal to those
of other disciplines for award, of MBBS degree.
e)
General practitioners of experience and standing
should be associated with ed.ucation/training of
und ergraduates.
Methods of teaching i
Reduce didactic lectures and encourage seminars,
group discussions and clinico-pathological conference.
9.
Examinations
25 percent of tot 1 marks allocated for university
.examination should be earmarked for internal assessment.
IO.
More mobile training cum ser-ice units (Chittaranjan
mobile hospitals) to be attached to medical colleges.
senior teachers' to pro--ide service facilities in
respective rural field practice areas.
11.
Medicum of instruction: English to continue.
12- National integration:
5-10 percent of seats in medical colleges to be
reserved for candidates from other states.
13. Reservations:
Continue practice of 5% reservation of sc/ST candidates.
Allot 5% reservation for candidates who undertake
to serve in rural areas.
14. Participation of Medical Profession:
Need far entire gamut of medical profession (Professors,
elders and leaders especially) to undergo corresponding
transformation in concern for health care in. rural
areas.
(3) REPORT OF THE GROUP ON MEDICttL EDUCATION ANTI
SUPPORT MANPOWER (SRI”ASTA”A COMMITTEE 1975).
Main recommend ations
1. To stop increase in medical colleges and admissions
2.
To generate a manpower policy along scientific
lines on a national basis.
3.
To e-ol’.e a national system, of medicine by integrating
modern and. indigenous systems of medicine
4.
to establish a medical and health education
commission to inclement needed reforms
5» Medical curriculum should be reoriented. as
follows:
a) Frame work of natural sciences, humanities
and social sciences in pre medical education.
b) Community medicine - joint endea--our of whole
faculty not only PSM. • .
)
c.
Rural and urban field practice areas with
active health service programmes...
d) Principles of educational sciences in
curriculum especially self-learning and small
group techniques'. . . .
e) Appropriate preparation of teachers and
production of effecti e teaching/learning materials.'.
f)
g)
Reform of hospitals attached to medical colleges
reducing duration by 6 months to a year.
h)
Training of interns in district/sub-di-isional
/Taluka/Tehsil hospitals not the teaching
■ hospital. . •
i)
Continuing education of all 'doctors after
graduation as’ joint activity. of medical
college, the professional associations and
the health services;....
ICMf/lCSSR
(ft) HEALTH FOR ALL - AN AL.TEQM/.TI--E STRATEGY (1981)
Recommend, at io n s on Medical Education
1. Greater emphasis on cultural/spciol/moral aspects of
medical actions/purposes.
2.
No need to over emphasise high technology
3.
Cdntinous effort to evolve simpler technologies.
4.
Training on social/cultural economic profile of people.
5.
Large base of primary . health care
6.
Regional health care:
- pre..enti’-e/promoti’-e/curati’.e problems/solutions
identified at each level
- skills/facilities at each level.
7.
Personnel-~specific training
- over education is counter productive.■
8.
9.
Man and environment to be presented as a biocultural science.
Interdisciplinary holistic approach.
More practical curriculum
-morbid anatomy
- surgery
-rare diseases
10.
skill development
- surgical/’orthoped ic
anaesthetic
11.
Health team concept
12.
Sociology
Human beha-iour
Soaial/political structure of society
13.
Practical field oriented training in
- epidemiology;
- health education.
14.
Management of health services
- cost effectiveness
- logistics
— personnel management
- methods of purchase and accounting
- medical audit
- basic knowledge of vehicles.
15.
Empathy with people
(i) selection of people closer to poor and underprivileged
groups
(ii) training process should not alienate.
ICMR/iCSSR con tri .
16.
District health care
17.
Remuneration of doctors
lo. Reduce o-er emphasis on post-graduation
19. Oontinous education
i. courses;
ii. inservice training;
iii. library facilities;
i--. disseminator of information/circular/newsletter
20. National orientation
a.
b.
c.
d.
e.
Ashram concept of life
non-consumerist approach
community/indi-.-iriual responsibility in health care
yoga
herbal medicines
Ayurveda
f-|
PC-SPIRS 3.40
' ■ jZa-S .S-o- eo f J.<l
MEDLINE (R) 1/96-1/97
MEDLINE (R) 1/96-1/97 usage is subject to the terms and conditions of the
Subscription and License Agreement and the applicable Copyright and
intellectual property protection as’ dictated by the appropriate laws of your
country and/or by International Convention.
1 of 9
Marked Record
TI: Gender differences in medical school attrition rates, 1973-1992.
AU: Fitzpatrick-KM; Wright-MP
AD: University of Alabama at Birmingham, USA.
SO: J-Am-Med-Womens-Assoc. 1995 Nov-Dec; 50(6): 204-6
____ this source is not Available in S.J.M.C.Library
LA: ENGLISH
AB: Retention is a critical problem in medical school education. We report here
on research that examined gender, differences in attrition rates between 1973
and 1992. Using secondary data compiled from the annual reports on
undergraduate education published in JAMA, both descriptive and inferential
analyses of medical school attrition rates were conducted. Data show that
medical school attrition rates have steadily increased across the country since
1973T^id~ that women drop out of medical school at consistently greater rates "
than men. These results highlight the importance of future analyses that
a'tTemp’V’to delineate the causes as well as the consequences of dropping out of
medical school for women and the institutions that support them.
2 of 9
Marked Record
TI: [Women in the medical profession in Israel]
AU: Notzer-N; Brown-S
AD: Medica1 Education Unit, Sackler Faculty of Medicine, Tel Aviv Univerity.
SO: Harefuah. 1995 Dec 1; 129(11): 449-51, 536
____ this source is not Available in S.J.M.C.Library
LA: HEBREW; NON—ENGLISH
AB: This paper describes the current status of women physicians in Israel at
various stages in their professional careers: in medical school, in the medical
specialties and in academia. In the past, as in most western countries,
medicine in Israel was regarded as a man's profession. The__last_decade has seen
demographic 'changes: the proportion of women entering medical school is
now similar to that of men, and as a result of immigration from the former
Soviet Union, the percentage of women physicians is approaching the level in
eastern European countries. Recent findings show an increase in women in all
specialty areas. However, they are concentrated in the lower status strata and
xn_pEjLmary_. care, occupying the. base of the academic pyramid. It- appears that
when objective criteria are employed, such as for admission to medical school
and licensing examinations, women and men have similar levels of achievement.
However, when subjective criteria are used, such as in admission to residency
training, gender—based differences in distribution in the medical specialties
are apparent. We suggest implementing objective standards for acceptance for
residency training which should help equalize the status of women in the
Israeli medical establishment.
3 of 9
Marked Record
TI: An assessment of stress among clinical medical students of the University
of the West Indies, Mona Campus.
AU: Foster—Wi11iams—K; Thomas-P; Gordon—A; Wi11iams-Brown —S
AD: University Health Centre, University of the West Indies, Jamaica.
SO: West-Indian-Med-J. 1996 Jun; 45(2): 51-4
____ this source is not Available in S.J.M.C■Library
LA: ENGLISH
AB: This study looks at sources of stress among the medical students of the
University of the West Indies at. the Mona campus. Students of the classes 1993
through 1995 were asked to fill out a questionnaire which had been developed
for a similar study at the University of Texas in 1983. The return rate was
667.. The results were compared for differences between males and females and
between the different year groups. The two most stressful items were rated the
same by men and women, i.e., 1) the amount of material to be learned, and 2)
examinations and/or grades. There was no statistically significant difference
between stress levels by gender in this study. The penultimate clinical year
was most stressful. It is hoped that the findings of this study will be the
basis for discussion about whether the identified stressors are inherent and
necessary to the medical training experience and, if so, how students can be
better prepared to cope with them.
4
of 9
Marked Record
TI: The feminization of the medical profession in Israel.
AU: Notzer-N; Brown-S
AD: Unit of Medical Education. Tel Aviv University, Israel.
SO: Med-Educ. 1995 Sep; 29(5): 377-81
____ This source is Available only few issues in S.J.M.C. Library
____ Call Number: From: 1977-1986
LA: ENGLISH
AB: Two factors have caused major changes in the gender composition of the
Israeli medical profession in recent years: (i) a wave of immigration from the
former USSR, which increased the doctor population by approximately 70% and
which included a majority of women physicians, and (ii) the entry of more
Israeli women into medical school. This report presents the current gender
status of the Israeli medical profession, regarding students and physicians,
and the choice of medical specialty and academic seniority, and compares gender
differences in Israel with those in other countries. Traditional patterns of
specialization persist in Israel, with women still concentrated in primary.. c.a.ce
(family medicine, paediatrics and psychiatry). In addition, women still face
o_bsJ2clles~'in entering- the more prestigious (mainly surgical) specialties.
„
Whilst the number of women in academic medicine has increased over the last
decade, women are still concentrated in the lowest., echelons of academic
medicine. However, the steady trend towards the feminization of medicine will
inevitably lead to an increase of women in all areas of the medical profession.
Because cross-cultural studies have repeatedly revealed that women doctors have
a more -humanistic and personal ized approach to patient care, a higher' ratio of
women in the profession should have a qualitative effect in this direction,
despite the bureaucratic and fiscaT constraints incumbent upon practising
__
doctors. As more women become role models for medical students, their approach
will influence the education of the doctors of the future.
5
of 9
Marked Record
II: Is registrarship a different experience for women?
AU: Saloojee-H; Rothberg-AD
AD: Department of Paediatrics and Child Health, University of the Witwatersand
Johannesburg.
SO: S—Afr-Med-J. 1996 Mar; 86(3): 253-7
1___ this source is not Available in S.J.M.C.Library
LA: ENGLISH
AB: OBJECTIVE: To determine differences between male and female registrars in
their subjective perceptions and experience of a paediatrics registrar training
programme. DESIGN: Cross-sectional survey. SETTING: University-affiliated
teaching hospitals. PARTICIPANTS: Thirty-nine paediatrics registrars. RESULTS:
Of the 39 respondents, 18 (467.) were women. Men were older than women (30.4 v"
29-.-1 years, P - 0.049). There were no gender differences in the number of "hours
worked per week (65.7 v. 67.8 hours, P = 0.384) or participation in the
training programme. Success rates in postgraduate paediatrics examinations were
also similar for the two groups (857. v. 767 P = 0.486). Male registrars were
more likely to have 'moonlighted' (437. v. 67., P = 0.011). Fifty-nine per cent
of female registrars believed that they had been disadvantaged in their careers
because of their gender, 287. felt that more was expected of a woman registrar
and 227. of the female trainees claimed to have been subjected to sexual
harassment. The majority (827.) of women registrars contemplated taking time off
from practising clinical paediatrics in the future (post-registrarship), mainly
for child-bearing purposes. Female respondents criticised both the academic
department and the hospital authorities for discriminatory practices, such as
the awarding of home loans to men and women who were breadwinners only. The
■findings suggest that women registrars do feel disadvantaged and discriminated
against, and highlight the need for flexible, creative programmes that
recognise the needs and aspirations of female registrars and, indeed, all women
in academic medicine.
6 of 9
Marked Record
TI: Abuse of residents: it's time to take action [editorial; comment]
AU: Myers-MF
SO: Can-Med-Assoc-J. 1996 Jun 1; 154(11): 1705-8
____ this source is not Available in S■J.M.C■Library
LA: ENGLISH
AB: The scientific study of the sexual dynamics that come into play during
residency training seems to both fascinate and repel trainees and their
supervisors. Dne of the more provocative and shameful dimensions of this area
of inquiry, the abuse of residents causes a good deal of distress. How do we
respond to findings of significant psychological abuse, discrimination on the
basis of sex or sexual orientation and sexual harassment in medical settings?
How can we ignore over a decade of research? How can we not heed the experience
of so many young physicians? Given the uncertain times in Canadian medicine and
the insecurity in our professional and personal lives, we must work together to
improve the culture of our teaching institutions and implement measures
nationally and locally to close this dark chapter.
7 of 9
Marked Record
TI: Residents' experiences of abuse, discrimination and sexual harassment
during residency training. McMaster University Residency Training Programs
[see comments]
AU: Cook—DJ; Liutkus-JF; Risdon-CL; Griffith-LE; Guyatt-GH; Walter-SD
AD: Department of Medicine, McMaster University Faculty of Health Sciences,
Hamilton, Ont.
SO: Can-Med-Assoc-J. 1996 Jun 1; 154(11): 1657-65
____ this source is not Available in S.J.M.C.Library
LA: ENGLISH
AB: OBJECTIVE: To assess the prevalence of psychological abuse, physical
assault, and discrimination on the basis of gender and sexual orientation, and
to examine the prevalence and impact of sexual harassment in residency training
programs. DESIGN: Seif-administered questionnaire. SETTING: McMaster
University, Hamilton, Ont. PARTICIPANTS: Residents in seven residency training
programs during the academic year from July 1993 to June 1994. Of 225 residents
186 (82.77.) returned a completed questionnaire, and 507. of the respondents were
women■ OUTCOME MEASURES: Prevalence of psychological abuse, physical assault
and discrimination on the basis of gender and sexual orientation experienced by
residents during medical training, prevalence and residents' perceived
frequency of sexual harassment. RESULTS: Psychological abuse was reported by
507. of the residents. Some of the respondents reported physical assault, mostly
by patients and their family members (14.77. reported assaults by male patients
and family members, 9.87. reported assaults by female patients and family
members), 5.47. of the female respondents reported assault by male supervising
physicians. Discrimination on the basis of gender was reported to be common and
was experienced significantly more often by female residents than by male
residents (p < 0.01). Ten respondents, all female, reported having experienced
discrimination on the basis of their sexual orientation. Most of the
respondents experienced sexual harassment, especially in the form of sexist
jokes, flirtation and unwanted compliments on their dress or figure. On
average, 407. of the respondents, especially women (p < 0.01), reported
experiencing offensive body language and receiving sexist teaching material and
unwanted compliments on their dress. Significantly more female respondents than
male respondents stated that they had reported events of sexual harassment to
someone (p < 0.001). The most frequent emotional reactions to sexual harassment
were embarassment (reported by 24.07.) , anger (by 23.47.) and frustration
(20.87.). CONCLUSION! Psychological abuse, discrimination on the basis of gender
and sexual harassment are commonly experienced by residents in training
programs. A direct, progressive, multidisciplinary approach is needed to label
and address these problems.
8 of 9
Marked Record
TI: Determinants of the generalist career intentions of 1995 graduating medical
students.
AU: Kassebaum—DG; Szenas—PL; Schuehert—MK
AD: Division of Educational Research and Assessment, Association of American
Medical College, Washington, DC, USA.
SO: Acad-Med. 1996 Feb; 71(2): 198-209
____ This source is Available in S.J.M.C Library
LA: ENGLISH
AB: Using national databases of the Association of American Medical College,
the authors employed logistic regression analysis to show the relative
predictive influences of selected demographic, structural, attitudinal, and
educational variables on the specialty careers choices of 1995 U.S. medical
school graduates. Plans to pursue certification in family practice or an
unspecified generalist career could be predicted with moderate success, while
choices of general internal medicine and general pediatrics could not. The
intentions of the 1995 graduates to pursue generalist specialty, were
significantly associated with demographic factors such as female gender, older
student age, and rural hometown; early interest in the generalist specialties;
attitudes favoring helping people over, seeking ..opportunities for leadership,
inte 11 ectua 1 challenge, or research.; fehe presence of a department of family 1
medicine in the medical school; and ambulatory care experiences in the third
and fourth years. In the multiple-regression models used in this study, a
number of factors widely touted as important to the cultivation of generalism
were not significant predictors of generalist decisions; an institutional
mission statement expressly addressing the cultivation of generalist, careers;
giving admission preferences to applicants who vowed an interest in generalism;
public (versus private) school sponsorship; discrete organization units for
general internal medical or general pediatrics; the proportion of institutional
faculty in the general specialty of medicine and pediatrics; the level of
educational debt; the students; clinical experiences in the first and second
years of medical school. The authors acknowledge the danger of inferring causal
relationships from analyses of this kind, and described how the power of
previous associations—e.g., that between a required third-year clerkship in
family medicine and graduates' family practice career choices—may be weakened
when the independent variable spreads across institutional cultures that at
present are less conductive to primary care. The findings of this analysis add
to the evidence that generalist career intentions are largely carried on the
tide of students' interests and experiences in family medicine and ambulatory
primary care. In terms of the predictive values of the input variable in this
study, career decisions for the other two generalist specialties—general
internal medicine and general pediatrics —were essentially a crapshoot, either
because the tactics to promote interest in these fields were ineffective (or
confounded), or because the efforts were underdeveloped. Moreover, the
statistical models of this study employed quantifiable variables that can be
discerned and manipulated to guide the result, whereas medical students tend to
identify less tangible elements as more powerful factors influencing their
career choices. The results sharpen the strategic focus, but must be combined
with those of other, descriptive analysis for a more complete understanding of
graduating students' career decisions.
9 of 9
Marked Record
TI: Physicians' documentation of sexual abuse of children.
AU: Socolar-RR; Champion-M; Green-C
AD; Department of Pediatrics, University of North Carolina School of Medicine,
Chapel Hill, USA.
SO: Arch-Pediatr—Adolesc-Med. 1996 Feb; 150(2): 191-6
____ This source is Available only few issues in S.J.M.C. Library
LA: ENGLISH
AB: OBJECTIVES: To assess the quality of documentation by physicians in their
evaluations for sexual abuse of children and to define factors that affect
documentation. DESIGN: Cross-sectional survey and blinded chart review.
SETTING: A statewide program for child abuse evaluations. PARTICIPANTS:
Physicians (n = 145) who performed evaluations during fiscal year 1992—1993
were surveyed. Up to five randomly chosen medical records (n = 548), obtained
from each eligible physician, were reviewed. INTERVENTIONS: None. MEASUREMENTS
AND RESULTS: A survey of physicians who participated in the statewide program
was made in summer 1993, with 787. participation. Knowledge scores were derived
from the survey based on a comparison with the responses of a panel of five
experts. Charts that were obtained from eligible physicians were assessed by
two blinded reviewers. Documentation of the history and physical examination
was evaluated as good or excellent by 307. and 23% of the physicians,
respectively. Factors that were positively associated with better documentation
of the history included a more structured format for the record, continuing
medical education courses on sexual abuse of children, female gender, and a
history of disclosure (P < .005 for all). Factors that were related to good
documentation of the physical examination included structured records,
continuing medical education courses, female gender, and knowledge scores.
Factors that were not related to knowledge or documentation included the number
of evaluations performed, practice group size or location, age of the
physician, and a physician's reading of journal articles about sexual abuse of
children. CONCLUSION: Duality of evaluations for sexual abuse of children may
be improved by the use of structured records and participation in continuing
medical education courses with regard to sexual abuse of children.
PC-SPIRS 3.40
MEDLINE (R) 1/97-9/97
MEDLINE (R) 1/97-9/97 usage is subject to the terms and conditions of the
Subscription and License Agreement and the applicable Copyright and
intellectual property protection as dictated by the appropriate laws of your
country and/or by International Convention.
1 of 9
Marked Record
TI: Medical school entrance and career plans of Malaysian medical students.
AU: Razali-SM
AD: Department of Psychiatry, School of Medical Sciences, Universiti Sains
Malaysia, Kelantan, Malaysia.
SO: Med-Educ. 1996'Nov; 30(6): 418-23
____ This source is Available only few issues in S.J.M.C. Library
Call Number; From: 1977-1986
LA: ENGLISH
AB: This study investigates the reasons for entry to medicine and the career
perspectives of phase III medical students of the Universiti Sains Malaysia
(USM). The majority of the students were Malays from low socio-economip
backgrounds who entered medical school after completing a 2—year matriculation
course. An interest in medicine and helping people were the two main stated
reasons for entry to medical school. A group of students wishing to work in
private practice was identified. In comparison to the rest of the study body,
students in the group were: not well prepared to enter medical school;
dissatisfied with the course; and subject to family influences. A desire for
monetary gain motivated their choice of medicine as a career. Overall, 137. of
the students wished to change career because they were dissatisfied with their
experience of medicine as undergraduates. The study did not find a significant
difference in career intentions between female and male medical students.
However, women were less likely to seek entrance into private practice or
pursue formal postgraduate education. The choice of surgery as a career was
confined to men. About 907. of the students had already decided on their future
specialty. Four well-established specialties were their most popular choices.
The gender of the students had no significant influences of the decision to
continue into postgraduate education. The proportion of female students wh.o
wished to marry doctors was significantly higher than for male students.
2 of 9
Marked Record
.TI: Gender sensitivity in medical curricula [see comments]
AU: Zelek-B; Phillips-SP; Lefebvre-Y
AD: Faculty of Health Sciences, University of Ottawa, Ont.
SO: Can-Med-Assoc—J. 1997 May 1; 156(9): 1297-300
____ this source is not Available in S■J.M.C.Library
LA: ENGLISH
AB: Both sex—the biologic aspects of being female or male—and gender—the
cultural roles and meanings ascribed to each sex—are determinants of health.
Medical education, research and practice have all suffered from a lack of
attention to gender and a limited awareness of the effects of the sex-role
stereotypes prevalent in our society. The Women's Health Interschool Curriculum
Committee of Ontario has developed criteria for assessing the gender
sensitivity of medical curricula. In this article, the effects of medicine's
historical blindness to gender are explored, as are practical approaches to
creating curricula whose content, language and process are gender-sensitive■
Specific areas addressed include ensuring that women and men are egually
represented, when appropriate, that men are not portrayed as the prototype of,—
normal (and women as deviant), that language is inclusive and that women.'s
health and illness are not limited to reproductive function. By eliminating or
at least addressing the subtle and often unintentional gender stereotyping in
lecture material, illustrations and problems used in problem-based learning,
medical educators can undertake a much-needed transformation of curriculum.
3 of 9
Marked Record
TI: Gender-associated differences in medical students' ratings of their
courses.
AU; Perez-J; Garrias-Ramis-R
AD: Unit of Medical Education, Faculty of Medicine, Autonomous University of
Barcelona, Spain. IKPI1@CC.UAB.ES
SO: Acad-Med. 1996 May; 71(5): 512
____ This source is Available in S.J.M.C Library
LA: ENGLISH
4 of 9
Marked Record
TI: Gender stereotypes and misconceptions: unresolved issues in physicians'
professional development.
AU: Bickel—J
AD: Association of American Medical Colleges, USA.
SO: JAMA. 1997 May 7; 277(17): 1405, 1407
____ This source is Available in S.J.M.C Library
____ Call Number: From: 1918+
LA: ENGLISH
5 of 9
Marked Record
TI: Gender issues and generalism in medicine.
AU: Elks-ML
AD: Texas Tech University Health Sciences Center, Lubbock 79430, USA.
SO: Acad-Med. 1996 Dec; 71(12): 1281-4
____ This source is Available in S.J.M.C Library
LA: ENGLISH
6 of 9
Marked Record
TI: A predictive model of student satisfaction with the medical school learning
environment.
AU: Robins-LS; Gruppen-LD; Alexander-GL ; Fantone-JC; Davis-WK
AD: Department of Postgraduate Medicine, University of Michigan Medical School,
Ann Arbor 48109-0201, USA. lrobins@umich.edu
SO: Acad-Med. 1997 Feb; 72(2): 134-9
This source is Available in S.J.M.C Library
LA: ENGLISH
AB: PURPOSE: To examine differences in attitudes toward the medical school
learning environment among student subgroups based oh gender and
race-ethnicity, to identify the most influential predictors of student
satisfaction with the learning environment, and to create a model of student
satisfaction with the learning environment. METHOD: Three years of survey data
(1992-93 to 1994-95) from first-year students at the University of Michigan
Medical School were combined. The total sample consisted of 430 respondents,
broken into two sets of subgroups: women (n = 171) and men (n = 259), and
whites (n = 239) and underrepresented minorities (n = 74). Asian students were
removed from analyses when comparisons were made by race-ethnicity, but were
included in the analyses for all students and those comparing men and women.
Student's t-tests were used to identify differences between gender and
racial-ethnic groups in mean responses to seven survey items, and effect sizes
were used to characterize the magnitudes and practical significances of the
differences. Forward stepwise regression was conducted to determine the best
predictive models for each student subgroup and for the total sample; the
subgroup models were compared with each other as well as with the total-sample
model. RESULTS: Cross-validation of the gender and race-ethnicity models showed
that the men's satisfaction and the women's satisfaction were predicted equally
well using either subgroup's model, and that the white students' satisfaction
and the underrepresented-minority students' satisfaction were predicted equally
well using either subgroup's model. Furthermore, the total-sample model,
employing a subset of five predictors, was similar in its predictive power to
the subgroup models. CONCLUSION: The study's findings suggest that curriculum
structure (timely feedback and the promotion of critical thinking) and
students' perceptions of the priority faculty place on students' education are
prominent predictors of student satisfaction (across all subgroups) with the
learning environment. In contrast, students' perceptions of the learning
environment as a comfortable place for all gender and racial—ethnic groups,
although less prominent predictors of satisfaction, will discriminate among the
subgroups.
7 of 9
Marked Record
TI: The prevalence of sexual harassment among female family practice residents
in the United States.
AU: Vukovich-MC
AD: Family Health Care of Wadsworth OH 44281, USA.
SO: Violence—Viet. 1996 Summer; 11(2): 175-80
____ this source is not Available in S■J.M.C.Library
LA: ENGLISH
AB: The purpose of this study was to determine the prevalence of sexual
harassment as defined by the AMA among female family practice residents in the
United States. Of all 1,802 U.S.FP female resident physicians surveyed, a total
of 916, or 517., completed a survey of which 327. reported unwanted sexual
advances, 487. reported use of sexist teaching material , 667. reported favoritism
based on gender, 367. reported poor evaluation based on gender, 377 reported
malicious gossip, 5.37. reported punitive measures based on gender, and 2.27.
reported sexual assault during residency. Thirty two percent of respondents
reporting sexual harassment experienced negative effects including poor
self-esteem, depression, psychological sequelae requiring therapy, and in some
cases, transferring training programs. Sexual harassment is a common occurrence
among family practice residents during residency training. Further studies are
needed to examine the effect of sexual harassment policies instituted by the
American Graduate Council -on Medical Education on the prevalence of sexual
harassment in medical training since the time of this study.
8 of 9
Marked Record
TI: Gender in medicine: the views of first and fifth year medical students.
AU: Field-D; Lennox-A
AD: Department of Epidemiology and Public Health, University of Leicester, UK.
SO: Med-Educ. 1996 Jul; 30(4): 246-52
____ This source is Available only few issues in S.J.M.C. Library
Call Number: From: 1977-1986
LA: ENGLISH
AB: This study of first and fifth year medical students found a general
recognition among male and female students that gender affects future career
choices and the ability to reach career goals. Females were seen as being
disadvantaged both in terms of career choice and their ability to" achieve
career goals. These views are less abstract and more based upon the reality of
personal experiences in clinical attachments among fifth year students. While
both male and female students describe negative experiences of- cLiaica_l_
training, female students were more likely “to suf fer discrimination because of
.their gender in certain specialties, such -as surgery, and to be dissuaded from
pursuing a career in that specialty. Despite the general awareness of the
effects of gender in medicine this did not appear to have an effect upon
personal career choice. However, some female students were considering career
choices at an early stage in their career based on accommodating their future
desire to have a family life. Over half of all male and female fifth year
students reported that having time for their family was an important
consideration in choosing a career.
9 of 9
Marked Record
TI: Experiences of women in cardiothoracic surgery. A gender comparison.
AU: Dresler-CM; Padgett-DL; MacKinnon-SE; Patterson-GA
AD: Division of Cardiothoracic Surgery, Washington University, St. Louis, Mo,
USA.
SO: Arch-Surg. 1996 Nov, 131(11): 1128-34; discussion 1135
____ This source is Available in S.J.M.C Library
____ Call Number: From: 1920+
LA: ENGLISH
AB: OBJECTIVE: To assess the career and practice experiences of cardiothoracic
surgeons, with references to gender similarities and differences. DESIGN:
Four-step mailed 115-question survey. SUBJECTS: All identified women, and a
cohort of men, certified by the American Board of Thoracic Surgery. MAIN
OUTCOME MEASURES: Academic rank, career background, salary, perceptions and
experiences of harassment or discrimination , and personal life characteristics .
RESULTS: No differences were found in training backgrounds. More men (647.) than
women (527.) were in university practices. Comparable proportions of men and
women were assistant professors (277.), but more men (27Z) than women (13.67.)
were full professors. Fifty-eight percent of women and 217. of men reported
salaries of less than $250000; 627. of men and 327. of women had incomes over
$350000. Career satisfaction was comparable between genders; however, women
perceived the promotion process as unfair and unrelated to academic, rank. Both
genders encouraged men toward a surgical career; men were less likely than
women to encourage women to pursue a surgical career (P < .01). Women, much
more than men, believed that discrimination hindered .their career development
(P < .001). Characteristics of personal life were also considerably different
between the genders. CONCLUSION: Although practice and training parameters for
male and female cardiothoracic surgeons are comparable, work experiences,
personal life, and career rewards such as salary and promotion, and perception
of discrimination are different.
PC-SPIRS 3.40
MEDLINE (R) 1/96-1/97
MEDLINE (R) 1/96-1/97 usage is subject to the terms and conditions of the
Subscription and License Agreement and the applicable Copyright and
intellectual property protection as dictated by the appropriate laws of your
Country and/or by International Convention.
1 of 5
Marked Record
Sexual harassment of female physicians by patients. What is to be done?
Phillips-S
Department of Family Medicine, Queen's University, Kingston, Ont.
Can-Fam-Physician. 1996 Jan; 42: 73-8
this source is not Available in S.J,M.C.Library
LA: ENGLISH
AB: OBJECTIVE: To determine the responses of female physicians who have been
sexually harassed by patients, as a means of answering the question, "What is
to be done?" DESIGN: As part of a larger study on the topic, randomly selected
participants were mailed a questionnaire requesting information about the
nature and extent of sexual harassment by patients and about resulting
feelings, actions, and suggestions for prevention. SETTING: Family practices in
Ontario. PARTICIPANTS: A random sample of the 1064 female certificants of the
College of Family Physicians of Canada in active practice in Ontario during
1992 was selected. A total of 599 were surveyed; 422 (70%) replied. MAIM
OUTCOME MEASURES: Responses to survey questions. RESULTS: Of the 422
respondents, 767. reported sexual -harassment by patients and their reactions to
it. Though most respondents had many suggestions about how to minimise
harassment. written comments suggested co_nf usipn._..as__tP-. .itscause. Many
participants wondered whether their behaviour, manner, or dress provoked
unwanted responses. The ability to root the cause of the harassmen.t—iax-t-em-a.1 ly
as a social rather than a personal problem seemed to decrease immobilization.
CONCLUSIONS: There is no single effective response to sexual harassment, but:
understanding its source as an abuse of the power of gender-K (perhaps to
overcome the powerlessness felt as" a patient) could enable female physicians to
act in protective and effective ways.
TI:
AU:
AD:
SO:
2 of 5
Marked Record
TI: Harassment of women physicians.
AU: Schiffman-M; Frank-E
AD: Department of Family and Preventive Medicine, Emory University School of
Medicine, Atlanta, Georgia, USA.
SO: J-Am-Med-Womens-Assoc. 1995 Nov-Dec; 50(6): 207-11
____ this source is not Available in S.J.M■C■Library
LA: ENGLISH
AB: This paper reviews current knowledge about the prevalence, characteristics ,
and costs of sexual harassment of women medical students and physicians. It
also addresses the limited research on other forms of physician and "sTudent
harassment, and notes the kinds of information that are still needed.
3 of 5
Marked Record
TI: Is registrarship a different experience for women?
AU: Saloojee-H; Rothberg-AD
AD: Department of Paediatrics and Child Health, University of the Witwatersand ,
Johannesburg.
SD: S-Afr-Med-J. 1996 Mar; 86(3): 253-7
____ this source is not Available in S.J.M.C.Library
LA: ENGLISH
AB: OBJECTIVE: To determine differences between male and female registrars in
their subjective perceptions and experience of a paediatrics registrar training
programme. DESIGN: Cross-sectional survey. SETTING: University-affiliated
teaching hospitals. PARTICIPANTS: Thirty-nine paediatrics registrars. RESULTS:
Of the 39 respondents , 18 (467.) were women. Men were older than women (30.4 v.
29.1 years, P = 0.049). There were no gender differences in the number of hours
worked per week (65.7 v. 67.8 hours, P = 0.384) or participation in the
training programme. Success rates in postgraduate paediatrics examinations were
also similar for the two groups (857. v. 767. P = 0.486). Male registrars were
more likely to have 'moonlighted' (437. v. 67., P = 0.011). Fifty-nine per cent
of female registrars believed that they had been disadvantaged in their careers
because of their gender, 287. felt that more was expected of a woman registrar
an-d"22T of the female trainees claimed to have been subjected to sexual
harassment. The majority (82%) of women registrars contemplated taking time off
from practising clinical paediatrics in the future (post-registrarship), mainly
for child-bearing purposes. Female respondents cr4.ticJ..sed_-bo-tfa_.the_a£_ademic
department and the hospital authorities for discriminatory practices, such as
the awarding of home loans to men and women who were breadwinners only. The
findings suggest that women registrars do feel disadvantaged and discriminated
against, and highlight the need for flexible, creative programmes that
recognise the needs and aspirations of female registrars and, indeed, all women
in academic medicine.
4 of 5
Marked Record
TI: Abuse of residents: it's time to take action [editorial; comment]
AU: Myers-MF
SO: Can-Med-Assoc-J. 1996 Jun 1; 154(11): 1705-8
this source is not Available in S■J.M■C■Library
LA: ENGLISH
AB: The scientific study of the sexual dynamics that come into play during
residency training seems to both" fascTn’ate~an'd repel trainees and their
supervisors. One of the more provocative and shameful dimensions of this area
of inquiry, the abuse .of . residents, causes a good deal of distress. How do we
respond to findings of significant psychologjc.a 1 abuse, discrimination on the
basis of sex or sexual orientation and sexual harassment in medical settings?
How can we ignore oyer a decade of research? How can we not heed the experience
of so many young physicians?" Given' the uncertain times in Canadian medicine and
the insecurity in our professional and personal lives, we must work together to
improve the culture of our teaching institutions and implement measures
nationally and locally to close this dark chapter.
5 of 5
Marked Record
TI: Residents' experiences of abuse, discrimination and sexual harassment
during residency training. McMaster University Residency Training Programs
[see comments]
AU: Cook—DJ; Liutkus-JF; Risdon-CL; Griffith-LE; Guyatt-GH; Walter-SD
AD: Department of Medicine, McMaster University Faculty of Health Sciences,
Hamilton, Ont.
SO: Can-Med-Assoc-J. 1996 Jun 1; 154(11): 1657-65
____ this source is not Available in S.J.M.C.Library
LA: ENGLISH
AB: OBJECTIVE: To assess the prevalence.of psychological abuse, physical
assault, and discrimination on the basis of gender and sexual orientation, and
to examine- the ^prevalence and impact of sexual harassment in residency training
programs. DESIGN: Self-administered questionnaire. SETTING: McMaster
University, Hamilton, Ont. PARTICIPANTS: Residents in seven residency training
programs during the academic year from July 1993 to June 1994. Of 225 residents
186 (82,77.) returned a completed questionnaire, and 507. of the respondents were
women■ OUTCOME MEASURES: Prevalence of psychological abuse, physical assault
and discrimination on the basis of gender and sexual orientation experienced by
residents during medical training, prevalence and residents' perceived
•frequency of sexual harassment. RESULTS: Psychological abuse was reported_by
50"Z of the residents. Some of the respondents reported physical assault, mostly
by .patieT'Ct S’; and: "t heir family members (14.77. reported assaul ts by male patients
and family members, 9.87. reported assaults by female patients and family
members), 5.47. of the female respondents reported assault by male supervising
physicians. Discrimination on the basis of gender was reported to be common and
was experienced significantly more often by female residents than by male
residents (p < 0.01). Ten respondents, all female, reported having experienced
discrimination on the basis of their sexual orientation. Most of the
respondents experienced sexual harassment, especially in the form of sexist
jokes, flirtation., and., unwanted compliments on their dress or figure. On"
average, 407 of the respondents, especially women (p < 0.01), reported
experiencing offensive body language and receiving sexist teaching material and
unwanted compliments on their dress. Significantly more female respondents than
male respondents stated that they had reported events of sexual harassment to
someone (p < 0.001). The most frequent emotional reactions to sexual harassment
11 were embarassaent (reported by 24.07.), anger (by 23.47.) and frustration
" (20.87.). CONCLUSION: Psychological abuse, discrimination on the basis of gender
and sexual harassment are commonly experienced by residents in training
programs. A direct, progressive, multidisciplinary approach is needed to label
and address these problems.
HlF
PC-SPIRS 3.40
SpxmA LJ1I97
pQifT %- /2-
MEDLINE (R) 1998/01-1998/10
-1998/fd usage is subject to the terms and conditions of the
Subscription and License Agreement and the applicable Copyright and
intellectual property protection as dictated by the appropriate laws of your
country and/or by International Convention.
1 of 13
TIs Changes in medical student attitudes as they progress through a medical
course.
AU: Price-J; Price-D; Williams-G; Hoffenberg-R
AD: Faculty of Medicine, University of Queensland.
SO: J-Med-Ethics. 1998 Apr; 24(2): 110-7
____ this source is not Available in S.J.M.C.Library
LA: ENGLISH
AB: OBJECTIVES: To explore the way ethical principles develop during a medical
•edm ,.«tion course for three groups of medir-il
i idents—in their first year, at
the beginning of their penultimate (fifihj
i
!he end of their
final
.. DL'tilGN: Survey questionnaire administered to medical
students in their first, fifth and final (sixth) year. SETTING: A large medical
school in Queensland, Australia. SURVEY SAMPLE: Approximately half the students
in each of three years (first, fifth and sixth) provided data on a voluntary
basis, a total of 385 students. RESULTS: At the point of entry, minor
differences were found between medical students and first year law and
psychology students. More striking were differences between male and female
medical students, suggesting early socialisation had a substantial impact here.
CONCLUSIONS: Results indicate that substantial changes in attitude have
developed by the beginning of fifth year with little change thereafter. Gender
difference persisted. Some difference in ethical attitudes were found when
groups of different ethnic backgrounds were compared. The impact of a move to a
graduate medical course, which gives high priority to ethics within a
professional development domain, can now be evaluated.
2 of 13
TI: Autopsies in children: are they still useful?
AU: Kumar-P; Taxy-J; Angst-DB; Mangurten-HH
AD: Department of Pediatrics, Lutheran General Children's Hospital, Park Ridge,
Ill 60068, USA.
SO: Arch-Pediatr-Adolesc-Med. 1998 Jun; 152(6): 558-63
____ This source is Available only few issues in S.J.M.C. Library
LA: ENGLISH
AB: BACKGROUND: Autopsy has traditionally been the criterion for determining
cause of death and has played a major role in medical education and quality
.-control. With increasing use of bedside technology, however, autopsy rates have
steadily declined. OBJECTIVE: To identify (1) trends in pediatric autopsy rates
during the past decade, (2) concordance between antemortem and postmortem
diagnoses, and (3) patient characteristics influencing autopsy rates or
diagnostic yield. METHODS: All pediatric deaths between January 1, 1984, and
December 31, 1993, were retrospectively reviewed. Data collection included
demographics for all patients, and length of stay, diagnostic imaging studies,
antemortem diagnoses, and autopsy findings for patients with autopsies. Autopsy
diagnoses were compared with antemortem findings and classified according to
their concordance. RESULTS: Of 297 pediatric deaths, autopsies were performed
on 107 patients (367.). Autopsy rates did not change significantly during the
study period. Autopsies were not associated with patient gender, race, or
insurance status, but increased significantly with age. Autopsies were
performed in 267. of infants 12 months or younger, 607. of children between 13 to
60 months of age, and 1007. of children 61 months or older (chi2; P <.001). In
347 of cases, new diagnoses were made at autopsy, including 7 cases where new
findings, if known before death, would likely have resulted in a change in
treatment or improved survival. There was no relationship between new findings
at autopsy and age, length of hospital stay, or antemortem imaging studies.
CONCLUSIONS: Autopsy can provide additional information in more than one third
of pediatric deaths. Pediatric autopsy continues to provide clinically
significant data and remains a valuable tool in modern pediatric practice.
3 of 13
TI: Sense and sensitivity: developing a gender issues perspective in medical
education.
AU: Lent-B; Bishop-JE
AD: Department of Family Medicine, University of Western Ontario, London,
Canada.
SO: J-Womens-Health. 1998 Apr? 7(3): 339-42
____ this source is not Available in S.J.M.C.Library
LA: ENGLISH
AB: As part of a larger project focused on integrating women's health issues
and gender issues into undergraduate medical education in Canada, the question
of what is actually meant by a "gender issues perspective" in medical education
was explored. Clinical experience, discussions with colleagues, and exposure
to a variety of medical education resources reinforced the complexity of the
subject and demonstrated the difficulty in making amorphous ideas concrete.
Eight dimensions encompass the key concepts underlying a gender issues
perspective. Practical applications highlight the usefulness of these suggested
dimensions in making sense of and bringing sensitivity to this complex subject.
4 of 13
TI: Do junior doctors feel they are prepared for hospital practice? A study of
graduates from traditional and non-traditional medical schools.
AU: Hill-J; Rolfe-IE; Pearson-SA; Heathcote-A
AD: Faculty of Science and Mathematics, University of Newcastle, New South
Wales, Australia.
SO: Med-Educ. 1998 Jan; 32(1): 19-24
____ This source is Available only few issues in S.J.M.C. Library
Call Number: From: 1977-1986
LA: ENGLISH
AB: A valid and reliable questionnaire was developed which assesses eight
subscales relating to key areas of medical hospital-based work. This was used
to evaluate junior doctors' perceptions of the adequacy of their undergraduate
medical training to prepare them for hospital practice. Data from 139 (607.)
first-year doctors (interns) showed that graduates from the problem-based
medical school rated their undergraduate preparation more highly than
traditional medical school graduates in preparing them for practice in the
areas of interpersonal skills, confidence, collaboration with other health care
workers, preventive care, holistic care and self-directed learning. These
findings persisted when ratings were adjusted for the effects of age and
gender. There were no differences between the intern groups for patient
management and understanding science. This research suggests that educational
experiences in different undergraduate medical courses are important in
preparing doctors for their early working life.
5 of 13
TI: Women's oral health issues: an exploration of the literature.
AU: Covington-P
SO: Probe. 1996 Sep-Oct; 30(5): 173-7
____ This source is Available only few issues in S.J.M.C. Library
____ Call Number: From: 1963-1980
LA: ENGLISH
AB: As interest in women's health issues grows, there is increasing concern
that today's practice of medicine may not meet the health needs of women. A
primary reason is the gender bias that has been inherent in medical education,
research and clinical practice. The prevailing medical viewpoint has often been
that the male body is considered to be the norm and that the female body
exactly the same except for the reproductive function. This attitude has led to
a lack of interest in researching gender differences and a consequent lack of
knowledge of women's health issues. Fortunately, there is a movement for
change. The Women's Health Interschool Curriculum Committee was formed in
January 1992 to develop curricula concerning women's health and examine bias
that may exist in existing curricula. The Canadian Women's Health Network has
been growing across the country and there have been calls to create a new
specialty in women's health. According to Angell, this proposal for a new
specialty was provocatively debated in the Journal of Women's Health, which
started publication in 1992. There is also a growing concern on how to conduct
better research to address women's health needs. As more attention is paid to
women's health issues, what will happen in the area of oral health? In health
care, it would seem that the mouth has become completely separated from the
rest of the body. Health conferences rarely have any oral health content at
all. To correct this problem, there must be an increase in general awareness of
the importance of oral health as it relates to the overall health of both women
and men. Good oral health is more than just decay-free teeth. Oral health
encompasses the teeth, the supporting periodontal structures, soft tissues of
the mouth and oral pharynx area, temporomandibular joints and muscles of
mastication. The mouth is a gateway to the body and will also reflect many
systemic health problems, such as diabetes, leukemia and lupus. The second step
would be the recognition that women may have different oral health needs and
issues than men. The common view may be that teeth are gender free, but how can
this be when teeth exist in a body, and that body is male or female? For many
years, the primary acknowledged difference between men and women's oral health
was pregnancy gingivitis. Like medicine, dentistry must re-examine the
viewpoint that women's oral health differs from men's only as it is influenced
by reproductive processes. There are many areas where women's oral health may
differ from that of men. This paper will explore the literature for potential
women's oral health issues in the areas of oral hygiene behaviours, esthetics,
eating disorders, temporomandibular disorders, and hormonal influences on
periodontal health.
6 of 13
TI: Improving residents' performances of clinical breast examination.
AUs Freund—KM; Burns-RB; Antab-L
AD: Women's Health Unit, Evans Department of Medicine, Boston Medical Center,
Massachusetts 02118, USA.
SO: J-Cancer-Educ. 1998 Spring; 13(1): 20-5
____ this source is not Available in S.J.M.C.Librarv
LA: ENGLISH
AB: BACKGROUND: Clinical breast examination and mammography are recommended as
combined modalities for breast cancer screening. Rates of mammography are
increasing; however, clinical breast examination rates are decreasing. Specific
training in breast examination may be warranted. METHODS: The authors developed
an ambulatory rotation to teach breast cancer screening to medical residents.
To assess whether this training improved screening performance, they compared
clinical breast examination and mammography rates in residents' continuity
clinics before and after training among residents who were assigned to the
training program and residents who were not. RESULTS: 314 women patients were
seen by 28 residents. The rates for annual clinical breast examination and
mammography were 397. and 717., respectively. Clinical breast examination rates
increased by 187. among the residents assigned to the training program, whereas
they dropped by 137. over than same period among the residents who had not
received the training (p < 0.005). Female residents performed more clinical
breast examinations than did their male counterparts (507. vs 347. p < 0.01).
Mammography rates did not change with training, and were not associated with
resident gender or career plans. CONCLUSION: Although the residents performed
mammography at high rates, clinical breast examination rates were low.
Short-term directed teaching about clinical breast examination increased the
performance of this screening test, and is important to incorporate into
teaching programs.
7
of 13
TIs Onset of acute psychotic states in India: a study of sociodemographic,
seasonal and biological factors.
AU: Malhotra—S; Varma-VK; Misra-AK; Das-S; Wig-NN; Santosh-PJ
AD: Department of Psychiatry, Postgraduate Institute of Medical Education and
Research, Chandigarh, India.
SO: Acta-Psychiatr-Scand. 1998 Feb; 97(2): 125-31
____ This source is Available only few issues in S.J.M.C. Library
LA: ENGLISH
AB: This is a comparative study of patients with acute-onset, non-affective,
non—organic, remitting psychoses and with non-remitting or schizophrenic
psychoses in India. Two groups of patients with acute remitting and
non-remitting or schizophrenic psychoses were compared with regard to the
following variables: month of onset of psychosis; presence of stress,
particularly fever, within 4 weeks preceding the onset of psychosis; childbirth
within 12 weeks preceding the onset of psychosis; gender differences. It was
found that the acute remitting psychoses showed an overrepresentation of
females, a higher frequency of associated stress preceding the onset of
psychosis, more often had onset during the summer months, i.e. between May and
September, and had fever and childbirth preceding the onset of psychosis in a
significantly higher proportion of patients, compared to acute non-remitting
psychoses or schizophrenia. The implications of the findings which point
towards biological factors in the aetiology of acute remitting psychoses are
discussed.
8 of 13
TI: Antibiotics for colds in children: who are the high prescribers?
AL): Mainous-AG-3rd; Hueston-WJ; Love-MM
AD: Department of Family Practice, University of Kentucky, Lexington, USA.
mainouagSmusc.edu
SO: Arch-Pediatr-Adolesc-Med. 1998 Apr; 152(4): 349-52
____ This source is Available only few issues in S.J.M.C. Library
LA: ENGLISH
AB: OBJECTIVE: To examine physician characteristics associated with being a
high prescriber of antibiotics for pediatric upper respiratory tract infections
(URIs). DESIGN AND SETTING: Analysis of 34624 episodes of care for URIs in
children (younger than 18 years) in the Kentucky Medicaid program from July 1,
1995, to June 30, 1996. PARTICIPANTS: Primary care physicians with at least 25
episodes of care (n=205). The proportion of patients with URIs receiving
antibiotics stratified the sample into low (< or =25th percentile) and high (>
or =75th percentile) antibiotic prescribers. MAIN OUTCOME MEASURES: Bivariate
analyses were computed comparing the high and low prescribers, A logistic
regression model was computed for likelihood of being a high prescriber by
number of URI episodes, proportion of patients receiving antibiotics that were
broad spectrum, years since medical school graduation, physician gender,
rural/urban practice, and specialty. RESULTS: The high prescriber group (n=52)
included data from 11899 episodes of care, with a mean prescribing rate of 80'/..
The low prescriber group (n=55) included data from 5396 episodes, with a mean
prescribing rate of 167.. High prescribers were significantly more years away
from medical school graduation (27 vs 19 years; P<.001) and had managed
significantly more URI episodes than low prescribers (229 vs 98; F'=.001). In
the logistic regression, compared with pediatricians, the odds ratios of being
a high prescriber were 409 (957. confidence interval [CI], 29-7276) for family
practitioners and 318 (95% CI, 17-6125) for other primary care physicians.
CONCLUSION: With the rise of antibiotic-resistant bacteria, more focused
training regarding treatment of URIs is warranted in residency and in
continuing medical education forums.
9
of 13
TI: Alzheimer's disease risk factors as related to cerebral blood flows
additional evidence.
AUs Crawford—JG
AD: Indiana University School of Medicine, Terre Haute Centerfor Medical
Education. 47890, USA. iccrawfoQscifac.indstate.edu
SO: Med-Hypotheses. 1998 Jan; 50(1): 25-36
____ this source is not Available in S.J.M.C.Library
LA: ENGLISH
AB: In a previous report, Alzheimer's disease risk factors, including alcohol
abuse, depression, Down's syndrome, cerebral glucose metabolism defect, head
trauma, old age, Parkinson's disease, sleep disturbance, and underactivity,
were shown to have an association with reduced cerebral blood flow. In this
report an attempt is made to strengthen a hypothesis that reduced cerebral
blood flow may be a required cofactor in the cause of Alzheimer's disease with
examples of additional putative risks, including aluminum, ApoE 4 alleles,
estrogen deficiency, family history of dementia, low education-attainment,
olfactory deficit, and underactivity coupled with gender, considered to have a
relationship or potential relationship with reduced cerebral blood flow.
Factors, believed to ameliorate Alzheimer's disease, associated with improved
or stabilized cerebral blood flow are tabulated. A tentative cerebral blood
flow nomogram is shown as a potential model to possibly help predict
Alzheimer's disease susceptibility.
10 of 13
TI: Resisting constraints, creating opportunities. The experiences of some
early medical women.
AU: Walker-L
AD: Department of Sociology, University of the Witwatersrand, Johannesburg.
SO: S-Afr-Med-J. 1997 Nov; 87(11): 1508-12
____ this source is not Available in S■J.M■C.Library
LA: ENGLISH
AB: This paper aims to document the experiences of some women doctors who
graduated between 1924 and 1940. It highlights some of the difficulties they
encountered in establishing themselves as respected medical practitioners and
briefly describes the social context in which they worked. The data for this
paper were gathered through the use of one qualitative research method, viz.
intensive interviewing. This paper draws on seven in-depth interviews. It
focuses on two aspects of these women's professional lives: their medical
training and their career paths. It seeks to demonstrate that while some were
subject to discriminatory practices by a male-dominated medical profession,
they were also involved in pioneering work and made their mark as respected
practitioners.
11 of 13
TI: Re: 'Skills of pre-registration house officer: gender differences reported
in Norway' [letter]
AU: Green-J; Morgen-C; Currie-C; Davies-S
SO: Med-Educ. 1997 Sep; 31(5): 394
____ This source is Available only few issues in S.J.M.C. Library
Call Number: From: 1977-1986
.. .
LA: ENG;
12 of 13
Home, training and work: mobility of British doctors.
Parkhouse-J; Lambert-TW
Department of Public Health and Primary Care, University of Oxford, UK.
Med-Educ. 1997 Nov; 31(6): 399-407
This source is Available only few issues in S.J.M.C. Library
Call Number: From: 1977-1986
LA: ENGLISH
TI:
AU:
AD:
SO:
AB: This study examines the locations of family homes, medical schools and
places of specialist training, and work of doctors qualifying from UK medical
schools in 5 calendar years between 1974 and 1993. The contribution of each UK
region to the medical workforce relative to its population is assessed and
trends over time are examined. The relationship between place of family home
and medical school attended is examined for 14,108 doctors. Career appointment
location and its relationship to medical school and family home location are
examined for over 4000 doctors. For the qualifiers of 1983, an additional
analysis incorporating place of training is included. Large differences were
found in the percentage of medical students from local family homes attending
each regional medical school. In some cases differences reflected local
populations but other cases had no obvious cause. Over all cohorts studied, 387.
of respondents attended a medical school in the region of their family home
(327. of 1993 qualifiers), 427. held a career post in the same region as their
medical school, and 387. held a career post in the same region as their family
home. Among the qualifiers of 1983, 657. had a career post in the same region as
their postgraduate training, 347. also attended medical school in the same
region, and 197. also came from family homes in the same region. More women than
men took up a career post in the same region as their postgraduate training.
The relationships to family home and medical school did not differ by gender.
Consultants appeared slightly less likely than GPs to have stayed within a
region, but this difference was not statistically significant.
13 of 13
TI: Analysis of stress levels among medical students, residents, and graduate
students at four Canadian schools of medicine.
AU: Toews-JA; Lockyer-JM; Dobson-DJ; Simpson-E; Browne11-AK; Brenneis-F;
MacPherson-KM; Cohen-GS
AD: Continuing Medical Education, University of Calgary Faculty of Medicine,
Alberta, Canada.
SO: Acad-Med. 1997 Nov; 72(11): 997-1002
____ This source is Available in S.J.M.C Library
LA: ENGLISH
AB: PURPOSE: To assess stress in medical students, residents, and graduate
science students at four Canadian schools of medicine. METHOD: Four schools
with different curricula in three different parts of Canada participated in the
study: the University of Calgary Faculty of Medicine, the University of Alberta
Faculty of Medicine, the Dalhousie University Faculty of Medicine, and the
McMaster University Faculty of Health Sciences. All the medical students,
residents, and graduate science students at each school were surveyed in
1994-95. The three instruments used were the University of Calgary Stress
Questionnaire, the Social Readjustment Rating Scale (SRRS), and the Symptom
Check.1ist-90. Demographic data were compared across all four schools. Analysis
of variance was calculated for all test-item scores, utilizing a four (school)
by three (program) by two (gender) design, which were all between subject
factors. Significant main effects were followed up by using planned comparisons
(Newman-Keuls, with a probability level of p < .05). Significant interaction
effects were followed up by using an analysis of simple effects. RESULTS: A
total of 1,681 questionnaires were returned as follows: 621 of 1,304 (487.) from
the medical students, 645 of 1,495 (437.) from the residents, and 415 of 829
(507.) from the graduate science students. There were significant differences
between the three groups in the natures and degrees of stress, with the
graduate students reporting higher levels of stress. There were significant
gender differences as well, with the women reporting higher levels of stress.
Overall, stress levels were found to be mild, based on the University of
Calgary Stress Questionnaire and the SRRS. CONCLUSION: This study suggests that
medical students and residents experience stress at levels that appear
acceptable, but ongoing monitoring and the provision of appropriate support
systems will continue to be important.
PC-SPIRS 3,40
MEDLINE (R) 1/95-1/96
MEDLINE (R) 1/95-1/96 usage is subject to the terms and conditions of the
Subscription and License Agreement and the applicable Copyright and
intellectual property protection as dictated by the appropriate laws of your
country and/or by International Convention.
1 of IS
Marked Record
TI: Interactive effects of traits, states, and gender on cardiovascular
reactivity during different situations.
AU: Burns—JW
AD: Department of Psychology, Finch University of Health Sciences, The Chicago
Medical School, Illinois 60064, USA.
SO: J-Behav-Med. 1995 Jun; 18(3): 279-303
____ this source is not Available in S.J„M■C.Library
LA: ENGLISH
AB: Interactive effects of anger and anxiety traits, negative affect state,
different situations, and gender on cardiovascular reactivity (CVR) to stress
were examined. Subjects (91 men, 92 women) performed a reaction time task under
either a Social Evaluation, a Harassment, or a Control condition; SBP, DBP, and
HR were recorded continuously. Hierarchical multiple regressions revealed
intricate interactions. The interaction of anger expression style and anger
experience was significant only among men, such that'anger suppressors with
high 'trait anger showed the largest CVR of any group during Harassment; anger
expressors exhibited generally high CVR across conditions. However, anger
expression style and state negative affect interacted to affect CVR in both men
and women. Finally, the fear of negative evaluation predicted elevated DBP
responses only among men in the Social Evaluation condition. Results imply that
the extent to which traits of anger and anxiety contribute to coronary risk may
depend on interactions with other traits, gender, and the environment.
2 of 18
Marked Record
TI: Clinical competence of interns. Programme Evaluation Committee (PEC).
AU: Rolfe-IE; Andren-JM; Pearson-S; Hensley-MJ; Gordon-JJ
AD: Faculty of Medicine and Health Sciences, University of Newcastle.
SO: Med-Educ. 1995 May; 29(3): 225-30
____ This source is Available only few issues in S.J.M.C. Library
Call Number: From: 1977-1986
LA: ENGLISH
AB: A clinical supervisors rating form addressing 13 competencies was used to
assess the clinical competence of graduates one year after qualification in New
South Wales (NSW), Australia. Data from 485 interns (97.27.) showed that
graduates from the problem-based medical school were rated significantly better
than their peers with respect to their interpersonal relationships,
'reliability' and 'self-directed learning'. Interns from one of the two
traditional NSW medical schools had significantly higher ratings on 'teaching',
'diagnostic skills' and 'understanding of basic mechanisms'. Graduates from
international medical schools performed worse than their peers on all
competencies. These results were adjusted for age and gender. Additionally,
women graduates and younger interns tended to have better ratings. Junior
doctors have differing educational and other background experiences and their
performance should be monitored.
3 of 18
Marked Record
TI: Severity-adj Listed differences in hospital utilisation by gender■
AU: Yuen-EJ; Gonnella-JS; Louis-DZ; Epstein-KR; Howell-SL; Markson-LE
AD: Center for Research in Medical Education and Health Care. Jefferson Medical
College, Philadelphia, PA 19107, USA.
SO: Am-J-Med-Qual. 1995 Summer; 10(2)s 76-80
____ this source is not Available in S.J.M.C.Library
LA: ENGLISH
AB: Gender-based differences in hospital use may result from biological
differences or may suggest problems of access to health services and quality cr
care. We hypothesized that there should be no difference in hospital care
between men and women, given the same diagnosis. Hospitalizations were
characterized by severity of illness, as this may indicate the timeliness of
hospital care. Hospitalizations may be too late (with higher severity of
illness) resulting in long stays and high costs, or too early (with lower
severity of illness) resulting in care that could be given in alternative
treatment settings. Three abdominal conditions were examined which could be
misdiagnosed or confused with other diseases involving the female reproductive
system: appendicitis, diverticulitis, and cholecystitis. The National Hospital
Discharge Survey (NHDS) was used for analysis. Disease staging was used to
assign a severity of illness, indicator, ranging from stage 1 (conditions with
no complications) to stage 3 (multiple site involvement, poor prognosis). For
each disease, the percentage of discharges and the age—adjusted discharge rate
per 1000 population was examined by stage of illness and gender. For
appendectomy, there was a significantly greater percentage of men at stage 1
(lower severity) compared to women (737. versus 67"Z). For diverticular disease,
women had higher proportions of stage 2/3 discharges than men for both medical
and surgical hospitalizations. For cholecystitis, women had a greater
percentage of hospitalizations at stage 1 than men, notably for surgical
treatment (637. compared with 387.), although more men were admitted at stage 2
for both medical and surgical treatment.(ABSTRACT TRUNCATED AT 250 WORDS)
4 of 18
Marked Record
TI: Psychiatrists' and non-physician psychotherapists' beliefs about
gender-appropriate behavior: a comparison.
AU: Kaplan-M; Free-N
AD: Department of Psychiatry, University of Cincinnati, College of Medicine,
OH, USA.
SO: Am-J-Psychother. 1995 Winter; 49(1): 59-67
____ this source is not Available in S■J,M.C,Library
LA: ENGLISH
AB: We adapted the Bern Sex-Role Inventory to survey therapists' beliefs about
gender-appropriate behavior for hypothetical patients. We previously studied
psychiatrists, finding that women were more likely to choose masculine or
androgynous (high masculine and high feminine) traits as optimal for female
patients while men were more likely to choose the undifferentiated (low
masculine and low feminine) category for patients of either sex. In this study
we used the same measure to compare psychologists and social workers to the
psychiatrists, to determine the effect of medical education on these attitudes.
We found that regardless of educational background, women were more likely to
choose the androgynous category and men were more likely to choose the
unja'iTTerehtiat'ecl^category. Women psychiatrists were more likely to choose
mascuTirre—trarttS' a's' optimal than were women non-physician therapists. Male ~~
therapists of all backgrounds were least likely to choose masculine traits as
optimal for either male or female patients. Medical education per se does not"!
seem to determine attitudes about gender-appropriate behavior. Men entering
professions in which they are concerned about others' emotional well-being may
have less stereotypically masculine beliefs about gender appropriate behavior
than women entering the same fields. Possible reasons for this difference ahe^.,
discussed.
5 of 18
Marked Record
TI : Cis gender of significance for specialization of physicians? An analysis of
specialization degree among female and male physicians]
AU: Gjerberg-E; Hofoss-D
AD: Seksjon for helsetjenesteforskning, Statens Institutt for Folkehelse, Oslo.
SO: Tidsskr-Nor-Laegeforen. 1995 Apr 20; 115(10): 1253-7
____ this source is not Available in S„J.M.C■Library
LA: NORWEGIAN; NON-ENGLISH
AB: Although there has been a substantial increase in the number of women in
medicine, we still find strong gender differences in career patterns. Female
physicians specialize to a lower degree than their male colleagues do, although
fhe percentage who do so has increased in recent years. The gender difference
in frequency of specialization is not an effect of female physicians' spending
a longer time on specialist training. Our results indicate that female
physicians, to a greater extent than their male colleagues have to~cTfoose
between „f.amil.y..-and ’career. A larger percentage of female than of maTe' '
physicians live alone, perhaps indicating that career demands a higher price
for the former. However, the percentage of singles is, larger among older than
among younger female physicians. We interpret this as indicating that the
necessity to choose between career and family is not as strong as it used to
be.
6 of 18
Marked Record
TI: A national study of the factors influencing men and women physicians'
choices of primary care specialties.
AU: Xu-G; Rattner-SL; Veloski-JJ; Hojat-M; Fields-SK; Barzansky-B
AD: Center for Research in Medical Education and Health Care (CRMEHC), Thomas
Jefferson University, Philadelphia, Pennsylvania, USA.
SO: Acad-Med. 1995 May; 70(5): 398-404
____ This source is Available in S.J.M.C Library
LA: ENGLISH
AB: BACKGROUND. Despite a recent increase in the percentage of graduating U.S.
medical students planning to pursue generalist careers, interest in primary
care among students is still far below what it was in the early 1980s and falls
well short of the stated goal of the Association of American Medical Colleges
that half of all graduates should choose generalist careers. Also during the
past decade, the number of women students and physicians has increased';’■•'Given
the importance of concerns regarding the primary care work force, it is timely
to examine the relationship between gender and other factors that influence the
decision to enter primary care. METHOD. Totals of 1,038 (65%) men and 558 (35%)
women primary care physicians selected from the 1983 and 1984 graduates of all
allopathic U.S. medical schools were surveyed in early 1993. Gender comparisons
were made on the 19 variables that influenced the physicians' decisions to
enter primary care specialties and on the six factor scores derived from a
factor analysis of these 19 variables. Also included in the gender comparisons
were characteristics of practice, populations served, timing of making the
decision to enter primary care, and personal demographic information. RESULTS.
Men., more than women, were influenced to become primary care physicians by
early role models. Women, more than men, were inf lu.en.c.ed...by ..person.a.l_..and...family
factors. Overall, medical school experience and personal values are two
important factors that explained the largest variances of the 19 predictor
variables influencing the physicians' choices of primary care disciplines.
There was no gender difference in place of origin, family income as a child,
timing of the decision to become a primary care physician, or the amount of
debt upon graduation. CONCLUSION. This nationwide study of primary care
physicians indicates that men and women physicians differ in their perceptions
of the relative importances of factors influencing the choice of a primary care I
specialty. Gender-specific factors should receive more attention in the
/
development of successful strategies to attract more medical students into
/
primary care specialties.
7 of 18
Marked Record
TIs Taking the pulse of older women's health. Despite advances, gender gap
still exists in medical education, research, and clinical care [editorial;
comment]
AU: Butler-RN
SO: Geriatrics. 1995 May; 50(5): 6, S
____ This source is Available only few issues in S.J.M.C. Library
Call Number: From: 1947-1979
LA: ENGLISH
8 of 18
Marked Record
TI: Older women's health: 'taking the pulse' reveals gender gap in medical care
[see comments]
AU: Butler-RN; Collins-KS; Meier~DE; Muller-CF; Pinn-VW
AD: Henry L. Schwarts Department of Geriatrics and Adult Development, Mount
Sinai Medical Center, New York, USA.
SO: Geriatrics. 1995 May; 50(5): 39-40, 43-6, 49
____ This source is Available only few issues in S.J.M.C. Library
Call Number: From: 1947-1979
LA: ENGLISH
AB: In the United States, for every 100 men age 65 and older, there are 147
women, a ratio that has social and medical consequences. Five panelists "take
the pulse" of older women's health in general and in the offices of- primary
care physicians in particular. They assess the status of medical education and
the need to_include older women in research and drug trials, issues of gender
bias'in health insurance and qual i ty„.of._ treatment, ways to improve the use of
preventive health services—such as mammography and Pap smears—by older women,
and the role of office physicians in identifying and helping victims of
domestic^ violence.
9 of 18
Marked Record
TI: Effect of anonymous test grading on passing rates as related to gender and
race.
AU: Dorsey-JK; Colliver-JA
AD: Department of Internal Medicine, Southern Illinois University School of
Medicine (SIUSM), Springfield, USA.
SO: Acad-Med. 1995 Apr; 70(4): 321-3
____ This source is Available in S.J.M.C Library
LA: ENGLISH
AB: BACKGROUND. Concerns about potential bias in the grading of medical
students at the Southern Illinois University School of Medicine led to a major
institutional policy change whereby students' identities were masked during the
test-grading process. The present study assessed the effect of this anonymous
test grading policy by comparing the performance of men and women students and
of white and African American students prior to and after adoption of the
policy change. METHOD. A test-passing rate was determined for each of 476
freshmen students in the comparison groups from the eight classes of 1988
through 1995. Mean test-passing rates for the four student cohorts prior to
policy implementation (1988-1991) were compared with mean passing rates after
the policy was implemented (1992-1995). RESULTS. The pre-post change in the
mean test-passing rate of men was not significantly different from the pre-post
change of women, and a nonsignificant effect was also found when the pre-post
change in the mean test-passing rate of white students was compared with that
of African American students. No significant pre-post change was found for
white men, white women, African American men, or African American women.
CONCLUSION. The results showed no effect of the anonymous test-grading policy,
which suggests that there was no widespread gender or racial bias in the
grading of freshman medical students before the change in institutional grading
policy.
10 of 18
Marked Record
TI: Gender comparisons of young physicians' perceptions of their medical
education, professional life, and practices a follow-up study of Jefferson
Medical College graduates.
AU: Hojat-M; Gonnella-JS; Xu-G
AD: Center for Research in Medical Education and Health Care, Jefferson Medical
College, Philadelphia, PA 19107-5083, USA.
SO: Acad-Med. 1995 Apr; 70(4): 305-12
____ This source is Available in S.J.M.C Library
LA: ENGLISH
AB: PURPOSE. To obtain information from a group of young physicians and compare
men and women on their evaluations of selected areas of the medical school
curriculum, their perceptions of issues related to medical practice and
professional life, and their specialty choices, professional activities, and
research productivity. METHOD. In 1992, a questionnaire was mailed to 1,076
physicians who had graduated from Jefferson Medical College between 1982 and
1986. The responses of men and women were compared using multivariate and
univariate analyses of variance, t-tests, chi-square, and median test. RESULTS.
Completed questionnaires were returned by 667 graduates (530 men and 137
women). The curriculum areas of interpersonal skills, disease prevention,
medical ethics, and economics of health care were rated by both men and women
as being the most important in medical training. Conversely, research
methodology and statistics received the lowest ratings. Women, in general,
valued psychosocial aspects of medical care higher than did men. Among the
areas of perceived problems related to practice, lack of leisure time received
the highest ratings (as being the greatest problem) and interpersonal
interactions received the lowest ratings (as being the least problem) from both
men and women. The men were more .concerned than the women about the areas of
patient chart and documentation, malpractice litigation, physician oversupply,
peer review, and interaction with patients. These differences remained when
specialties and numbers of hours worked per week were held constant. Generally,
the physicians reported satisfaction with their professional lives, but the men
tended to be more satisfied than the women about their decisions to become
physicians and in their perceptions of medicine as a rewarding career. The
proportion of men employed full-time (99.47.) was significantly higher than that
for women (847.). Women were more likely to practice general pediatrics, while
men were more likely to practice surgery and surgical subspecialties.
Full-time—employed women worked fewer hours per week (57) than men (63), and
men reported more research productivity than women. CONCLUSION. The
implications of the findings of numerous gender differences are discussed
regarding the issues of physician workforce, types of care rendered by men and
women, and possible changes in the national health care system.
11 of 18
Marked Record
TI: The professional structure of Soviet medical care: the relationship between
personal characteristics, medical education, and occupational setting for
Estonian physicians.
AU: Barr-DA
AD: Department of Social and Behavioral Sciences, University of California, San
Francisco 94143-0612.
SO: Am-J-Public-Health. 1995 Mar; 85(3): 373-8
This source is Available only few issues in S.J.M.C. Library
____ Call Number: From: 1942-1991
LA: ENGLISH
AB: OBJECTIVES. Using the Estonian example, this study provides data to
describe the ways in which personal, educational, and occupational factors
interacted to determine the professional structure of the Soviet health care
system. METHODS. The study analyzes data gathered from a survey of 207. of the
physicians in Estonia. It measures the frequencies of pertinent personal and
occupational factors, and uses multivariate analysis to explore relationships
between these factors. RESULTS. Most physicians in Estonia are women and work
in urban settings. About half of the physicians work in hospitals, and one
third work in large outpatient clinics called polyclinics. About one third work
in primary care. Gender affects education, specialty, type of workplace, and
administrative duties; nationality affects education and administrative duties.
CONCLUSIONS. The Soviet system of health care derived its professional
structure from a combination of personal and occupational factors. Those
considering options for reform of the health care systems of the newly
independent states that once constituted the Soviet Union should appreciate the
nature of these structural forces.
12 of IS
Marked Record
TI: Age and gender differences in students', preadmission qualifications and
medical school performances.
AU: Ramsbottom-Lucier-M; Johnson-MM; Elam-CL
AD: Department of Medicine, University of Kentucky College of Medicine (UKCM),
Lexington 40536-0284.
SO: Acad-Med. 1995 Mar; 70(3): 236-9
____ This source is Available in S.J.M.C Library
LA: ENGLISH
AB: PURPOSE. To investigate the age- and gender-related differences in
matriculants' preadmission performances and in their subsequent medical school
performances. METHOD. A longitudinal database was used to provide information
on the 557 students in six entering classes (1984-1989) at the University of
Kentucky College of Medicine. The preadmission variables were undergraduate
science and cumulative grade-point averages (GPAs), Medical College Admission
Test (MCAT) scores, and interview ratings. The medical school variables were
GPAs for the four years of school and scores on the National Board of Medical
Examiners Part I and Part II examinations. Age- and gender—related differences
were analyzed by analyses of variance. To examine age differences, the students
were grouped by age at matriculation: less than 23 years old, between 23 and
27, and 28 or older. RESULTS. The younger matriculants had significantly higherundergraduate GPAs than did their older peers; however, their performances on
the MCAT were nearly identical. The men had higher MCAT scores than the women
in all age groups, but the older women had higher undergraduate GPAs than the
older men. The younger students tended to have slightly higher medical school
GPAs than the older students. No age differences were found for the NBME I and
II, and no gender difference was found for the NBME II; however, a modest
gender difference was found for the NBME I, with the men performing better than
the women. CONCLUSION. Dramatic age and gender differences were evident in the
preadmission performances, while the differences in the medical school
performances were much smaller.
13 of 18
Marked Record
TI: The relationship of indebtedness, race, and gender to the choice of general
or subspecialty pediatrics.
AU: Brotherton-SE
AD: Division of Research on Health Policy, American Academy of Pediatrics, Elk
Grove Village, IL 60009-0927.
SO: Acad-Med. 1995 Feb; 70(2): 149-51
____ This source is Available in S.J.M.C Library
LA: ENGLISH
AB: BACKGROUND. Little research has examined indebtedness and the choice of
continued subspecialty training. Concerns about a decline in the proportion of
primary care physicians obliges medical educators to understand factors that
influence the choice of subspecialty training. METHOD. Survey data on 437
pediatricians who graduated between the years 1981 and 1987 were collected in
1991. Logistic regression was used to examine the influences of sex,, race,
graduation year, type of medical school, and educational debt (adjusted for
inflation) on whether a pediatrician had trained in a subspecialty. RESULTS.
Three variables were associated with subspecialty training. Men and whites were
significantly more likely to have trained in subspecialties, as were earlier
graduates. Type of medical school and debt did not enter the equation.
CONCLUSION. Other variables were found to be more influential than indebtedness
in the career decisions of primary, care and subspecialty pediatricians.
Distinguishing between subspecialties that have noticeably higher incomes and
those that serve to enhance primary care pediatrics may be illuminating. That
men and whites were more likely to train in subspecialty pediatrics suggests
that financial considerations, if present, may be masked under other cultural
and societal factors.
14 of 18
Marked Record
TI: Women's healths time for a redefinition [editorial; comment]
AU: Simkin-RJ
SO: Can-Med-Assoc-J. 1995 Feb 15; 152(4): 477-9
this source is not Available in S.J.M.C.Library
LA: ENGLISH
AB: Traditionally, women's health has been defined in mainly biologic terms.
The various contexts within which women's health can be considered have been
ignored, and many people have been unable to recognize the need for such a
clinical entity as "women's health" in the first place. It is time for a change
in attitudes and approaches. We need a more inclusive definition of women's
health, one that takes into account social, cultural, spiritual, emotional and
physical aspects of well-being. Case histories that have recently received
media attention and statistics on the impact of poverty and violence on women
also show how urgently a redefinition of "women's health" is needed.
Regardless of whether "women's health" will always have to be viewed as a
separate discipline or whether it can be brought within mainstream medical
practice, it is clear that, by altering their perception of women's health and
of the problems unique to women, physicians can improve both health care and
medical education to the benefit of all members of our society.
15 of 18
Marked Record
TI: Determinants of career choices among women and men medical students and
interns.
AU: Redman-S; Saltman-D; Straton-J; Young-B; Paul-C
AD: Faculty of Medicine, University of Newcastle, Australia.
SO: Med-Educ. 1994 Sep; 28(5): 361-71
____ This source is Available only few issues in S.J.M.C. Library
Call Number: From: 1977-1986
LA: ENGLISH
AB: Women continue to be poorly represented in medical specialties other than
general practice. A cross-sectional design was used to explore the development
of career plans as medical training progressed; men and women students were
compared in their first (n = 316), final (n - 295) and intern (n = 292) years.
Women at each stage of training were significantly more likely to choose
general practice as the field in which they were most likely to practise. There
was little evidence that these differences were influenced by experience during
training: women were as likely to choose general practice in first year as in
the intern year. The most important determinant of career choice appeared to be
the flexibility of training and of practice of medicine: variables such as the
opportunity for part-time training, flexible working hours and part-time
practice were important determinants of career choice and were of more
importance to women than to men. The study also found high rates of
discrimination or harassment reported by women medical students and interns.
The results indicate the need for continued debate about these issues within
medicine and the development of more flexible styles of medical training and
practice.
16 of IS
Marked Record
TI: Development of a measure of medical faculty attitudes toward clinical
evaluation of students.
AU: McGaghie-WC; Richards-BF; Petrusa-ER; Camp-M; Harward-DH; Smith-AS;
Willis-SE
AD: Northwestern University Medical School, Chicago, IL. 60611-3008.
SO: Acad-Med. 1995 Jan; 70(1): 47-51
____ This source is Available in S.J.M.C Library
LA: ENGLISH
AB: PURPOSE. This research involved the development, and in particular the
evaluation of the reliability, of scales to measure medical faculty attitudes
toward clinical evaluation (ACE) of medical students. The intent was to create
measures that yield reliable data and have practical utility in medical
education research and faculty development. METHOD. A systematic, eight-step
scale development protocol was used to create the instrument. In early 1993
factor analysis was used on data from 217 clinical faculty at four medical
schools to refine the measures. Internal consistency and test-retest
reliability analyses were performed. Analyses were also done to determine
whether the attitude scores were influenced by such faculty demographic
attributes as employing medical school, gender, age, tenure track status,
academic rank, or academic department. RESULTS. An initial pool of 52 items was
reduced to 30 items based on iterative reliability studies. Factor analysis on
the 30 items yielded two scales: (1) Quality of Evaluation Procedures, 12
items, alpha = .81; and (2) Content of Departmental Evaluations, eight items,
alpha = .85. Test-retest reliabilities (12 weeks) for the scales were .67 and
.74, respectively. Faculty demographics did not influence attitudes about the
quality of evaluation procedures. However, family physicians showed a slightly
more positive attitude toward the content of departmental evaluations than did
physicians in five other medical specialties. CONCLUSION. The goal of
developing reliable measures of faculty attitudes toward clinical evaluation of
medical students has been achieved. With baseline reliabi1ities established,
future research should assess the validity and utility of the scales,
especially in the context of clinical practice examinations.
17 of 18
Marked Record
TI: Factors that affect surgical rates in Iowa.
AU: McGuire-SM; Phillips-KT; Weinstein-JN
AD: Faculty of Medicine, Harvard University, Cambridge, Massachussetts.
SO: Spine. 1994 Sep 15; .19(18): 2038-40
____ this source is not Available in S■J■M.C.Library
LA: ENGLISH
AB: STUDY DESIGN. This study analysed insurance claims to estimate the
probability of medical and surgical treatments in different Iowa communities.
The likelihood of surgical treatment was associated with patient
characteristics of age and gender as well as hospital characteristics of size
(number of beds), occupancy rate, and number of staff. OBJECTIVES. Our findings
are being used by a study group of 25 physicians to understand the causes of
variation in surgical rates for low back pain. Medical education and other
interventions are being implemented. SUMMARY OF BACKGROUND DATA.
Hospitalization rates for lower back operations in the United States increased
by more than 207. from 1978 to 1985. Consequently, several studies in Iowa and
the US have been initiated to examine the medical effectiveness of these
treatments. METHODS. A logistic regression model was used to determine the
factors associated with the likelihood of having a low back surgery in a
population of Blue Cross/BIue Shield (BOBS) subscribers in Iowa. The outcome,
or dependent variable, of interest was a hospitalization that resulted in a
surgical procedure on a low back pain patient. RESULTS. Surgical rates for the
treatment of low back pain are likely to be increased if a BCBS Iowa subscriber
is female, older than 44 years of age, or if the surgery is performed in a
hospital with either an occupancy rate less than 627., with fewer than 774 staff
members, fewer than 267 beds, or no residency programs.
18 of 18
Marked Record
TI: Gender in medical encounters: an analysis of physician and patient
communication in a primary care setting.
AU: Hall-JA; Irish-JT; Roter-DL; Ehrlich-CM; Miller-LH
AD: Department of Psychology, Northeastern University, Boston, Massachusetts
02115.
SO: Health-Psychol . 1994 Sep; 13(5): 384-92
this source is not Available in S■J.M.C.Library
LA: ENGLISH
AB: The relation of physician and patient gender to verbal and nonverbal
communication was examined in 100 routine medical visits. Female physicians
conducted longer visits, made more positive statements, made more partnership
statements, asked more questions, made more back-channel responses, and smiled
and nodded more. Patients made more partnership statements and gave more
medical information to female physicians. The combinations of female
physician-female patient and female physician-male patient received special
attention in planned contrasts. These combinations showed distinctive patterns
of physician and patient behavior, especially in nonverbal communication. We
discuss the relation of the results to gender differences in nonclinical
settings, role strains in medical visits, and current trends in medical
education.
PC—SPIRS 3.40
MEDLINE (R) 1998/01-1998/10
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Subscription and License Agreement and the applicable Copyright and
intellectual property protection as dictated by the appropriate laws of your
country and/or by International Convention.
1 of 6
Marked Record
TIs Learning, satisfaction, and mistreatment during medical internship: a
national survey of working conditions.
AU: Daugherty—SR; Baldwin—DC Jr; Rowley—BD
AD: Rush Primary Care Institute and Rush Medical College, Chicago, IL
60612-3833, USA. sdaugherSrush.edu
SO: JAMA. 1998 Apr 15; 279(15): 1194-9
____ This source is Available in S.J.M.C Library
____ Call Number: From: 1918+
LA: ENGLISH
AB: CONTEXT: Concerns about the working and learning environment of residency
training continue to surface. Previous surveys of residents have focused on
work hours and income, but have shed little light on how residents view their
training experience. OBJECTIVE: To provide a description of the internship year
as seen by a large cross section of second-year residents. DESIGN: Mail survey
conducted in 1991. SETTING: Residency programs in the United States.
PARTICIPANTS: Random 107. sample (N=1773) of all second-year residents listed in
the American Medical Association's medical research and information database.
MAIN OUTCOME MEASURES: What and who contributes most to residents' learning
during internships, degree of satisfaction with the internship experience,
on-call and sleep schedules, incidents of perceived mistreatment or abuse,
observations of unethical behavior, and experiences .of harassment or
discrimination. RESULTS: A total of 1277 surveys (72%) of 1773 mailed were
returned. Overall, respondents reported a moderate level of satisfaction with
their first year of residency. On a scale of 0 to 3, residents rated, other
residents as contributing most (score of 2.3) to their learning, with special
patients ranked second (2.1). During a typical work week, residents reported
that they spent an average of 56.9 hours on call in the hospital. A total of
1185 (93%) residents reported experiencing at least 1 incident of perceived
mistreatment, with 53% reporting being belittled or humiliated by more senior
residents. Among women residents, 63% reported having experienced at least 1
episode of sexual harassment or discrimination. A total of 457. of residents
reported having observed another individual falsifying medical records, and 707.
saw a colleague working in an impaired condition, most often lack of sleep.
Regression analyses suggest that satisfaction with the residency experience was
associated with the presence of factors that enhanced learning, and fewer
experiences of perceived mistreatment. CONCLUSIONS: Residents report
significant problems during their internship experience. Satisfaction with
internship is enhanced by positive learning experiences and lack of
mistreatment.
2 of 6
Marked Record
TI: Discrimination against gay, lesbian and bisexual family physicians by
patients.
AU: Druzin-P; Shrier-I; Yacowar-M; Rossignol-M
AD: Herzl Family Practice Centre, Sir Mortimer B. Davis-Jewish General
Hospital, McGill University, Montreal, Que.
SO: CMAJ. 1998 Mar 10; 158(5): 593-7
____ this source is not Available in S.J.M.C.Library
LA: ENGLISH
AB: BACKGROUND: Discrimination against gay, lesbian and bisexual (GLB) patients
by physicians is well known. Discrimination against GLB physicians by their
colleagues and superiors is also well known and includes harassment, denial of
positions and refusal to refer patients to them. The purpose of this study was .
to identify and quantify the attitudes of patients toward GLB physicians.
METHODS: Telephone interviews were conducted with 500 randomly selected people
living in a large urban Canadian city. Subjects were asked if they would refuse
to see a GLB family physician and, if so, to describe the reason why. They were
then given a choice of 6 reasons obtained from consultation with 10 GLB people
and 10 heterosexual people. RESULTS: Of the 500 subjects 346 (69.27.) were
reached and agreed to participate. Of the 346 respondents 41 (11.87.) stated
that they would refuse to see a GLB family physician. The 2 most common reasons
for the discrimination (prevalence rate more than 507.) were that GLB physicians
would be incompetent and the respondent would feel "uncomfortable" having a GLB
physician. Although more male than female respondents discriminated against GLB
physicians, the difference was not statistically significant. The proportion of
male and female respondents who discriminated increased with age (p < 0.01).
CONCLUSIONS: The observed prevalence of patient discrimination against GLB
family physicians is significant. The results suggest that the discrimination
is based on emotional reasons and is not related to such factors as
misinformation about STDs and fear of being thought of sexually. Therefore,
educational efforts should be directed against general perceptions of
homosexuality rather than targeting specific medical concerns.
3 of 6
Marked Record
TI: Relationships of gender and career motivation to medical faculty members'
production of academic publications.
AU: Barnett-RC; Carr-P; Boisnier-AD; Ash-A; Friedman-RH; Moskowitz-MA;
Szalacha-L
AD: Women's Studies Program, Brandeis University, Waltham, Massachusetts, USA.
r_barnettQharvard.edu
SO: Acad-Med. 1998 Feb; 73(2): 180-6
____ This source is Available in S.J.M.C Library
LA: ENGLISH
AB: PURPOSE: To evaluate the relationships between both internal and external
career-motivating factors and academic productivity (as measured by the total
numbers of publications) among full-time medical faculty, and whether these
relationships differ for men and women■ METHOD: In 1995 a 177-item survey was
mailed to 3,013 full-time faculty at 24 randomly selected U.S. medical schools
stratified on area of medical specialization, length of service, and gender.
Two-tailed t-tests and regression analyses were used to study the data.
RESULTS: A total of 1,764 faculty were used in the final analyses. The women
had published two thirds as many articles as had the men (mean, 24.2 vs.
37.8). Intrinsic and extrinsic career motivation were rated similarly (on a
three-point scale) by the women and the men: intrinsic career motivation was
rated higher (women's mean rating: 2.8, men's mean rating: 2.9) than was
extrinsic career motivation (mean rating:.2.1 for both). The main findings of
the regression analyses were (1) intrinsic career motivation was positively
associated, and extrinsic career motivation was negatively associated, with the
number of publications; (2) publication rates were higher for the men than for
the women after controlling for career motivation; and (3) there was no
significant effect of gender on these relationships. CONCLUSION: The women
faculty published less than did their men colleagues, but this difference
cannot be accounted for by gender differences in career motivation. Further
research on institutional support, family obligations, harassment. and other
factors that could affect academic productivity is necessary to understand the
gender difference in numbers of publications.
4 of 6
Marked Record
TI: Prevalence and correlates of harassment among US women physicians.
AU: Frank-E; Brogan-D; Schiffman-M
AD: School of Medicine, Emory University, Atlanta, Georgia, USA.
ef rankQfpm.eushc.org
SO: Arch-Intern-Med. 1998 Feb 23; 158(4): 352-8
____ This source is Available in S.J.M.C Library
____ Call Number: From: 19.18+
LA: ENGLISH
AB: BACKGROUND: Despite concerns about its prevalence and ramifications,
harassment has not been well quantified among physicians. Previous published
studies have been small, have surveyed only 1 site or a convenience sample, and
have suffered from selection bias. METHODS: Our database is the Nomen
Physicians' Health Study, a large (4501 respondents; response rate, 59Z),
nationally distributed questionnaire study. We analyzed responses concerning
gender-based and sexual harassment. RESULTS: Overall, 47.77. of women physicians
reported ever experiencing gender-based harassment, and 36.97. reported sexual
harassment. Harassment was more common while in medical school (317. of
gender-based and 20% for sexual harassment) or during internship, residency, or
fellowship (297. for gender-based and 197. for sexual harassment) than in
practice (25% for gender-based and 117. for sexual harassment)■ Respondents more
likely to report gender-based harassment were physicians who were now divorced
or separated and those specializing in historically male specialties, whereas
those of Asian and other (nonwhite, nonblack, non-Asian, non-Hispanic )
ethnicity, those living in the East, and those seif-characterized as
politically very conservative were less likely to report gender-based
harassment. Being younger, born in the United States, or divorced or separated
were correlated with reporting ever experiencing sexual harassment; those who
were Asian or who were currently working in group or government settings were
less likely to report it. Those who felt in control of their work environments,
were satisfied with their careers, and would choose again to become physicians
reported lower prevalences of ever experiencing harassment. Those with.
histories of depression or suicide attempts were more likely to report ever
having been harassed. CONCLUSIONS: Women physicians commonly perceive that they
have been harassed. Experiences of and sensitivity to harassment differ among
individuals, and there may be substantial professional and personal
consequences of harassment. Since reported rates of sexual harassment are
higher among younger physicians, the situation may not be improving.
5 of 6
Marked Record
TI: A woman in medicine. From the 1940s to the 1990s. A personal saga.
AU: Mellette-SJ
AD: Internal Medicine, Medical College of Virginia, Virginia Commonwealth
University, USA.
SO: Va-Med-Q. 1998 Winter; 125(1): 58-62
____ this source is not Available in S.J■M.C■Library
LA: ENGLISH
AB: The past 50 years through which I have lived as a woman in medicine have
been an exciting time. Women in medicine have increased from a small minority
to sizeable numbers. It remains for women in medicine to become more active in
organizations and to assume more leadership roles. The current leadership of
the Medical Society of Virginia is a step in that direction.
6 of 6
Marked Record
TI: Women in medicine: shaping the future.
AU: Kornstein-SG; Norris-SL; Woodhouse-SW
AD: Medical College of Virginia, Virginia Commonwealth University, Department
of Psychiatry, Richmond 23298-0710, USA.
SO: Va-Med-Q. 1998 Winter; 125(1): 44-9
____ this source is not Available in S.J.M.C.Library
LA: ENGLISH
AH: The dramatic increase in the number of women in medicine presents some new
challenges to an old institution. This article provides an overview of current
trends and future directions as greater numbers of women are entering medicine
The first section describes women's particular approach to medicine, including
their motivations for pursuing medicine as a career, their specialty choices
and practice patterns, their attitudes about patient care and doctor-patient
relationships, and their advocacy for women's health issues. The second section
documents women's negative experiences in medicine, such as higher stress
levels than men, gender discrimination, sexual harassment, role strain, and a
paucity of mentors and role models.. In the final section, the authors suggest
how medicine as an institution can change to better accommodate women.
PC-SPIRS 3.40
MEDLINE (R) 10/97-12/97
MEDLINE (R) 10/97-12/97 usage is subject to the terms and conditions of the
Subscription and License Agreement and the applicable Copyright and
intellectual property protection as dictated by the appropriate laws of your
country and/or by International Convention.
1 of 2
Marked Record
TI: Assessing medical students' perceptions of mistreatment in their second and
third years.
AU: Richardson—DA; Becker-M; Frank-RR; Sokol-RJ
AD: Department of Gynecology-Obstetrics, Henry Ford Hospital, Detroit,
Michigan, USA.
SO: Acad-Med. 1997 Aug; 72(8): 728-30
____ This source is Available in S.J.M.C Library
LA: ENGLISH
AB: PURPOSE: To study medical students' perceptions of mistreatment in their
second and third years of training. METHOD: A questionnaire was distributed at
Wayne State University School of Medicine to the class of 1993 at the end of
its third year and to the class of 1994 at the end of its second and third
years. The students were asked if they had been subjected to various forms of
mistreatment; the third—year students were asked to rate their perceptions of
each clinical department's response to them on the basis of gender and
race-ethnicity, as well as their overall treatment. The students also completed
demographic information about age, gender, and marital status, number of
children, and race-ethnicity. Results were analyzed using chi-square
statistics, multivariate statistical analyses, analyses of variance, and
Duncan's post-hoc comparisons. RESULTS: The response rate for the class of 1993
was 71.5%; response for the class of 1994 were 66.9% in their second year and
75.2% in their third year; 41.7% were women. and the racial-ethnic breakdown
was 71.2% white/Caucasian, 11.7% black/African American and 16.8% other. There
was a significant difference between the percentages of second-year and
third—year students reporting any experience of -mistreatment (37.2% vs 75.8%, p
< .001). Canonical correlation analysis revealed bias in the third year based
on gender (p < .0001) and race-ethnicity (p < .0002); both variates were
related to sexual humor. The students' perceptions of mistreatment were lowest
for family medicine and highest for obstetrics-gynecology and surgery.
Perceptions of mistreatment in departments varied significantly by gender and
race-ethnicity. The nonwhite males reported the least favorable treatment in
most departments. CONCLUSION: Marked variability in the students' perceptions
of mistreatment within departments suggest that a variety of approaches will be
required to improve the medical training environment.
2 of 2
Marked Record
TI: Evaluation of sexual misconduct complaints: the Oregon Board of Medical
Examiners, 1991 to 1995.
AU: Enbom-JA; Thomas-CD
AD: Oregon Board of Medical Examiners, Portland 97201, USA.
SO: Am-J-Obstet-Gynecol. 1997 Jun; 176(6): 1340-6; discussion 1346-8
This source is Available in S.J.M.C Library
Call Number: From 1925+
LA: ENGLISH
AB: OBJECTIVE: In 1991 the Oregon Board of Medical Examiners initiated a
separate category for the complaint of sexual misconduct. Investigated
complaints of sexual misconduct brought, to the Oregon Board of Medical
Examiners were analyzed for the years 1991 to 1995 to serve as a baseline.
Comparison was made to the Federation of State Medical Boards sexual misconduct
data for 1991 and 1992. STUDY DESIGN: One hundred complaints brought against 80
j.\censees were evaluated by practitioner's degree, age group, sex, specialty,
and disposition of complaints for the years 1991 to 1995. The allegations were
classified into behavior categories of sexual impropriety, sexual
transgression, and sexual violations. RESULTS: Sexual misconduct was the
allegation in 5.97. of the complaints investigated for the study period. Oregon
had more sexual misconduct complaints than the average reported to the
Federation of State Medical Boards for the years 1991 and 1992. Most (727.)
complaints came from the patients or their families. Two female physicians
(2.47.) had sexual boundary complaints. Sexual misconduct complaints increased
by a risk ratio of 1.44 with advancing age by decades. Allegations classified
into behavior categories according to severity revealed 397. sexual impropriety,
31% sexual transgression, and 307. sexual violation. Reportable disciplinary
actions occurred only with multiple allegations of sexual impropriety (6.57.)
and for sexual transgression (277.) whereas sexual violation allegations often
had one complainant but there were 54% reportable disciplinary actions. Family
practice, obstetrics and gynecology, and psychiatry had the highest incidence
of sexual misconduct complaints whereas psychiatry and obstetrics and
gynecology had the highest incidence of reportable disciplinary actions.
Twenty-five percent of the closed cases resulted in reportable.disciplinary
actions. This analysis is discussed in relationship to legal and ethical issues
and the goal of aero tolerance. CONCLUSIONS: Oregon has a higher percentage of
sexual misconduct complaints than the average for 42 states reporting to the
Federation of State Medical Boards for the years 1991 and 1992. Analysis of the
Oregon Board's experience for the study years will provide a baseline for
future evaluation and as an educational resource for the Oregon Board of
Medical Examiners and professional and specialty societies. Ethical standards,
the reporting and investigative processes, and the legal framework are in place
and lessen the incidence of sexual misconduct and work toward zero tolerance.
pj " *3 IH .li Ji A' Ip
, .., > < ■
medical education
VERY now and then a hue
and cry is raised about the
reluctance of doctors to
serve in villages. No one can deny
the necessity of rural health ser
vice. but are doctors alone respon
sible for the sorry state of medical
service in the country? At one end
we have state-of-the-art medical fa
cilities for the well-to-do and at the
other end abysmal service for the
poor, especially in the villages
where quacks play with the lives
of hapless villagers. In order to
correct this lopsided development
of medical service in our country
medical education has to be re
planned with imagination and
commitment. If our dream of
‘Health for all’ has to be realised
at least in another ten years, a
complete overhaul of medical edu
cation is required.
We can take our cue from the
Engineering faculty, where they
have alimr-tier-system of educatiom)
i
ITI (Certificate Course)
ii
Diploma
iii
Degree
iv
Post Graduation
Medical Education too may offer
a 4-tier system.
i 2-Year certificate course after
SSLC.
ii 3-Year diploma course after
PUC.
iii. 51/2 Year MBBS course after
PUC.
iv. 3-Year post graduate course.
Students for the certificate and
diploma courses should be com
pulsorily recruited from rural
E
A complete^verhaul of medical
education's required in order to
realise the dream of ‘Health for AH’,
writes Dr K V Sanjeevi Shayana.
families, preferably with some ed. so that our Indian doctors are
landed property. They should be well versed in both the systems.
given education with stipends in Separate Ayurvedic/ Unani col
nearby taluk or district centers by leges become unnecessary, if the
above course is adopted.
doctors in government hospitals.
This modified system of medical
The certificate holders should be
recruited by the government as education should be introduced at
health workers, who should be one go in order to ensure a fair
provided with a two-wheeler to distribution of medical services.
visit villages regularly. They This will also ensure an end to
should give basic medical care, quackery.
maintain case sheets, and inform
If rural health care is to be im
their higher ups about the cases proved our focus should be on cer
treated. They should be trained to tificate and diploma health
carry out immunization and workers, who should be provided
simple blood and urine tests. They housing, basic amenities, free hos
should refer difficult cases to taluk tel facilities for their children’s
and district level hospitals. The di education etc., so that they are not
ploma holders . should man pri forced to move out of their
mary health centers, and MBBS villages. Here again, the engineer
and post graduates should man ing sector which has built model,
taluk and district level hospitals.
self-contained townships for their
At present, though we have factory workers in remote areas
health workers working in should be emulated.
villages, they are not systemati
Only if primary health care and
cally trained in basic health care. primary education is invigorated
They don’t have any idea about and brought to the door step of our
the anatomy and physiology of the vast rural populace can we hope
human body or what constitutes to achieve a substantial improve
an infection.
ment in our ‘Human Development
Another important fact to be Index’, a standard measurement
considered is the role of our for assessing the progress achiev
traditional ayurvedic medicines. ed by a nation. (At present India
At all levels of medical education ranks 132 among 172 countries in
from certificate to post graduate the Human Development India re
course, Ayurvedic/ Unani medical port graded by the United Nations
knowledge should be incorporat Development Programme).
Hf SB
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