MEDICAL ETHICS
Item
- Title
- MEDICAL ETHICS
- extracted text
-
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I
I p. Patodhi
>gy of rcspirahdian Pediatr
M. Menon
distress synrth India. A
»cdiatr 1981,
ainder YA,
of perinatal
Child Health,
2. 9: ^06.
Fren^^ N,
y ill neonates
4sc and with
0-181.
VOLUME 24----JANUARY 1987
'
NEONATOLOGY IN THE
UNDERGRADUATE MEDICAL
EDUCATION
Current Status
I. Narayanan
O.N. Bhakoo
ABSTRACT
This paper presents the current status of neo
natal teaching in the undergraduate medical edu
cation in 50 medical colleges.. There, appears to he a
lad: of uniformity in the various institutions not
only in basic facilities for neonatal care but also
in the course content and periods of the teaching
programmes. Objectives of neonatal training have
been defined and a broad outline for education
provided, it is suggested that an optimal programme
be drawn up and presented through the Medical
Council of India for implementation by the different
Institutions.
Key words:
Neonatal education, Undergraduate
Medical education.
ions about
s). '^s,s
th adopt a
must ..be in
ctuiH badly
Vqp-'SCA
'
'\-
i newborn y
/
i) tckccMz-^.^i V<5-/- S^t, I 9^°/
Zex_ci\Ce^
'
The importance of making under
graduate medical education more needoriented to the current health require
ments of the country is being increasingly
accepted. Basic MCH care is a top
consideration and care of the newborn
a high priority. Since neonatal morta
lity constitutes approximately 50% of
the high infant mortality(l), it is
essential that the basic doctor is equipped
with the relevant knowledge, skills and
attitudes to provide at least minimal care
for this crucial period. This study was
undertaken by the National Neonatology
Forum in order to identify the current
status of neonatal care in the teaching
curriculum of the various medical colleges
with a view to define an optimal course
content and methodology which could
form the basis for an improved, needoriented and more uniform policy.
Material and Methods
A questionnaire on the subject was
sent to 100 medical colleges. Replies
were obtained from 50 institutions. The
salient features are noted below.
Results
f-collcagues
ce Building
—Editor
’■rpared on behalf of the National Neonatology
Forum, India.
Among all the 50 respondents, the
main department concerned with the
teaching of Neonatology was that of
Pediatrics. The teaching programmes
were organised mainly during the student’s
posting in the department of Pediatrics;
although in 6 it was during the period
in the Department of Obstetrics and
Gynecology. Some of the basic data
on the bed strength of the nurseries,
and the number of deliveries conducted
in these institutions arc indicated ii
Table I. It may be noted that three
institutions actually bad no neonatal
NEONATOLOGY IN MEDICAL EDUCATION
NARAYANAN ET AL.
TABLE I—Background Information Related to
Rieonalal Care
Feature
Annual No. of deliveries
< 2000
2001 - 4000
4001 — 6000
6001— 8000
8001-10000
>10000 ■
Not specified
Nurseries
Nil or -Makeshift’
One
j WO
Three
Total bed strength (Nurseries)
<10
11—20
21—30
31—40
41—50
>50
. Not specified
No. of
colleges
(n=50)
14
12
5
Evaluation
20
21
6
16
17
5
2
4
1
5
special care units or had only make-shift
arrangements.
The stages in which the teaching
sessions in Pediatrics and in Neonatology
were commenced are noted in Tables II
and III. As can be seen, there were
considerable variations. Several colleges
had actually not started teaching these
subjects until the third clinical or final
year. Again, there were marked diffrences in the number of sessions (didactic
lectures and clinical demonstrations or
group discussions) devoted to each.
(i.e., Pediatrics and Neonatology).
The topics covered in the field of
neonatology as lectures are recorded in
Table IV. In most of the institutions
the topics included for group discussions
82
:
or clinical demonstrations conducted in j
smaller batches were noted to be similar |
to this list. Demonstrations on exami- |
nation of the newborn infant and the use ■
of equipments for resuscitation was done j
by all the centres. In two instances each, f
demonstration on the use of equipment ;
for exchange transfusion and of the use of a
incubators were noted. Assessment of .
gestational age and neurological exami- .
nation of the newborn were taught in S
and 6 centres, respectively.
Regarding the status of Pediatrics io ;
the local University examinations, in ■
only 3 was the subject allotted a full I
paper in the final evaluation. In 39.
centres, one section of the paper ir.
General Medicine was devoted to Pedia- •
tries. In the remaining, there was only Ir
one question or a short note on the subject j
Two centres indicated that a Pediatriciat i
was an examiner and in one institution, a j
‘short case’ in Pediatrics was included int
the clinical evaluation. In one centrej
Pediatrics did not form part of the,
evaluation at all.
As far as Neonatology was concerned, j
it was included as a short note in th:;paper in Pediatrics in 29 centres, id
Obstetrics and Gynecology in 19 centre.'
and in Medicine in 6 institutions. It
not covered at all in 3 centres.
Discussion
The objectives of undergraduate mec. i
cal education is to train a doctor fcl
manning the primary health centre^
(PHC) and provide basic health care:
people. To achieve this in terms J
neonatal care, he should be able to :
(a) Advise about the routine neona:.care in a way so as to promote baby|
INDIAN PEDIATRICS
VOLUME 24—JANUARY 1987
TABLE II—Distribution of Teaching Session
No. of colleges
O'-’mencement of session
subject
First
clinical
year
Second
clinical
year
Third
clinical
year
13
24
6
10
22
21
14
17
15
5
30
-F<rst Pediatrics lecture
Fint Pediatric clinic
First Lecture on Neonatal care
Ftm clinic on Neonatal care
Period of clinical posting
Period (weeks)
First clinical year
Second clinical year
Nil
Ped
19
Ped
13
29
6
_
2
5- «
Neon
34
12
2
-• I
1
Not mentioned
J
—
—
of
Teaching Sessions
Third clinical year
Neon
. Ped
16
7
_
2
24
10
13
1
Neon
i
14
20
7
1
Ped — Pediatrics,
Seen = Neonatology
TABLE ITT—Distribution
(c) Supervise and train paramedical
workers in basic neonatal care.
The methods of training used can be
No. of Lectures
Colleges
in (he form of lectures, seminars, bed
side clinics and follow-up of normal and
6-10
35
11—15
6
sick babies at home and in the hospital.
16—20
1
Table V describes the list of essential
Not mentioned
3
neonatal topics which can be covered
during this training. For adequate
fulfilment of the objectives, such a training
optimal growth and development and should be carried out in collaboration
protect him from illnesses.
with the Departments of Obstetrics and
fi) Diagnose a sick baby and treat Gynecology and that of Community
minor illnesses at home and in the PHC Medicine. Neonatal care at birth, peri
natal asphyxia and care of a normal
settings.
(c) Give prompt treatment in an newborn can be usefully learnt during
emergency and identify those needing their posting in the labor room while
they complete record of twenty labor
referral for special care.
(d) Advice and provide adequate care cases. Follow-up of the babies thus
faring transport of a sick baby to the born, till discharge from the hospital,
can be a very good learning experience.
■ sspital.
Neonatology
83
NEONATOLOGY IN MEDICAL EDUCATION
NARAYANAN ET AL.
TABLE IV— Course Content in Neonatology
(The figures in brackets indicate the number of institutions which included the subject in their
curriculum)
1.
Risk .approach (7)
2.
Nomenclature related to the perinatal period (5)
3.
General care of the normal newborn (45)
4.
Birth asphyxia and resuscitation (42)
5.
low birthweight and prematurity (43)
6.
Feeding including breast feeding (17)
7.
Problems in the newborn
(u) Jaundice (43)
(6) Infections (39)
(c) Birth injuries (20)
(r/) Convulsions ‘(f7)
(e) Congenital malformations (8)
j/) Respiratory distress (11)
(<?) Hemorrhagic disease (4)
(A) Tetanus neonatorum (2)
(»’) Miscellaneous (4)
(Thermoregulation, surgical problems, metabolic problems, cyanosis)
TABLE
Recommended List of Essential Neonatal Topics for Undergraduate Training
Teaching method
1. Introduction to neonatal care
Role of antenatal and inlranatal care in
preventive neonatology, definition of high risk
pregnancy, nomenclature related to perinatal
period, causes of perinatal and neonatal mortality
2. Care at birth, perinatal asyphyxia and
resuscitation
3. Care of normal newborn
Routine care and breast feeding
4. Problems ofLBW and preterm
Feeding and temperature control
5. Neonatal infections
6. Respiratory problems
8. Seizures and neonatal tetanus
9. Congenital malformations
10. Care during transport .
Danger signals, indications for referral,
special care etc.
84
Lecture or Seminar with Departments of
Obstetrics and Gynecology and Community
Medicine
Lccture/Seminar/Demonstration with
Department of Obstetrics Gynecology
Lecture/CJinic
Lecture/Clinic
Lecture/Clinic
Lecture/Clinic
Lecture/Clinic
Lecture/Clinic
Lecture/Clinic (Ped. Surgery)
Lecture/Demonstration
VOLUME 24— JANUARY 1 987
INDIAN PEDIATRICS
Besides this, students can have clinics on
a neonatal patient once a week during
their posting in Pediatrics.
As shown in Table I, it is clear that,
there is adequate patient material in our
teaching hospitals for training students
in neonatology. It is often asked if
presence of a Special Care Baby Unit
iSCBU) is essential for training a student
in level-I care. Since a teaching hospital
is a place providing the highest level of
patient care in a particular region, pre
sence of SCBU should be mandatory in
such a centre. Besides, such a unit can
be utilised in training students in clinical
monitoring of patients, their early diagno
sis and for the management of neonatal
emergencies.
It was encouraging to .note
that
nearly 85% teaching centres covered areas
related to the care of normal newborn,
low birth
weight
neonates, birth
asphyxia, jaundice and infections. How
ever. it was surprising to note that topics
like neonatal feeding, respiratory prob
lems. neonatal tetanus, convulsions,
congenital malformations and care during
transport were missing in the course
content of more than half of the insti
tutions (Table IV). Absence of uniform
in the course content in various centres
is a reflection of lack of awareness about
the guidelines for neonatal training to
the undergraduates provided by the
National Neonatology Forum(2), Indian
Academy of Pediatrics(4), Ministry of
Health and Family Welfare, Govern
ment of India(5), and the World Health
Organisation^). In fact, it is high time,
that an optimal programme for training
in neonatology is finalised by the national
bodies and approved by the Medical
Council of Indiafor implementation by the
different medical colleges in the country.
Lastly, a word about evaluation in
neonatology. Evaluation is a part of
training process, i.e., it provides reinforce
ment to the student about the importance
of a particular topic. Hence, some
question from neonatology, be it a short
note, in Pediatric or Obstetric paper in the
final examination, will go a long way in
motivating students for the study of
neonatal care.
Acknowledgement
The National Neonatology Forum and
the authors in their persona! capacity
wish to thank the co-operation extended
by the staff of the Departments of the
Medical Colleges who participated in this
study.
REFERENCES
1.
2.
3.
4.
5.
6.
Central Bureau of Health Intelligence.
Health Statistics of India.
Directorate
General of Health Services, Ministry of
Health and Family Welfare, Government i>1
India. Govt of India Press, New Delhi, 1985.
Narayanan I, Masand M, Gujral VV.
Neonatology in Undergraduate Medical
Education. In: Recommendations on Edu
cation andTrainingin Neonatology. National
Neonatology Forum, Eds. Bhargava SK,
Kumari S. New Delhi, Darpan Printers and
Publishers, 1981, pp 21-30.
Medical Council of India: Recommendations
on Undergraduate Medical Education, 1980.
Recommendations for Course Content of
Undergraduate Pediatric Education, Pro
ceedings of a Workshop by Indian Academy
of Pediatrics. Convener Kaul KK,-Jabalpur,
1983.
Minimum Training Schedule for Under
graduates: Report of the task force on
Minimum Perinatal ■‘Care, Government of
India, Ministry of Health and Family
Welfare, 1982, p 33.
Guidelines on the Teaching and Practice of
Neonatology. WHO Regional Publications,
South-East Asia Scries No. 6. World Health
Organisation, New Delhi, 1977.
85
RESPIRAlUAi
MISRA
3.
4.
Khatua SP, Gangwal A, Basu P, Patodhi
PKR. The incido^kand etiology of respira
tory distress in^mwborn. Indian Pediatr
1979, 16: 1121-1126.
Thomas S, Verma IC, Singh M, Menon
PSN. Spectrum of repiratory distress syn
drome in the newborn in North India. A
prospective study. Indian J Pediatr 1981,
48: 61-65.
9. Karan S, Mathur BP, Surainder YA,
Seetha T. Incidence and cause of perinatal
mortality at the Institute of Child Health,
Hyderabad. Indian Pediatr 1972, 9: 99-106.
10. Prodham LS, Choffat JM, French N,
Mazeumi M. Care of seriously ill neonates
with hyaline membrane disease and with
sepsis. Pediatrics 1974, 53: 170-181.
7.
Ghosh S, Bhargava SK. Shanna DB,
Bhargava V, Saxena HMK. Perinatal mor
tality—a preliminary report on a hospital
based study. Indian Pediatr 1971, 8:
8.
421-426.
Maheshwari NB, Kuldcep T, Savita R.
Causes of late fetal and neonatal death—an
autopsy study. Indian Pediatr. 1971, 8:
417-420.
5. Taylor PM. Respiratory distress in newborn.
Clin Obst Gyn 1971, 14: 763-789.
6. Driscoll SG, Smith CA. Neonatal pulmonary
disorder. Ped Clin North Amer 1962, 9:
325-352.
VOLUME 24--- JANUARY 1987
NEONATOLOGV IN THE
UNDERGRADWlTE MEDICAL
EDUCATION
Current Status
'
I. Narayanan
O.N. Bhakoo
ABSTRACT
This paper presents the current status of neo
natal leaching in the undergraduate medical edu
cation in 50 medical colleges. There appears to be a
lack of uniformity in the various institutions not
only in basic facilities for neonatal care but also
in the course content and periods of the teaching
programmes. Objectives of neonatal training have
been defined and a broad outline for education
provided. It is suggested that an optimal programme
be drawn up and presented through the Medical
Council of India for implementation by the different
Institutions.
NOTES & NEWS
Key words:
WRITING FOR INDIAN PEDIATRICS
Neonatal education, Undergraduate
Medical education.
A small booklet has been published giving detailed instructions about
preparation of manuscripts for Indian Pediatrics (or for other journals). It lists
common mistakes of usage and expression. The Journal will henceforth adopt a
stricter policy towards the form and structure of the manuscripts; these must be in
the style of the Journal and be free of mistakes. We will be forced to return badly
Material and Methods
A questionnaire on the subject was
sent to 100 medical colleges. Replies
were obtained from 50 institutions. The
salient features are noted below.
Results
prepared manuscripts.
The Heads of the Departments of Pedi atrics are requested to urge their colleagues
and students to purchase a copy of this tract.
Price: Rs. 10/-; Rs. 15/- by post.
The profits made by the sale of this booklet will go towards the Office Building
Fund for Indian Pediatrics.
Kp - ac , |
The importance of making under
graduate medical education more needoriented to the current health require
ments of the country is being increasingly
accepted. Basic MCH care is a top
consideration and care of the newborn
a high priority. Since neonatal morta
lity constitutes approximately 50% of
the high infant mortality(l), it is
essential that the basic doctor is equipped
with the relevant knowledge, skills and
attitudes to provide at least minimal care
for this crucial period. This study was
undertaken by the National Neonatology
Forum in order to identify the current
status of neonatal care in the teaching
curriculum of the various medical colleges
with a view to define an optimal course
content and methodology which could
form the basis for' an improved, needoriented and more uniform policy.
—Editor
spared on behalf of the National Neonatology
F°rum, India.
Among all the 50 respondents, the
main department concerned with the
teaching of Neonatology was that of
Pediatrics. The teaching programmes
were organised mainly during the student’s
posting in the department of Pediatrics;
although in 6 it was during the period
in the Department of Obstetrics and
Gynecology.
Some of the basic data
on the bed strength of the nurseries,
and the number of deliveries conducted
in these institutions are indicated in
Table I. It may be noted that three
institutions actually had no neonatal
81
NEONATOL^^ IN MEDICAL EDUCATION
INDIAN PEDIATRICS
VOLUME 24—JANUARY 1987
NARAYANAN ET AL.
TABLE I— Background Information Related to
Neonatal Care
Feature
Annual No. of deliveries
< 2000
2001— 4000
4001— 6000
6001— 8000
8001—10000
>10000
Not specified
colleges
or clinical demonstratjpns conducted in
smaller batches were noted to be similar
to this list. Demonstrations on exami
nation of the newborn infant and 'the use
of equipments for resuscitation was done
by all the centres. In two instances each,
demonstration on the use of equipment
for exchange transfusion and of the use of
incubators were noted. Assessment of
gestational age and neurological exami
nation of the newborn were taught in 8
and 6 centres, respectively.
Nil or ‘Makeshift’
Three
Total bed strength (Nurseries)
CIO
11—20
21—30
31—40
41—50
Not specified
special care units or had only make-shift
TABLE ll-Distribulion of Teaching Session
No. of colleges
Commencement of session
subject
First Pediatrics lecture
First Pediatric clinic
First Lecture on Neonatal care
First clinic on Neonatal care
evaluation at all.
As far as Neonatology was concerned,
aiigciucnts.
arrangements.
was included as a short note in the
The stages in
which the teaching
luv
-- --------sessions in Pediatrics and in Neonatology paper in Pediatrics in 29 centres, in
were commenced are noted in Tables II Obstetrics and Gynecology in 19 centres
and III. As can be seen, there were and in Medicine in 6 institutions. It was
considerable variations. Several colleges not covered at all in 3 centres.
had actually not started teaching these
subjects until the third clinical or final Discussion
year. Again, there were marked diffThe objectives of undergraduate medi
, rences in the number of sessions (didactic cal education is to train a doctor for
lectures
and
clinical
demonstrations
or
car
cuuv»uthe
UU —primary
maiming
mw
r.i____. *health
’*’• -ontres
group discussions) devoted to each, manning
centres
(f.e., Pediatrics and Neonatology).
iiogyj.
(PHC) and provide
’’ basic health care to
the field of people. To achieve this in terms of
The topics covered in the fi— __ neonatal care, he should be able to :
neonatology as lectures are recorded in
(a) Advise about the routine neonatal
Table IV. In most of the institutions care in a way so as to promote baby’s
'■
:"''’”de<lfor group discussions
Second
clinical
year
Third
clinical
year
13
22
21
14
17
15
5
30
6
10
Period of clinical posting
Period (weeks)
Evaluation
Regarding the status of Pediatrics in
the local University examinations, in
only 3 was the subject allotted a full
paper in the final evaluation. In 39
centres, one section of the paper in
General Medicine was devoted to Pedia
trics. In the remaining, there was only
one question or a short note on the subject.
Two centres indicated that a Pediatrician
was an examiner and in one institution, a
‘short case’ in Pediatrics was included in
the clinical evaluation. In one centre
Pediatrics did not form part of the
First
clinical
year
Nil
5- 8
9-12
Not mentioned
First clinical year
Ped
19
23
2
1
Neon
34
12
-
Second clinical year
Third clinical year
Ped
13
29
6
Ped
Neon
16
7
2
10
13
Neon
14
Ped = Pediatrics,
Neon = Neonatology
TABLE HI—Distribution of Teaching Sessions
Neonatology
(e)
Supervise and train paramedical
workers in basic neonatal care.
The methods of training used can be
in the form of lectures, seminars, bed
6—10
35
side clinics and follow-up of normal and
11—15
’
6
sick babies at home and in the hospital.
16—20
1
Table V describes the list of essential
Not mentioned
3
neonatal topics which can be covered
during this training. For adequate
optimal growth and development and fulfilment of the objectives, such a training
should be carried out in collaboration
protect him from illnesses.
(6) Diagnose a sick baby and treat with the Departments of Obstetrics and
Gynecology
and that of Community
minor illnesses at home and in the PHC
Medicine. Neonatal care at birth, peri
settings.
natal
asphyxia
and care of a normal
(c) Give prompt treatment in an
emergency and identify those needing newborn can be usefully learnt during
their
posting
in
the labor room while
referral for special care.
(d) Advice and provide adequate care they complete record of twenty labor
during transport of a sick baby to the
cases. Follow-up of the babies thus
born, till discharge from the hospital,
hospital.
can be a very good learning experience.
No. of Lectures
Colleges
NEONATOLOGY IN MEDICAL EDUCATION
TABLE Vt-Course Content in Neonatology
(The figures in brackets indicate the number of institutions which included the subject in their
curriculum)
1. Risk approach (7)
2. Nomenclature related to the perinatal period (5)
3. General care of the normal newborn (45)
4. Birth asphyxia and resuscitation (42)
5. Low birthweight and prematurity (43)
6. Feeding including breast feeding (17)
7. Problems in the newborn
(a) Jaundice (43)
(b) Infections (39)
(c) Birth injuries (20)
(if) Convulsions (17)
(e) Congenital malformations (8)
(/) Respiratory distress (11)
(g) Hemorrhagic disease (4)
(A) Tetanus neonatorum (2)
(i) Miscellaneous
(Thermoregulation,
(4) surgical problems, metabolic problems, cyanosis)
trdList ofEssential Neonatal Topics for Undergraduate Training
TABLE N—Recommended List oj zssenu
Teaching method
1.
:
Lecture or Seminar with Departments of
Obstetrics and Gynecology and Community
Introduction to neonatal care
Role of antenatal and intranatal care in
Medicine
preventive neonatology, definition of high risk
pregnancy, nomenclature related to perinatal
period, causes of perinatal and neonatal mortality Lecture/Seminar/Demonstration with
; 2. Care at birth, perinatal asyphyxia and .
Department of Obstetrics Gynecology
resuscitation
3. Care of normal newborn
Routine care and breast feeding
Lecture/CJimc
4.
Problems ofLBW and preterm
Feeding and temperature control
5.
6.
7.
8.
9.
10.
Neonatal infections
Respiratory problems
Jaundice and bleeding
Seizures and neonatal tetanus
Congenital malformations
Care during transport
Danger signals, indications for referral,
special care etc.
Lecture/Clinic
Lecture/Clinic
Lecture/Clinic
Lecture/CJimc
Lecture/Clinic
Lecture/Clinic (Ped. Surgery)
Lecture/Demonstration
VOLUME 24—JANUARY 1987
INDIAN PEDIATRICS
Besides this, st^knts can have clinics on
NARAYANAN FT AL.
a neonatal patient once a week during
their posting in Pediatrics.
As shown in Table I, it is clear that,
there is adequate patient material in our
teaching hospitals for training students
in neonatology. It is often asked if
presence of a Special Care Baby Unit
(SCBU) is essential for training a student
in level-I care. Since a teaching hospital
is a place providing the highest level of
patient care in a particular region, pre
sence of SCBU should be mandatory in
such a centre. Besides, such a unit can
be utilised in training students in clinical
monitoring of patients, their early diagno
sis and for the management of neonatal
emergencies.
It was encouraging to note
that
nearly 85% teaching centres covered areas
related to- the care of normal newborn,
low birth
weight
neonates, birth
asphyxia, jaundice and infections. How
ever, it was surprising to note that topics
like neonatal feeding, respiratory prob
lems, neonatal tetanus, convulsions,
congenital malformations and care during
transport were missing in the course
content of more than half of the insti
tutions (Table IV). Absence of uniform
in the course content in various centres
is a reflection of lack of awareness about
the guidelines for neonatal training to
the undergraduates provided by the
National Neonatology Forum(2), Indian
Academy of Pediatrics(4), Ministry of
Health and Family Welfare, Govern
ment of India(5), and the World Health
Organisation^). In fact, it is high time,
that an optimal programme for training
m neonatology is finalised by the national
bodies and approved by the Medical
Council of India for implementation by the
different medical colleges in the country.
Lastly, a word about evaluation in
neonatology. Evaluation is a part of
training process, i.e., it provides reinforce
ment to the student about the importance
of a particular topic. Hence, some
question from neonatology, be it a short
note, inPediatric or Obstetric paperinthe
final examination, will go a long way in
motivating students for the study of
neonatal care.
Acknowledgement
The National Neonatology Forum and
the authors in their personal capacity
wish to thank the co-operation extended
by the staff of the Departments of the
Medical Colleges who participated in this
study.
REFERENCES
1. Central Bureau of Health Intelligence,
Health Statistics of India.
Directorate
General of Health Services, Ministry of
Health and Family Welfare, Government of
India. Govt of India Press, New Delhi, 1985.
2.
Narayanan I, Masand M, Gujral W.
Neonatology in Undergraduate Medical
Education. In: Recommendations on Edu
cation andTrainingin Neonatology. National
Neonatology Forum, Eds. Bhargava SK,
Kumari S. New Delhi, Darpan Printers and
Publishers, 1981, pp 21-30.
3.
Medical Council of India: Recommendations
on Undergraduate Medical Education, 1980.
4.
Recommendations for Course Content of
Undergraduate Pediatric Education, Pro
ceedings of a Workshop by Indian Academy
of Pediatrics. Convener Kaul KK, Jabalpur,
1983.
5. Minimum Training Schedule for Under
graduates: Report of the task force on
Minimum Perinatal Care, Government of
India, Ministry of Health and Family
Welfare, 1982, p 33.
6. Guidelines on the Teaching and Practice of
Neonatology. WHO Regional Publications,
South-East Asia Series No. 6. World Health
Organisation, New Delhi, 1977.
27
PAEDIATRIC EDUCATION IN INDIA
TABLE I
IndeNo. of
pendent
colleges Reply pediain the recd.
tries
zone
depart-
Paediatric Education in India
(Postgraduate and Undergraduate)
ZONES
.
States
BY
West
Rajasthan, Guja
rat, Maharashtra,
Goa.
22
16
14/2
1958 onwards
(1 in 1948)
9
20-120
3.5-1.5
East
Bihar, Bengal,
Orissa, Assam
17
11
5/6
1956 onwards
5
20-170
4-12
42-200
8-15
Dr. S. GUPTA, Dr. G. SRIVASTVA
“ Productivity of the adult population
is directly related to the health of the child
population and a country losing large mem
bers of potentially healthy and productive
adults because of needless infections and
disease in infancy and childhood is wasting
its national wealth.”
The fundamental principle of medical
education is to produce a good basic doctor.
With tremendous advances in medical
knowledge every day, every speciality has
advanced considerably and the medical
student is confronted with ever-enlarging
curriculum on individual subject. It is
therefore imperative that the courses should
be prescribed in a manner that he is able to
accumulate knowledge of various branches
of medicine without overburdening. A
pragmatic approach is needed to prune
those specialities which he is not likely to
come across in day-to-day practice, while
increasing the courses of study of speciali
ties which he is likely ,to come across
amongst majority of his patients. Child
health assumes greater significance in our
country because 41% of the population is
under 15 yeais of age and 45% deaths in the
country occur among those below 15 years
of age (U. N. Demographic year book,
1966). In India it is only in the last decade
that realization has come to put the discip
line of pediatrics on its proper footing.
However, although thoughts have turned
towards according pediatrics its due plaee
amongst the various disciplines of medical
education, the present day curriculum with
respect to teaching of pediatrics still falls
short of the minimum requirements. A
general practitioner is expected to answer
such questions as rearing of a child, infant
feeding, immunization, prevention of disease
and behaviour problems. With present day
standard of pediatric education at under
graduate level the above demands of the
patients are hardly ever met with and they
have to fall back to methods in child care
handed down the generations through
mothers and grandmothers. With family
planning as national policy it is timely to
review the standards of undergraduate
teaching and to ask whether the. training of
doctors in India is appropriate for the tasks
they would be required to do, always keep
ing in mind the concern about the edu
cation of the basic physician. To assess the
present day standard of pediatrics education
at undergraduate and postgraduate level, a
proforma was sent to all the medical colleges
in India first time in February, 1967. Rep
lies have been received from 73 of them
over a period of 2 years and the following
is based upon the data supplied therein
(Table I & IV).
% of ped
Profc- Pediatrics beds to
ssor
beds
total
beds.
Ycar of
establish
ment
North
Kashmir, Punjab,
Haryana, LLP.
Plimachal Pradesh,
Delhi, Chandigarh
19
13
11/2
1957 onwards
8
South
Tamil Nad, Andhra
Pradesh, Mysore,
Kerala,
Pondicherry.
31
27
21/6
1957 onwards
(4 before 1957)
(1 in 1948)
18
30-200
6-16
Central
Madhya Pradesh
6
6
6
1957 onwards
2
30-120
10-18
* Denominates indicate the number of colleges where paediatrics is under Department of Medicine.
TABLE II
Teaching and Research
Postgraduate training
Undergraduate training
No. of I3.C.H.&M.D. D. C. H.
only
only
colleges M. D.
ZONES
No. of
colleges
No of
leciures
Ward posting
Internship
West
16
10-24
4 weeks to
3 months
15 days
to 2 months
10
East
11
9
4 weeks to
8 weeks
1 month to
6 months
5
3
111
9
—
—
3
1
—
North
13
South
27
6
Central
3 weeks to
2| months
15 days
to 1 month
9
10-30
12 days to
3 months
2 weeks to
2 months
13
15-30
15 days to
3 months
15 days to
1 month
4
10-60
6
1
3
3
28
INDIAN JOURNAL OF MEDICAL EDUCATION
PAEDIATRIC EDUCATION IN INDIA
TABLE in
Paramedical Staff Pattern with total
'Number of Colleges in each Zone
No. of col
leges with
paramedical
staff
ZONES
West
East
North
South
Centra]
9
...
...
Public
Health
Health
5
2
6
9
3
2
9
2
5
G
2
9
1
1
-
-
Social
10
16
1
Aux. Nurse
Dietician
Sp. Ped.
4
I
1
_
7
2
r.
2
3
1
10
5
TABLE IV
Health Centres
ZONES
West
East
North
South
Centra]
...
Number
Rural & Urban
Only Urban
Orly Rural
12
5
10
17
6
8
5
5
11
6
I
2
Autonomous Departments
The paediatric departments in various
medical colleges have been set up only since
1948, the first two departments being in
Bombay and Madras and till the year 1957
only in Six more medical colleges a separate
department was existing. It is only after the
year 1957 that separate departments were
established in different medical colleges in
the country. Of the 73 medical colleges
from which replies were received, in 57,
paediatric departments exist independently
while in 15 as a subspeciality of medicine
and in one under the obstetric department.
Maximum number of paediatric depart
ments exist as independent units in colleges
belonging to south zone. In Madhya
_
I
5
4
-
Pradesh, it is heartening to note that all
six departments are independent.
Pediatric Beds
It is really a matter of concern that the
number of paediatric beds in various teach
ing hospitals in the country vary from
5-15% of the total hospital bed strength.
The number of pediatric beds in district &
smaller hospitals is extremely small. Assign
ment of beds for children al least in the
district hospitals is an immediate need.
This will lessen the load on the teaching
hospitals and would result in belter care of
the child. At any time, any children ward
or hospital is over-crowded. It has now be
come necessary to have sub-specialities like
pediatric cardiology, hematology, neuro
logy, ophthalmology, otolaryngology, ortho
pedics etc., for better understanding and
treatment. In fact a large number of attendencc and admission in these specialities is
from pediatric age group. No doubt with
present day limitation of resources, it may
not be possible to attain these objectives in
the near futu’e, but a beginning has to be
made at least in a few selected teaching
institutions.
Medical Personnel
A separate chair of Professor and Head
exists in 42 out of 73 colleges and in the rest
an Assistant Professor. Reader or Lecturer is
the Head of the Department where paedia
trics exists as a separate discipline. The staff
pattern in the colleges is far too short of
the needs. Not only the staff has to meet
with the teaching requirements of the
undergraduate and postgraduate students
but have tomanage the hospital services. In
most of the teaching hospitals, the staff is
appointed mainly on the basis ofthe number
of students on roll rather than on the basis of
work load.
Undergraduate Teaching
The state of undergraduate teaching is
evident from the reports obtained in various
colleges. The number of didactic lectures
vary from 6 to 52 hours in the entire clini
cal years during MBBS course. The clinical
or bed side teaching comprises of postings
in paediatric wards varying from 15 days to
3 months. This is usually split in some
colleges between 4th and 5th year of
M.B.B.S. Course. No doubt every college is
including pediatric lectures and clinical
teaching in its curriculum; the number
is hardly sufficient for the requirements.
Whatever teaching is being done is mostly
theoretical and very little practical training
is being given. The Medical Council of India
29
has recommended three months of pediatric
posting, one month each in pediatric, medi
cine, paediatric surgery and neonatology out'
of the time allotted for internal medicine,
general surgery and obstetrics & gynae
cology respectively. It is felt that the paedia
tric education at undergraduate level must
bear some relationship to the prevalent
disease pattern in the country. It is also
necessary to teach comprehensive child care
and to coordinate the teaching with major
local health problems of the area served by
the medical college. A major cause for lack
of interest exhibited by the under-graduate
students towards the subject is the absence
of examination in pediatrics.
Rotating internship in pediatrics varies.
for a period of 15 days to three months in
different colleges. However, in a majority
of the medical colleges (60%) the posting is
done for one month. At present posting in
pediatrics has not been recommended by
the Medical Council of India, and whatever
time institutions have given for the subject,
has been bortowed either from time allot
ted for Preventive & Social Medicine or
other subjects combined.
Postgraduate Teaching
Paucity of beds and non-availability of
trained and qualified teachers has resulted
in the provision of post-graduate teaching
in only 56.1% of the above colleges. As seen
in Table II maximum number of colleges
imparting postgraduate training were in
North, followed by Central and Western
regions. In South India even though the
number of medical colleges was higher,
those imparting postgraduate training were
only 45%. Majority of the colleges impart
training both for M.D. and D.C.H. The
postgraduate training is thecietically biased
in most of the institutions. In comparitively
smaller number of institutions, the training
30
INDIAN JOURNAL OF MEDICAL EDUCATION
is residential with
training.
emphasis on ward
Paramedical Staff & Preventive
Pediatric Services
The enquiry from the medical colleges
revealed that the pediatric departments
have paramedical staff only in 56.3% of
the colleges.
This comprises social workers, health
nurses, health visitors, auxiliary nurses and
pediatric trained nurses. In al) colleges ex
cept two there is no pediatric dietician. As
seen in Table IV 70.4% of colleges are
engaged in running the rural or urban
health centres. Some of them have only an
urban centre or a rural centre. Most of
these centres are run in collaboration with
department of preventive and social medi
cine. With a shift of emphasis from care of
sick child to comprehensive child care,
study of child health and preventive pediat
rics has recently been included in some of
the university pediatric departments, which
till now was the function of community ser
vices having no relation with medical colle
ges, and it is hoped that if not al), at least
most medical colleges will be able to impart
training for their students. Thus although
two thirds of the departments have an
urban or rural centre attached to them,
minimum preventive and social pediatric
coverage is possible. For the comprehensive
child health care to succeed infracture
like health visitors, social workers, nurses
are very important and in their absence it
is not likely to succeed.
Role in family planning
Role of pediatrician in family planning
had till now been not recognised. It has
been realised that the greatest motivation
factor towards family planning is optimum
health of the living children. It is this
factor which leads the parents to adopt
family planning.Incentives, propaganda and
use of diverse forms of contraceptive techni
ques fail to motivate the parents for family
planning if a number of children have died
due to disease or are suffering from them.
As parents learn that the death of a high
percentage of infants is not inevitable they
become more receptive to the idea of family
planning.
Research
Research at present is clinical oriented.
Whatever is being done consists ot evalua
tion of clinical data. Research being a time
consuming process involving money and
personnel, reason for its neglect is obvious.
Lack of funds, personnel and time has
resulted in hardly any experimental woik.
In the field of pediatric education no
single agency has done more to further the
cause of pediatrics as UNICEF and W.H.O.
UNICEF has aided in either the establish
ment or otherwise of 52 of these depart
ments and in a majority of them grant in
one form or other is continuing. Further
UNICEF and WHO have aided in drawing
attention of medical educationists to the
needs of pediatric education by holding
various conferences on pediatric teaching.
Recommendations
For any recommendation to be effective
it should be realistic. With advancement at
all stages of medical knowledge all the
branches are craving for greater recogni
tion. Initially fewer objectives are to be
kept and once these are achieved, further
aim should be based upon the past experi
ence. It is felt that :
(i) Pediatrics should exist as a separate
department in not only teaching
institutions but at district hospital
levels to be assigned for children.
PAEDIATRIC EDUCATION IN INDIA
(ii) Pediatric medical personnel have
to be increased at all levels.
(iii) Pediatric care has to be assigned only
to pediatrics trained doctors. The
current practice of utilising the
services for duties other than pedia
trics must come to an end as other
wise training in pediatrics like
DCH and MD is futile.
(vi)
Postgraduate training has to be clini
cal oriented. Also it should be resi
dential during the duration of the
course.
(vii)
Research facilities have to be in
creased especially in experimental
pediatrics.
(viii)
Training in comprehensive child
care has to be an important aspect
of pediatric education.
(iv)
Paramedical staff in pediatrics have
to be increased and greater facilities
for their training provided.
(v)
During undergraduate course this
Thanks are accorded to Heads of Pediatric
subject has to be treated as a major
discipline. All candidates are to be Departments of all institutions who have
examined by the Professor of Pedia very kindly supplied the data as per pro
trics either on his own or along- forma sent to them and to Dr. Premchand,
for helping in the analysis.
with the Professor of medicine.
Acknowledgements
REFERENCES
1. W. H. O. Report of the meeting on pediatric education, India, WHO, Regional Office for
South East Asia, New Delhi India May, 1969.
r\ p - s
ANNEXURE II
RECOMMENDATIONS OF NATIONAL WORKSHOP ON UNDERGRADUATE PEDIATRICEDUCATION (1983, JABALPORE)
1.
Objectives
Objectives that relate to undergraduate
medical education in general, also apply to
pediatric education. However, in view of
special requirements of training in child
health care, emphasis needs to be laid on
certain specific objectives. The group
discussion which endeavoured to define
these objectives came to the following
conclusions in the form of their final
recommendations.
(a)
(b)
(c)
(d)
(e)
(f)
(g)
II.
It was agreed that a common set of national
objecives, modified by local needs be
available for training in child health. Such
objectives should take into account the
limitations of time, staff and equipment.
Growth and development being the essence
of child health the training should
emphasise normal growth and development
as an indicator of health, any deviation
being recognised as ill health.
The training should emphasise prevention
of disease, affective promotion of health
and care of common illness of infancy and
childhood in their social, economic and
cultural context.
The tater-rlationship between illness in the
context of the family and environment and
that the child and mother are one
inseperable unit should be understood thus
emphasising the totality of care in health
and disease.
The student should be able to appreciate
his limitations and seek assistance when
required.
The training should attempt at inculcating
among the students the ability to appreciate
the role of a doctor as a manager, teacher
and organiser within the community
entrusted to his care. His ability should
therefore include the development of skills
of communication and education.
The student should be imbued with the
spirit of selfimprovement in knowledge and
skills in his day to day work.
involves several disciplines in predinical
paraclinical and clinical, with considerable
overlap in their course content, it can not
be taught in isolation. Thus teaching of
pediatrics cannot be done in the
department of pediatrics alone. The group
therefore strongly felt the need for having
curriculum committees in all medical
colleges with the head of the institution
acting as chariman in order to achieve
integration between departments for better
teaching of child health.
A considerable part of the course content
including growth and development, age
dependent variations in structure and functions
in a normal child, pathologic and immunologic
responses etc., should be taught by the faculty in
the related basic desciplines in collaboration
with pediatric teachers during the period of pre
and para-clinical training.
While curriculum organisation could vary
from one institution to another depending upon
the overall curricular structure and local
convenience, the training programme should
have a structured course with formal opening
and closing sessions. The opening sessions
should introduce the subject and outline its
scope, explain training arrangements and the
role of students in it; the closing session should,
apart from student assessment, include course
evaluation through student feed-back and
discussions with the pediatric faculty.
The course content recommended in
the areas of knowledge and skils is as under :
KNOWLEDGE
1.
Growth & Development
Definition, parameters of growth, principles
of growth, factors affecting physical growth,
anthropometry (height, weight, arm and
chest circumferences). Longitudinal growth
and growth monitoring, weight charts,
velocity of growth, growth centiles, physical
and sexual growth at adolescence and sex
differences in growth. Appreciation of and
simple methods of screening children under
three. Intelligence, its meaning and
principles of assessment.
Course Content
Since learning related to child health care
127
CHILD HEALTH MANPOWER: 2000 A. D.
The knowledge of growth and development
should be essentially clinically oriented.
2.
Nutrition
Normal requirements of essential nutrients
from birth to puberty, Breast feeding,
physiology of lactation, composition of
human milk, advantages, techniques, socio
cultural factors,pattern of normal stool in
breast-fed babies. Normal nutritional values
of common foods used in the region. Breast
milk versus animal milk, hazards of tinned
milk and the feeding bottle. Prevalence,
incidence, etiopathogenesis and clinical
recoginition cf deficiency disorders. Dietary
management in health and disease
including various grades, and types of PEM,
Vitamin deficiencies, anaemia, goitre
(where prevalent), their management in
hospital health centre and home. Beliefs,
customs, fallacies related to foods, and
breast feeding. Principles of appropriate
weaning foods, locally available, home
made and cheap. A brief outline of national
nutrition and i elated programmes (ICDS,
MCH, EPI etc).
3.
Preventive and Social Asects
Essential demographic facts, special
problems of child in rural areas and urban
slums, mortality and morbidity and their
major causes. Family planning and child
health, advantages of birth spacing,
disadvantages of large families. Available
special health services for children in the
region. At risk concept. Immunisation :
basic principles, schedules, storage, cold
chain, absolute contraindications and
fallacies.
4.
New Born
Normal newborn and events during
neonatal period. Problems of low birth
weight
babies
at
home
and
community.Common causes of morbidity
and mortality.Perinatal asphyxia and its
consequences. Birth traums-recognition
and referral. Neonatal jaundice-common
causes and genesis. Sepsis in newborn.
Early recognition of life-threatening
anomalies and illness (e.g., septicemia,
tetanus,
esophageal
atresia
etc)
Recognition of danger signals in the
newborn. Common respiratory problems,
their recognition and management. Feeding
of normal newborn with special reference
to the first feed in relation to hypoglycemia..
Drug therapy in newborn. At-risk concept
in pregnancy and newborn.
5.
Common Symptoms & Signs and their
Diagnosis
Fever, crying, failure to thrive, pallor,
edema, failure to move a limb, anorexia,
vomiting, diarrhoea, abdominal pain,
abdominal distension, bleeding per rectum,
constipation, acute abdomen in a child,
jaundice,
cough,
stridor,
wheezing,
breathlessness, cyanosis, headache, stupor
and coma, convulsions, failure to pass
urine, frequency and polyuria, passage of
coloured urine (haematuria etc), abnormal
urinary stream, joint swelling and pain,
bruises,
purpura
and
petechiae,
hepatomegaly
and
splenomegaly,
lymphadenopathy, stunted growth and
delayed development.
6.
Common Systemic Diseases in Children
Listed below with special reference to their
clinical recognition and management in
hospital, health centre and home, their
prevention where, possible and point
referral.
Diarrhoea and dehydration: recognition
and
management
including
oral
rehydration. Hepatitis, Indian childhood
cirrhosis and cirrhosis in children, hepatic
failure. Acute respiratory infections,
suppurative
pulmonary
disease
(bronchiectasis,
lung abscess), foreign
body inhalation, asthma and asthmatic
bronchitis. Meningitides, encephalitides,
encephalopathy,
epilepsy,
myelitis,
polyneuritis, poliomyelitis, intracranial space
occupying lesions (general features,
diagnosis, referral) hydrocephalus, chorea,
cerebral palsy, mental retardation, subdural
effusion. Rheumatic fever and heart
disease, recognition of acyanotic and
cyanotic
congenital
heart
disease,
pericarditis, myocarditis, hypertension,
congestive cardiac failure. Rheumatoid
arthritis. Anaemias (congenital and
acquired),
leukemias,
purpura
and
hemophilia Underscended tests, pituitary
disorders (gigantism, dwarfism, hypogo
nadism, diabetes insipidus), thyroid
disorders (cretinism, juvenile myxedema),
Diabetes mellitus, adrenals (adreno-genital
syndrome, adrenocortical insufficiency).
Common poisoning^ and accidents in
children. Common behavioural disorders in
children met with in practice such as breath
holding, pica, enuresis etc. Minor surgical
problems, surgical emergencies recognition
and timely referral.
7.
Common Specific Infections in Children
(Clinical recognition
management
and
CHILD HEALTH MANPOWER: 2000 A. D.
prevention) Measles, whooping cough,
diphtheria, mumps, poliomyelitis, rubella,
chickenpox, typhoid, dysentry (amoebic and
bacillary), tuberculosis, leprosy, tetanus,
malaria, infective hepatitis rabies, worm
infestations
(roundworm,
threadworm,
hookworm,tapeworm,
filariasis,
guinea
worm).
and recognition of gross deviations from
normal, estimations of gestational age and
distinguishing term from preterm babies.
Starting an I.V.line, umbilical vein
catheterisation.
Aseptic technique in newborn care.
II.
SKILLS
Practical and clinical procedures
1. The student should be able to take a good
but relevant history conduct a clinical
examination, demonstrate physical findings
and explain their significance. The student
should be able to make a provisional
diagnosis and indicate major differential
diagnosis, prescribe routine investigations
and carry out basic management.
2. The student should be able to do the
following:
Assessment of nutritional status of mother
and child.
Weight, height, head circumference and
mid-arm-circumference
measurement,
interpretation of growth curves.
Development assesment in children below
3 years.
Venepuncture.
Throat, nasal, rectal swab.
Intradermal test.
Immunising procedures.
Enema.
Side-lab investigations.
Interpretation of common X-rays.
Feeding techniques.
Oxygen therapy (catheter and mask).
3. The student should have observed the
following procedures in children: Vensec
tion; I.V. infusion; lumbar puncture;
paracentesis'
(abdominal/thoradc);
preparation of patient for radiological
procedures, bone-marrow aspiration;
biopsies, intubation, exchange transfusion;
postural therapy.
4. Regarding newborn:
Receiving the newborn, transportation
during referral.
Ressuscitation including suction, Ambu
bag and endotracheal intubation (learnt
from still births).
History taking and physical examination
1^9
Teaching Methods
It was appreciated that the methods of
teaching employed must take into account the
constraints of time, faculty-student ratio,
equipment and a large course content. Under
the circumstances it was agreed that even
though the lecture method was relatively
ineffective, yet in view of the constraints
enumerated, it could continue and therefore
efforts should be made to imporve the lecture
technique through improving competence of
teachers and techniques e.g., by providing
hand-outs, including references and factual
information, limiting the lecture to essence
and concept; demonstrating material and
patients, effective use of the blackboard,
judicious use of slides, help as to where
further information could be qbtained,
involving students by raising questions and
splitting the lecture.
With respect to clinical teaching it was felt
that the under-graduate was inade-quately
prepared in techniques of history writing and
clinical examination when he arrived for
posting in the pediatric department so that he
could not benefit adequately from the learning
experiences provided in the department To
strengthen / this aspect of teaching it was
agreed that the pediatric faculty should offer
its services to the institution outside the
teaching time alloted to pediatrics. In view of
large batches required to be taught at the
bedside, it was felt necessary to have adequate
physical facilities in a room adjacent to the
children’s wards for students and teachers to
sit around a patient for facilitating
demonstration and discussion. Clinical
teaching could be done through the symptom
complex approach by discussions of a number
of patients of the same symptom/sign in a
clinical session as well as by taking up
individual disease entities. Teaching in the
OPD was considered desirable provided that
teaching and services were separated so that
the teacher not conducting services on that
particular day could be made available for the
purpose.
CHILD HEALTH MANPOWER: 2000 A. D.
Group teaching was considered useful and
effective and could include socio-medical
conferences
and
demonstration
of
emergencies and teachniques. ‘Tutorial group’
could replace didactic teaching as far as
possible.
Since sensitizing students to socio-medical
care including problems of the handicapped
was considered desirable, visits to PHC and
institutions like schools for the handicapped,
creches, anganwadis etc supported by group
discussions was recommended as a learning
experience in collaboration with reapective
departments and agencies.
It has been generally agreed by various
expert groups (WHO etc) that a minimum of
300 hours is absolutely essential to do justice
to a curriculum in child health. However, time
available to the pediatric departments in most
institutes in the country does not exceed 200
hours. Until such time as the optimum hours
become available to the department of
pediatric the distribution is recommended as
under.
(A)
Lectures:
Hours
(1) By the department of pediatrics
(weekly lectures during the final year) 30
(2) Integrated teaching in structure, function,
pathology, immunology, etc with the
preclinical deptts (10 hours), de-partment
of community medicine (10 hours) &
obsteric & gynaecology (10 hours)
30
(B)
Clinical teaching : 12 weeks posting.
■ (4) weeks junior and 8 weeks senior)
approximately 5 working days per week,
effective teaching 3 hours per day
(60x3 = 180)
180
This includes 5 morning sesions (15 hours)
for socio-medical conferences on the
pattern of "Small group discussions".
(C)
Visits to community & field practice areas 3
hours per visit, total 3-5 visits
15
(D)
Evening tutorial group (clinical clerkship) 4-5
(2hrs. each)
10
The topic-wise time distribution at the
institution and departmental level can be worked
out depending upon local needs and convenience.
Curriculum organization (Please see under
Course Contents)
IV. Student Assessment & Course Evaluation
The group unanimously felt that the overall
assessment of the student must take into
account not only his performance in the final
examination but should also provide adequate
weightage to regularity, performance of
assigned work, clinical records and assessment
carried out at the end of the clinical posting
(alloting marks to each) to ensure as far as
possible that the final examination does not
become a mere obstacle course. Thus, as
much as possible of the students’ work and
performance should be brought up to the final
examination.
In the assessment of students’ knowledge at
the final year examination, a balanced
combination of objective (M.C.Q.) short
answer and essay-type questions should be set.
It was felt that setting of objective-type
questions required experience and hence the
need to improve competence of teachers. At
the Final clinical examination the group felt
that effort should be made at, as objective an
assessment, as possible. Evaluation should not
be heavily clinically oriented but be broad
based to include related nutritional,
developmental, preventive and socio-cultural
aspects in relation to patient management
problems.
Evaluation of each training session at the end
of the posting was considered necessary. This
could be done through analysis of periodic
feedback by the students and discussions
among members of the pediatric faculty. Such
an ongoing
excercise
could
ensure
improvement
of
subsequent
training
programmes.
130
ANNEXUREIII
RECOMMENDATIONS OF PEDIATRIC EDUCATION SUB-COMMITTEE OF INDIAN ACADEMY OF
PEDIATRICS (DELHI BRANCH) (1987)
Course Content of Pediatric Medical Education for Undergraduates
Training Programme
In order to achieve the objectives of training the
undergraduates as per expectations, one has to re
examine the course content of their teaching and
training programme which is grossly inadequate at
present.
Training programme of undergraduates can
be discussed under following headings:
II.
III.
IV.
V.
I.
3.
BIOCHEMISTRY
(i)
Biochemical examination of samples of
body fluids
Laboratory work in practical biochemistry
with normal variations in values in
children.
(ii)
Introduction to peculiarities of neonates,
infants and children in Pre Clinical (Phase
I) teaching programme.
Introduction to Pediatrics in Paraclinical
(Phase II) teaching programme.
Introduction and training in Pediatrics in
Clinical (Phase III) of undergraduate
training programme.
Pediatrics as a separate subject in Final
Year MBBS Examination.
Training in Internship Period.
I.
4.
INTRODUCTION TO COMMUNITY
PEDIATRICS :
In accordance with the recommendations
of Medical Council of India 3 months of
Preclinical training out of toal 18 months
(preferably during first 3 months) should be
spent in introduction to community Medicine.
Pediatrics with relevance to community should
be introduced during this period with special
attention to:
Introduction to Pediatrics in Pre Clinical
(Phase I)
1.
from newborn period to adulthood.
Nutrition and dietetics with special
reference to nutritional requirements and
nutritional disfordcrs in children.
(iii)
(i)
HUMAN ANATOMY:
The following subjects relevant
Pediatrics should be introduced:
(ii)
to
Human Embryology and reference to
various congenital malformations and
developmental defects.
(ii) Principles of human genetics and its
practical application with reference to
genetic disorders in children.
(iii) Introduction to growth and development
by a teacher from Pediatrics.
(i)
2.
HUMAN PHYSIOLOGY :
(i)
Changes in human physiology from birth
(ii)
to adult-hood
Variations of normal physiological values
(iii)
Introduction to Pediatrics in Para Clinical
(Phase II)
II.
1.
CLINICAL PHARMACOLOGY
(i)
Emphasis should be given to metabolism
of drugs in neonates, infants and children.
Dosage schedule for Pediatric Drug
Therapy in colloboration with teachers of
Pediatrics.
(ii)
131
Principles
of
sociology
including
demography, population dynamics, social
factors related to health and disease,
community behaviour and ecology.
Visit to hospital for familiarisation with
elementary nursing practices, immuni
sation clinics, Under five clinics, art of
communication with patients including
history taking and medico social work.
Visit to various projects related to child
health - ICDS, MCH services etc.
CHILD HEALTH MANPOWER: 2000 A. D.
(Hi)
Group discussion on actual cases where
therapeutic programmes are carried out in
the Ward.
2.
MICROBIOLOGY AND
PARASITOLOGY
(i)
Microbiology teaching should give more
stress on preventable common infectious
diseases in children.
Parasitology with special emphaisis on the
prevailing parasitic disease in India
including childhood malaria, giardiasis etc.
(ii)
3.
COMMUNITY MEDICINE
(i)
The course curriculum of Community
medicine should give due emphasis on
health promotion, health education and
maternal and child health.
Special emphasis on :
Immunisation programme including
immunisation techniques and maintainance of cold chain.
Nutrition and growth monitoring.
Organisation of Pediatric services.
Teachers from Pediatrics should introduce
community orientation
in
training
programmes in colloboration with teaching
staff
from
Community
Medicine
Department.
(ii)
(iii)
III.
(iii)
(iv)
(v)
(vi)
(vii)
(viii)
(ix)
(x)
Duration of Training:
1.
A Minimum period of 8 weeks training in
Pediatrics ought to be imparted to medical
students in 2nd Clinical year (IVth year).
The training should include:
(i)
History taking and examination
(ii)
Assessment of growth and development
(iii)
Diagnosis
and
management
of
malnutrition
<
(iv)
Identification of various nutritional
deficiencies
(v)
Management of diarrhea
(vi)
Student should get familiar with
emergency pediatrics and should be posted
in Pediatric casualty department by
rotation.
(vii)
Practical
procedures
should
be
demonstrated
(viii)
Each students to be alloted some beds in the
wards and their respective patients to be
followed by the students and the case
records to be submitted to the Department
at the end of the posting for further
evaluation of internal assessment.
Introduction and Training of Pediatrics in
Clinical Training Programme (Phase III)
Course Content:
The training programme should be geared in
such a way that every medical graduate is able to
manage the common pediatric problems especially
the common pediatric emergencies. Greater
emphasis should be laid on Growth monitoring,
breast feeding, ORT and Immunisation.
A
At least 25% of teaching schedule should be
directed to Neonatology. Following subjects should
be dealt with in detail:
(i)
(ii)
(breast, artifical and weaning)
Normal
nutritional
requirements and deficiencies
with special emphasis on PEM
GROWTH & DEVELOPMENT:
- Normal and variations in
growth and development
- Growth monitoring
DIARRHEAL DISEASE:
- With special reference to
management of diarrhea at
community
level
with
emphasis on ORT
IMMUNISATION:
- Schedule, Techniques
- Maintainance of Cold chain
ACUTE RESPIRATORY INFECTIONS
IN CHILDREN
INFECTIOUS DISEASES
PEDIATRIC EMERGENCIES
ACCIDENTS AND POISONING IN
CHILDREN
PEDIATRIC DRUG THERAPY
-
NEONATOLOGY:
- High risk infants
- Resuscitation of newborn
- Management of Premature
baby
- Normal newborn and its care
- Neonatal emergencies e.g.
birth anoxia, birth injuries,
hyperbilirubinemia, infections
etc.
NUTRITION: Infant
feeding
2.
(i)
(ii)
132
12 weeks training in 3rd clinical year (Final
year). The training should include :
A revision of knowledge acquired in 4th
year
Sufficient cases to be shown to cover all
CHILD HEALTH MANPOWER: 2000 A. D.
(iii)
important areas of Pediatrics.
Due stress should be laid so that the
students acquire practical skills in the fol
lowing procedures:
-
(iv)
Simple laboratory techniques, blood
examination, urine analysis, stool and
sputum examination.
- Injections:
- subcutaneous, intramuscular, intra
venous infusions and transfusions
- Venesection
- lumbar puncture, ascitic tap, pleural
tap etc.
- immunisation techniques
Case records - same as above (viii)
Examination
IV.
in Pediatrics
In order to implement the desired course
content, to effectively impart the knowledge to
undergraduates and to monitor the training scheme
it is very essential to have a sseperate examination
in pediatrics as a part of Final year MBBS
examination. Considering the importance of the
subject, it is not possible to assess the knowledge
and clinical acumen of students just from one
section of part-I of theory paper in General
Medicine as suggested bu MCI. Unless a student is
thoroughly examined in clinical cases and viva voice
the assessment is not really rational.
Therefore it is suggested that Pediatrics be
a seperate subject in Final year MBBS Part II
examination besides General Medicine, Surgery,
Obstetrics and Gynaecology. This is already a
practice in most of the developing countries
particulrly, African countries where the problems
are similar to India.
In many universities including Kashmir
University and Nagpur this long overdue
recommendation is already being implemented and
it is a pity that some of the leading universities like
University of Delhi is so impractical and backward
in its implementations.
Written - one paper
Oral
Clinical
Internal assessment
(theory)
Int. Assess. Clinical
.
.
.
.
80 marks
20 marks
75 marks
15 marks
.
10 marks
TOTAL
.
200 marks
Pass=
50% in the aggregate provided the
candidate obtains 50% in the
clinical examination.
V.Internship training Programme
The compulsory Rotatory Internship must
include training in Medicine, Surgery, Obst. &
Gynae. and Pediatrics on equal basis. The training
should consist of:
(i)
(ii)
(iii)
(iv)
(v)
(vi)
(vii)
(viii)
The distribution of marks should be as under:
133
Labour room and neonatology posting
seperately or from the training period in
Obst. and Gynaecology.
Exposure to Community Pediatrics and
actual case management of Pediatric
patients. This may be done during their
posting in Community Medicine.
Adequate training to handle the patients in
OPD
Recording of case history, examination
and investigations of hospitalised cases.
Exposure as, first on duty, to all
emergencies in Pediatrics under the
supervision of seniors.
Involvement in departmental activities like
case presentation, seminar etc.
Laboratory techniques, blood examination,
urine analysis, stool and sputum
examination.
Practical procedures like lumbar puncture,
ascitic tap, pleural tap, liver biopsy, bone
marrow aspiration etc.
DEVELOPMENT OF TASKS AND OBJECTIVES FOK
training. However there is no substitute for References :
UNDERGRADUATE TRAINING IN NEONATOLOGY
1. Abbat F.R: Teaching for Better Lea
the teacher himself setting a role model
ing,
Geneva:
World
Health
Organlsatli.
B.VISHNU BHAT
*
H P - SCbefore the students for triggering the affec
**
B.V.ADKOLI
1986.
tive domain.
•Associate Professor of Pediatrics “Assistant Professor of Educational Technology
Since mother and child constitute one in 2. Desai A.B : Teaching of Integra^
JIPMER, Pondicherry.
separable unit, it is essential to integrate Maternal and Child Helth and Family Vi.
the training with the help of three depart fare, Ind Paediatrics 28:435-441, 1981
3.
Guilbert
J.J
:
Education
Handbook^
ments viz.. Paediatrics, Obstetrics and
Gynaecology and Preventive and Social Health Personnel. Geneva:Who Offset Pt ABSTRACT
Medicine (Desai. 1980). For Example, at llcation No.35,1981.
The present day undergraduates' training programme in Neonatology is found to be
Medical Councilor India. ^ecomrnen^J-iadequate and fragmentary. The training lacks clear definition of objectives. The present
risk concept, can be imparted as follows: 4.
tlons
on
Undergraduate
Medical
E
du(_
tudylsana(-t:empt_t0formuiat.eaiist-0f-ras|<sexpectecj to be performed by the students
An Obstetrician can deal with at risk mother,
the Paediatrician with at risk baby and the tion, 1980
llongwith Educational Objectives so that the training programme in this vital field
Narayanan I,et al: Neonatology in ljecornes more effective and relevant to the needs of a basic doctor.
Specialist from the Preventive and Social 5.
Medicine with Health Education of Para Undergraduate Medical Education :|
National
Neonatology Forum Recomm^
medical workers in identifying high Risk
Mother and baby in the community. Simi dations on Educations and Training j.
larly topics such as ante-natal care, normal Neonatology, Proceedings of the find /introduction
only if we are able to ensure the survival of
labour. Purperium, complications of preg nual Convention^ 1-30, 1981.
babies without any defects.
6.
Narayanan
I,et
al
:
In-Service
ContisThere
is
an
increasing
stress
on
the
health
nancy can be tackled successfully under
Urifortuately. the training imparted to the
integrated teaching. (Narayanan, 1981). ing Education in Newborn Care. Ind P»f children while formulating the social and undergraduates in this vital area is far from
dlatrics, 17:677-82,1980.
jealth policies of any country. The ultimate being satisfactory (Narayanan, 1987). Pres
7.
Narayanan I & Bhakoo N: Neonatohihysical, socio-economical and intellectualently neonatology is an upcoming branch
Conclusion
The approach to the identification of in in the undergraduate Medical Educatlitatus of any society depends to a large of Pediatrics with no definitive guidelines
xtent on the quality of the care given to the for the undergraduate training. In most of
structional methods In the area of neo Ind Paediatrics, 24:81-85, 1987.
Philip E: Development of MCH Cunthildren during the early years of life. Inthe medical colleges, there is no proper
natology should be based on sound educa 8.
tional principles and practical considera him for the Undergrtaduates in Medieveloping contries 50% of the infant mor- coordination among the Obstetricians and
tions. The methods suggested in this paper colleges. Ind Paediatrics 28:429-433,19allty takes place during the neonatal pe- Pediatricians' as regards the training pro
lod. In India about 50% of the live boms gramme. Unless the curriculun is defined
are not only suited to realise the pre-deter
411 not see their second month of life {Govt. properly and implemented systematically,
mined objectives, but also feasible in terms
f India, 1987). The outcome among the the basic medical doctor will not be in a
of physical facilities and availability of train
urvivors will also be decided either at the position .to deliver the goods. With this in
ing manpower. Much depends upon the
jme of birth or within the first four weeks mind,a study was undertaken to formulate
degree of co-ordination among allied disci
p. during neonatal period. Moreover the curriculum in neonatology for the training
plines to impart holistic training programme
mctice of small family norm can be achieved of undergraduates.
in this vital area.
46
47.
Since the tasks were identified on tl
basis of actual functions to be performed)
a basic doctor,they tend to be realistic <
relevant to the actual needs. Care of tl
normal new bom. identification and t!
management of common problems are t
eluded in the curriculum. Inborn errors
metabolism, uncommon genetic disorde
have not been included keeping in view tj
requirements of a basic doctor.
The objectives formulated in this study a
observable and to large extent measurab!
This will enable the adoption of prop
training experience and also measureme
An attempt was made to identify the func of the learning outcome objectively at
tions to be performed by a basic doctor for reliably. In case of attitudinal objective
the care of the newborn (Narayanan, 1981; accurate measurement may not be feasih
Govt, of India, 1982; W.H.0,1977). Based However, their inclusion the training pt
on these a number of 'Tasks' were identi gramme is felt indispensable. For instan.
fied (Guilbert, 1981). The precision and the appreciation of the need to recogn!
relevance of the tasks were ensured by hold the newborn as an Individual and eviti
ing discussion with colleagues, students care while performing procedure on t;
besides taking into consideration the delib baby are of vital importance in the traln|
erations of the National Neonatology Forum programme.
and the personal experience of the authors The consideration of' feasibility' is ani
sential factor In the formulation of ®
over the years.
The present part of the work relates to the objective in the training programme. In tl
identification of Tasks and formulation of present study a successful attempt li
been made to see that the tasks Identlff
Specific Instructional Objectives.
and the objectives formulated are atta"
able within the constraints of availai
DISCUSSION
A list of tasks and corresponding state physical resources, training manpower
ment of Instructional Objectives has been the time. The normal Infrastructure cl
given in Table-1. The highlights of the same sisting of the faculty members, resld®
are as follows:
and nursing staff is adequate to attain f
METHODOLOGY
The systematic approach to the develop
ment of curriculum involves the following
steps. (Abbat,1986)
1.
The study of curriculun deteminants
2.
The analysis of Tasks
3.
Formulation of Educational Objec
tives
4.
Provision of Teaching-Learning ex
perience including course content, meth
ods and Media and time schedule.
5.
Plaining of Evaluation, both during
the training and at the end of the training.
48
TABLE: 1
Table showing the list of Tasks and Educational objectives
KNOWLEDGE OBJECTIVES
SKILL OBJECTIVES
ATTITUDINALOBJECTIVES
The learner shall be able to
The learner shall be able to
Task 1 : To manage a normal new bom
The learner shall be able to:
1. Enumerate the normal anthropometric 1. Clean the eyes, umblicus, and
measurements.
skin of the new bom
2. Enlist the physiological variations
1. Convince the mother the
need for breast feeding
2. Prevent hypothermia by
covering the baby
2. Appreciate that mother and
child constitute one unit.
3.Demonstrate breast feeding
3. Appreciate that the new born is an
individual with a right to love,
affection and protection against
painful stimuli and infection.
1. Resusciatate an asphyxiated
baby using bag and mask
1. Appreciate the need for the
immediate resuscitation of the new
bom
Task 2 : Resusciatate an asphyxiated baby
1. Define asphyxia and identify its
causes
2. List the equipments needed for
resuscitation
2. Evince care in giving the
prognosis of an asphyxiated
baby to the parents
3. Apply apgar scoring for the assessment
of asphyxia
4. Enumerate the steps involved in the
resusciatation and management of any a
sphyxiated baby
Task 3 : Assessment of Gestational Age
1. Enumerate morphological and
neurological criteria for assessing the
gestational age
1. Assess the gestational
age by using the criteriae
49
Task 4 : To diagnose common congenital -Malformations
1. Enumerate the common congenital
malformations
Task 8 : Management of neonatal jaundice
1. Identify congenital malformations 1. Give proper counselling to the
including passing of rectal catheter parents in cases of the
congenital malformations
and gastric suction
2. Refer the cases requiring surgery
appropriately
Task 5 : Management of low birth Weight Baby
1. Define low birth weight
1. Differentiate between term and
pre-term low birth weight
1. Appreciate the need for
special care in the management
2. List the differences between term
and pre-term low birth weight
2. Able to manage a low birth
weight baby
2. Explain the prognosis of a
low birth weight to the parents
3. List the risk factors in a low birth
weight baby
2. Define physiological jaundice
3. Enumerate the causes of physiological
jaundice and haemolytic disease of the
new bom
4. List the clinical features in case of kemictcrus
Task 9: Management of Neonatal Convulsions
1. List the common causes of neonatal
convulsion
1. Conduct appropriate investigation
and treat a case of neonatal convulsion
1. Convincing the parents
the need for long term
treatment in persisting
convulsion
Task 10: Management of Anaemia
Task 6 : Management of common birth injuries
1. Diagnosis birth injury and
manage effectively
1. Take preventive care to
avoid birth injury
2. Enumerate the steps involved in the
management of common birth injuries
1. List the common causes of anaemia
1. Perform investigation and manage
a case of anaemia
1. Impress the paramedic
in the proper tying of the
cord and avoiding injury to
the baby
2. List the steps involved in the
investigation & management
Task 7 : Management of neonatal infections
1. Enlist common neonatal infections
1. Manage neonatal jaundice after 1. Educate the parents regarding the
appropriate investigations
need for antenatal blood grouping
and prevention of Rh disease of the
new bom
2. Enumerate the steps in the management
4. Enumerate the steps involved in the
management of low birth weight baby.
1. Enlist common birth injuries and
their causes
1. Enlist the causes of neonatal jaundice
Task 11: Management of respiratory distress
1. conduct appropriate
investigation and manage a
given case
1. Evince care for preventing
neonatal infection
1. Enumerate the common causes
1. conduct appropriate investigation
/management of respiratory distress
2. Enumerate the predisposing factors
3. List the clinical presentations
1. Appreciate the need for
prevention of premature
delivery to avoid hyaline
membrane disease
2. List the steps involved in investigation
and management of respiratory distress
COMMUNITY HEALTH CELL
50
326. V Main, I Block
51
Koiambnga'3__
Bangs'o'®'560034
India
Task 12: Management of bleeding in the New bom
1. List the common causes of bleeding
1. conduct appropriate investigation 1. Makes habit to avoid injury
and management of bleeding in
during delivery and
new bom.
collection of blood samples
2. List the steps involved in the diagnosis
and management of bleeding in newborn
Task 13 : Management of a high risk baby
h. Enumerate the high risk factors
1. Diagnosis of high risk neonate 1. Appreciate the need for
and conduct appropriate
identifying a high risk baby in
management
preventing neonatal mortality
and morbidity.
2. Refer to the appropriate level of
health care
General
1. Collect approprite blood samples
for investigations
2. Perform Lumbar puncture
3. Start an intravenous drip
1. Assume leadership to
paramedical staff in
neonatal care
2. Educate the public and
the paramedics in neonatal
care
3. Assume responsibilities
for continuing education in
the care of the new bom
objectives set in the curriculum. The actual
implementation of these objectives over the
last two years is found to be highly satisfac
tory.
In conclusion, an attempt has been made
to formulate Tasks and Objectives, which
are realistic and highly useful in imparting
training to the undergraduates in Neonatol
ogy which has been gaining significant at
tention recently. The tasks and the objec
tives identified are requirements. However,
it is hoped that the model suggested in the
paper will stimulate other workers to initi
ate similar efforts, so that the curriculum in
this vital field becomes more systematic
and meaningful.
tions, South East Asia Series No.
W.H.O., 1977
6.
3. Guilbert J.J : Educational Handbook
for Health Personnel. Geneva: W.H.O offset
Publication, No.35,1981.
4. Health Service Information. General
Bureau of Health Intelligence, DGHS,
Ministry of Health and family Welfare.
Government of India. 1987.
5. Minimum training schedule for the
Undergraduates:Report of the task-force
on Minimum Perinatal Care, Govt, of India.
Ministry of Health and Family Wel
fare's, 1982.
6. Narayanan I et al: Neonatology in the
Undergraduate Medical Education: In Na
tional Neonatology forum. Recommenda
REFERENCES:
tions on Education and Training in Neona
1. Abbat F.R : Teaching for better Learntology. Proceedings of the II, Annual Con;
ing, Geneva: World Health Organisation, vention: 21-30,1981.
1986
7. Narayanan I, Bhakoo, N : Neonatology
2. Guidelines on the Teaching and Praticein the Undergraduate Medical Education,
of Neonatology. W.H.O regional publica Ind Peadiatrics, 24:81-85.1987.
4. Insert umblical canulatio
5. Use warmer, phototherapy unit,
oxygen-tent etc
52
53
TABLE—IV
IMPORTANCE
Medical Edition for Child Health
By
David P. Haxton
LAY
P U B L IC
-J
Regional Direcor, UNICEF South Central Asia New Delhi
Education and health—of, by and for the
people—are prime movers of social progress.
It is only natural that these should focus
primarily on children who—after all—have the
highest potential for development. This briefly
is the perspective in which UNICEF sees the
televance of advancement of medical education
and the theme of Child Health Care chosen for
this Session. We are naturally delighted to
participate in this influential discussion. And
we look forward to its accelerating impact on
current efforts to formulate a national medical
and health education policy, in pursuance of
the National Health Policy announced two
years ago.
From the beginnings of UNICEF coopera
tion in India in the late forties, our involve
ment in the field of health has been more
intimate than in any other sector. And our
collaboration with the medical profession has
been closer than with any other professional
group. This continuing relationship encourages
us to present a few observations on the health
system in general and on medical education in
particular—in the context of child health and
development,
I will first touch on what I perceive to be
certain broad characteristics, positive or
negative, of the present situation ; proceed to
add my own support to proposed and needed
changes in policy, and finally suggest some
possibilities for action which may be taken
right away by the medical profession to trans
form child ill-health into child health, without
waiting for structural changes.
UNICEF views the present phase as one of
transition of a public health system developed
in a particular historical context into another,
more suited to a democratic society. The
trend is evident and unmistakable but the
time it it taking to come into its own is
unacceptable in the social sense. The task of
all of us is to strengthen the trend and compress
the time.
The UMCEF concern with child health
and development is predicated upon tha effec
tive emergence of whit the Bhore Committee
of 40 years ago termed the 'social physician’.
We understand this ideal as an alloy of pro
fessional competence, social concern and
leadership quality on the part of a medical
doctor who would assume the responsibility for
the health of a defined population group,
insofar as the people cannot ensure it on their
own. The essential function ’of a doctor is
suggested by its original meaning of‘teacher’.
We note with concern that this vision is, by
and large, yet to be realised. How to move
towards it is, in our view, the crux of medical
and health education.
Fortunately there is little that can be added
to the wealth of insights contained in a series
COMMUNITY HEALTH CELL
102 The Indian Journal of Medical Education
of reports by leaders from the medical pro
fession itself: such as the committees linked to
eminent names like Mudaliar (1962), Mukerjee
(1955), Jungalwalla (1967), Kartar Singh
(1975), Shrivastav (1976). and Ramalingaswami (1981). The sum of these reports points
to the need to establish a harmonious and
dynamic balance between clinical and com
munity medicine, medical doctors and para
medical workers, health services and medical
colleges, common ailments and esoteric
concerns, theoretical knowledge and practical
priorities. Given the pre-existing bias, this
implies major correctives in directions in which
considerable preparatory action has already
been taken. Decisive steps will have to follow.
For example we should be greatly encour
aged by the fact that the health infrastructure
has been developed to a potential which could
permit preventive and social medicine to be
practised successfully and countrywide. .The
nearly 6 000 primary health centres, more than
70.000 sub-centres some 250,000 community
health volunteers are in position. This means
that on the average 100,000 population will
have a primary health centre, over a dozen
. sub-ccntres, • around 50 medical and para
medical employees and a hundred or more
community health volunteers. This is apart
from other m tjor health-related facilities like
the integrated Child Development Services
(ICDS) which would cover in about a year’s
time a fifth of the development blocks in the
country. And there is the vast strength of
tens of thousands of private medical practi
tioners. If access to health for all is not
achieved in appointed time the reason will not
certainly be any lack of infrastructure. Rather
it will be related to the orientation and capabi
lity of the health professionals and supporting
Volume XXIII No. 2
cadres—the health workers. Their education,
orientation, and motivation are therefore the
key to change.
The imperative for change is underlined
both by the functional weaknesses of the
existing health system despite its impressive
spread, and the social challenge posed to it by
the goals set for the current century. The life
expectancy is 52 years agtinst a target of 64,
crude mortality 14 against 9 and infant morta
lity 125 against 60. Against this background,
the importance of reducing child mortality
becomes crucial, in a country where children
comprise over two-fifths the total population:
For, 45 percent of deaths occur below the age
of 5 years, more than half in infancy. And the
first month of life accounts for half of infant
deaths due to low birth-weight, neonatal
asphyxia, tetanus of the new born and other
intra-partal problems. In the first year of life
diarrhoea and pneumonia claim the bulk of
deaths, aided, of course, by malnutrition. And
immunizable diseases, prominently including
measles, continue to claim a large number of
lives in spite of availability of effective vaccines
It is the considered view of UNICEF that this
dismal picture, related largely to rural com
munities, can be changed and that the national
health targets including an infant mortality
rate of 60 are attainable within the time,
resources and technologies presently available
in India. The point at which people, resources
and technologies can be efficiently marshalled
to a common purpose is in medical education
—in the initial training and orientation of all
health workers and in in-service upgrading of
knowledge and skills,
It is hardly necessary for me to go into the
means and methods of strengthening this
dimension of medical education—beyond ,
May-August 19S4
conveying
our
brol® support
to certain
1
proposals alreadly widely discussed.
!
For instance, most of the present training
of graduate doctors is examination-oriented,
Medical Education for Chiid Health ...
103
deeply involved in community work tend to
suffer in the present system. Unless this is
changed through appropriate curriculum
design, training methods, evaluation techniques
and continuing medical education, it is unlikely
that Indian doctors can assume the leadership
role to their own country’s advance towards
better health through primary and preventive
care.
didactic, clinical and curative in emphasis.
Students become at best clinical curative
doctors with little knowledge of, or interest in
community interaction or in leading a health
I
team with a measure of managerial compe
tence. Even where social aspects of a disease
A useful criterion to identify a "social
are recognized, there is only marginal involve
physician” would be the time he or she spends
ment by the health services or medical colleges
in curative services. It has been suggested
in coming to grips with them — barring an
that medical officers in the health service should
exception or two which only prove the rule.
be encouraged to spend less than a quarter of
Even where medical colleges have tried to
their time in curative services, making greater
reorient medical education in the direction of efforts to delegate these tasks and allowing
community health, often they have only moved themselves more time to administer the health
clinical curative services into the community
system under their control. This presumes
rather than accepting the responsibility for the
that medical personnel will willingly take up
health of the population. Such a responsi
a career of providing healih care in rural areas.
bility should be understood not so much in
The presumption would be valid only if under
terms of providing health service as in working
graduate training and orientation is radically
together with the community for its health.
reshaped towards that end. Even pos'graduate
This concept implies that the experience of
training in preventive and social medicine
living and working with the community and
could be geared much more than now, to the
para-medical personnel—who should be consi
practical needs of the public health system,
dered colleagues—should become a substantial
based on an epidemiologic understanding of
part of undergraduate training. And the
diseases.
examination process leading to the medical
degree should be concerned equally with
Childhood diseases in India are well-knownclinical and community tasks. This concept
thcir prevalence, locations, causes and con
should be extended internship.
sequences. Certain priorities are dictated by
/The view is widely shared that the present them in the context of the present, and pros
pects in the nation’s future. These priorities
examination system is the major single obstacle
cannot wait until reorientation of medical
in the way or comprehensive health care at
education is achieved. The answers made
the village level. As of now, community
available by medical science and development
experience, clinical competence and supervisory experience have to be applied here and now
capabilities are of little help in passing exami before further irreversible damage is done to
nations It is even arguable that students the country’s human resource.
104
Th« Indian Journal of Medical Education
For example, every 10 seconds, somewhere
in India a child is struggling for life against
diarrhoeal dehydration. The answer is known,
uptodate, scientific, safe, inexpensive, practical
and effective for 95 percent of the cases of
diarrhoea. But unless it is used, on the initia
tive that rests with the medical profession, it
will rematn a mere potential, A national
programme of diarrhoea management exempli
fies the opportunity for practising some of the
principles we have discussed earlier in the
context of reshaping medical education. Thus,
—Mothers give the home made oral rehy
dration solution to prevent dehydration.
—Health workers use ORS packets to
correct mild to moderate dehydration,
and
—Health centres and hospitals provide
intravenous therapy to treat severe
dehydration.
A complementing design such as this for
team work in community health is what
primary health care is about. Even as medical
students are ‘educated’ on it, medical practi
tioners tn and outside government can set a
trend—to the immediate and lasting benefit of
children among the poorer segments of
society.
The same principles applies to equally
simple, but socially vital, primary health
intervention like measuring weight and height
for age, without which neither mother nor
health worker nor peadiatrician may notice
growth faltering in time to arrest and reverse
it relatively easily. Thus it becomes a func
tion of the community health system, under
the leadership of the medical doctor, to make
weight and height (or length) measurement
possible fur children from poor communities,
Volume XXIII No. 2
We all know that the best protection against
six of the most dangerous diseases of childhood
is complete immunization during the first year
of life. There is no technological or financial
reason for India not to achieve universal im
munization within the next few years, despite
the relatively low coverage at present. Priorities
in medical education have, once again, to be
established through social priorities in medical
practice. In our co-operation in this in India
we are often brought to a standstill by evident
lacunae in knowledge of principles of immuni
zation. It is still beset with taboos, supersti
tions, out-dated practices with regard to con
traindications, vaccine control, schedules and
recording and reporting systems.
There is no longer any argument about the
mother’s milk being the best food for the
infant. But promotion of natural feeding, in
the face of the commercial competition of
artificial substitutes, will not be possible unless
scientific knowledge is communicated to the
community through the influential channel of
the medical profession. As curriculae are
slowly being reshaped on this and similar
priorities in health and nutrition, the example
set by the practising professional is crucial.
Preventive and promotive health care
remains, for a cluster of reasons, the Cinderella
of medical education and practice which is
unfortunate because it is more relevant to the
health of children than to other age groups.
With the rapid growth of brain and body
which occurs in the early years of life, and
with each stage of mental and phjsical deve
lopment having its own time and place in
that process, children (specially those from
impoverished families) canned afford to fall ill
and be treated only to fall ill again. Our
common task is to hasten the process of gear
ing medical education to their support.
Role of Medical Students in Strengthening
Family Planning Services in India.
By
O. P. Bhatnagar
Prof & Head, Department of Physiology.
Muulana Azad Medical Collige, New Delhi.
ABSTRACT
A unique feature of annual conference of lAAMEis the organisation of a student’s
seminar which gives opportunity to the future doctors to express their views on current
topics in medical education. The topic for discussion at the XXIII annual conference of
IAAME was 1‘RoIe of Medical Students in strengthening the family planning services in
India". Since this topic was of national and international importance, it generated lot of
enthusiasm and interest amongst the participants and august members of the audience
present. In this report, an attempt is being made by the moderator to highlight the
important aspects of the presentation.' The participants included Karthik Chandra and
Gauri Kapoor from Lady Hardjnge Medical College, Aditya Parkash and Amit
Bhargava from Maulana Azad Medical College and Saodip Majumdar and Suomyo
Gorai. from as distant an institution as JIPMER Pondicherry.
The participants emphasised that popula
tion growth was a major barrier to social well
being and' economic growth. Even at the
global level—more sp/tn the under-developed
and in the developing countries, the problem
of population explosion occupies the highest
priority. TheZrovernment of India launched
the National/Family Planning Programme, in
1953. Initially it was implemented on a
limited scale, but later it was placed at the
very ceritre of plan development.
family planning as those practices which help
individual or couples to attain certain objec
tives, which are :—
Family planning is an integrated amalgam
of MCH, family planning and family welfare..
An expert committee of the WHO defined.
—to adopt small family norm, by deter
mining the number of children in the
family.
—to avoid unwanted births,
— to bring about wanted births,
—to regulate intervals between pregnancies,
—to control the time at which birth occurs
in relation to ages of the parents, and
■
MEDICAL EDUCATION FOR CHILD HEALTH
By: David P. Haxton
Ragional Director
UNICEF South Central Asia
Neu Delhi.
Source: I.3.M.E. Vol.23 No.2 Bay-Aug.1984
For instance, most of the present training of graduate
doctors is examination-oriented, didactic, clinical and curative
in emphasis. Students become at best . clinical curative
ductors with little knowledge of, or interest in community
interaction or in leading a health team with a measure of managerial
competence. Even uhere social aspects of a disease are recognized,
there is only margial involvement by the health service or
medical colleges in coming to grips with them-barring an
exception or two which only prove the rule. Even uhere medical
colleges have tried to reorient medical education in the direction
of community health, often they have only moved clinical curative
services into the community rather than ac epting the responsi
bility for the ■
’ health of the population. Such a responsi
bility should be understood not so much in together with a the
community for its health. This concept implied that the experience
of living and working with the community and para-medical
personnel-who should be considered colleagues-should become a
substantial part of undergraduate training. And the examination
process leading to the medical degree should be concerned
equally with clinical and community tasks. This concept
should be extended internship.
The view is widely shared that the present examination
system is the major single obstacle in theway of comprehensive
health care at the village si level. As of now, community
experience, clinical competence and supervisory capabilities are
of little help in passing examinations. It is even arguable
that students deeply involved in community work tend to suffer
in the present system. Unless this is changed through appropriate
curriculum design, training methods, evaluation techniques
and continuing medical education, it is unlikely that Indian
doctors can assume the leadership role to their own country s
advance towards better health through primary and praventive care.
A useful criterion to identify a ’social Physician” would be
the time he or she spends in curative services. It has been
suggested that medical officers in tha health service should
be encouraged to spend less than a quarter of their time in
curativa services, making greater efforts to delegate these
tasks andallowing themselves more time to administer the health
system under theircontrol. This presumes that medical
personnel will willingly take up a career of providing health
care in rural areas. The presumption would be valid only if
undergraduate training and orientation is radically reshaped totowsrds that end. Even ;
‘
.
. .
.
. .
postgraduate
training in preventive
and social medicine could be gearad much more than now, to the
practical needs of the public health system, based on an epide
miologic understanding of diseases.
MEDICAL EDUCATION FOR CHILD HEALTH
By: David P. Haxton
Regional Director
UNICEF South Central Asia
Neu Delhi.
Source: I.J.M.E. Vol.23 No.2 Ray-Aug.1984
For instance, most of therprasent training of graduate
doctors is examination-oriented, didactic, clinical and curative
in emphasis. Students become at best ' clinical curative
doctors with little knowledge of, or interest in community
interaction or in leading a health team with a measure of managerial
competence. Even where social aspects of a disease are recognized,
there is only margial involvement by the health service or
medical colleges in coming to grips with them-barring an
exception or two which only prove the rule. Even where medical
colleges have tried to reorient medical education in the direction
of community health, often they have only moved clinical curative
services into the community rather than ac epting the responsi
bility for the
i health of the population. Such a responsi
bility should be understood not so much in together with ■ the
community for its health. This concept implied that the experience
of living and working with the community and para-medical
personnel-who should be considered colleagues-should become a
substantial part of undergraduate training. And the examination
process leading to the medical degree should be concerned
equally with clinical and community tasks. This concept
should be extended internship.
The view is widely shared that the present examination
system is the major single obstacle in theway of comprehensive
health care at the village
level. As of now, community
experience, clinical competence and supervisory capabilities are
of little help in passing examinations. It is even arguable
that students deeply involved in community work tend to suffer
in the present system. Unless this is changed through appropriate
curriculum design, training methods, evaluation techniques
and continuing medical education, it is unlikely that Indian
doctors can assume the leadership role to their own country's
advance towards better health through primary and preventive care.
A useful criterion to identify a 'social Physician" would be
the time he or she spends in curativa services. It has been
suggested that medical officers in the health service should
be encouraged to spend less than a quarter of their time in
curative services, making greater efforts to delegate these
tasks andallowing themselves more time to administer the health
system under theircontrol. This presumes that medical
personnel will willingly take up a career of providing health
care in rural areas. The presumption would be valid only if
undergraduate training and orientation is radically reshaped totowards that end. Even ^stgrSduat.
training in preventive
and social medicine could ba geared much more than now, to the
practical needs of the public health system, based on an epide
miologic understanding of diseases.
- wm/
Medical Education and Pediatrics in India
BY
Dr G. Coelho
Cambridge Court, Pedder Road, Bombay 26
In the last ten years the Indian Associa
tion for the Advancement of Medical
Education has made its own contribution
to pediatric education. At its Annual
Conferences on under-graduate education,
post-graduate education, and Medicine and
Society, papers were discussed on pediatric
education in its bearing on the main theme
of the Conference. The Conferences re
commended a minimum period of three
months in pediatrics for under-graduates;
post-graduate training and examinations in
Pediatrics as a speciality; and provision of
greater knowledge of pediatrics, to the
general practitioner.
The three-month period of under
graduate training, post-graduate teaching
and diplomas and degrees in pediatrics
have been accepted by the Medical Council
of India and introduced by the Universities
in India. Courses for general practitioners
are organised by various medical associa
tions.
Teaching Institutions have introduced
separate Pediatric Departments and, barring
a few, they have a Pediatrician as a Pro
fessor and as Head of the Department.
Greater attention is being paid to post
graduate teaching and some institutions
accept post-graduates only on the basis of
full-time students.
The Universities confer the Doctorate
degree and diploma in Child Health.
Those who hold the doctorate take up a
teaching appointment and/or enter con
sulting practice. The diploma holder enters
a service or into general practice. Yet, few
of those in service are so posted that they
can use their special knowledge. The
school health service does not always
employ a DCH, if one is available. Simi
larly, there is only a low rate of employment
of such pediatric trained personnel in the
Primary Health Service, public hospitals
and dispensaries.
For some years it will not be possible to
provide diploma holders to fill vacancies in
the public services. We should improve
the training of the under-graduate in this
subject. I intend to touch upon a few
aspects of under-graduate and post-graduate
training in pediatrics in India.
In advanced countries women and
children have come into their own. In
India though much is made of them in
political talk, they are subjected to hardships
in daily life. Women bear large families
in great poverty, children grow-up under
deprivation. If children, as a group, need
more attention than the grown-up, then
those, in India particularly, need this
attention.
They are poor, numerous,
underfed, exposed to unhygienic life, die
early, their growth and development is
interrupted through frequent illnesses.
Quite a few do not reach adolescence, a
good number of those who do so are not
even at the average grade. Though child
ren form only two-fifths of the population,
yet because of the greater risks they run,
they need a bigger slice of our concern.
If the aim of medical education is pri
marily to enable the recipient to serve the
health of the community in India every
medical student should have a greater
familiarity with the life and health of our
children. In the curriculum now in vogue
this is not so. Correction of this anomaly
is, I submit, a first call on our medical
education.
It is true there has been a slow reali
sation of this need but the progress in the
content is not in keeping with the tempo of
other advances. We have been and we
are still being trained in a foreign tradition.
Those of us who are in the universities or
- dv
421
For doctorates we insist on resident
is also a lack of knowledge of the nonurban population and in India there is a training. The idea behind is that the
wide disparity between life in the village student should be able to see patients in all
situations,
emergency, acute, convalescence
and the big industrial town, particularly in
customs and food. An Indian student and chronic, learn to make independent
should know of the life lived by the people decisions and be responsible for the manage
who do not normally patronise his hospital. ment of patients. Having seen the material
While reforming our people is a highly he needs time to think over it, study and
laudable objective, and children are the discuss about it. How does our- average
best material to begin this process, because resident fulfil these ideals? The pediatric
of the very backward and religious attitude department is generally the most crowded
of our people, one has often to curb one’s one. As there are few units, sometimes
enthusiasm and go slow. Parents are even only one, the emergencies have to be
hesitant to try anything new on their child. attended to by the same person daily, if
Even if a reform in diet or clothes is initiated not on alternate days. The laboratory and
in the hospital unless it is maintained it minor procedures consume a lot of his time.
comes to nothing. For this we need the If the resident completes the routine con
co-operation of the parents. When pumping sciously, there is very little time left, even to
modern knowledge and standards into the sleep. Study, thinking and discussions all go
student he should also be made conversant by the board. Now would it not be better
with the foods, customs and beliefs of our if, in place of this one single resident in a
people and the patterns of their resistance to unit, we have six or eight post-graduates
among whom the in-patient, out-patient,
change.
laboratory, follow-up, special clinics and
Pediatrics is considered a minor speciality
and, therefore, there is no university exa emergencies are distributed in rotation?
mination. However, whenever a woman They will be able to gather all the first-hand
delivers, she delivers a baby and, in our knowledge of the present residents and
country one woman may deliver anywhere learn more as they would have wider
from five to ten babies. If the process of opportunities, more time to study, think
pregnancy and the act of parturition with its and discuss. Why should it be essential
hazards need so much attention from the for them to reside all the 24 hours on the
medical student as to form a major subject premises if they can maintain their
of Obstetrics, should not the care of these attendance for the full period of their
multiple children with many years of life— duties while they stay, perhaps more com
Pediatrics—, be equally an important and fortably, in their own homes? This in
major subject and therefore a subject for sistence on a residency is the blind transfer
a university examination? I am not en of an idea worked in the affluent Western
amoured of university examinations. I, institutions offering high stipends and
for one, would like this, single, qualifying comfortable quarters to many residents.
examination, to be quickly replaced by a There is a big demand for registration as
day-to-day assessment. But so long as it post-graduates and this residency clause
exists, the student considers the demands greatly reduces the number of seats. The
on his attention by any subject on the basis quality and quantum of the performance of
whether it is a subject of an university post-graduates depends greatly on the in
examination or not. The absence of a uni terest taken by their teacher in the de
versity examination should not make any partment and in the students. Unfor
difference to the performance of the teachers; tunately this is our weak link. I submit
even when it does not at the teacher’s,—the that by substituting our residents by non
giving-end, it does at the student’s,—the resident full-time post-graduates we will be
receiving-end. The result is annoyance able to enlarge our activities and give a
and frustration. Till the position is as better and more practical training to our
at present, the pediatricians could organise teachers to be and simultaneously accept
periodic tests but as they do not carry more candidates at a time.
The same defects, namely, accent on
any sanctions behind them they will soon
diagnosis and management of disease, a
become unreal.
£
MEDICAL EDUCATION AND PEDIATRICS IN INDIA
•3
420 INDIAN JOURNAL OF MEDICAL EDUCATIONI
VOL. IX, JUNE-JULY 1970
councils through which these changes can three months in this department to equip
be effected are yet absorbed in older them better for their general practice.
traditions, and to us child health does not Again till more time is allotted to the
seem important enough to need special under-graduate I submit we should not
consideration. The pleas of pediatricians divide them into terms and during these
are turned down or passed over as being three months they should have the full
partisan. When a foreign adviser comes morning and the afternoon free to be spent
and talks of pediatrics, of social pedia in the pediatric department only.
trics, of peripheral centres, then there is a
There is a second point. Today our
bustle, more to come in line with a foreign
pattern, than because it is the need of clinical teaching is limited to demonstrating
the country. If that was realised by us we the case material in the wards. I admit a
would not need foreign advisers to act as knowledge of management of disease con
ditions is essential for every practising
catalyst.
In the thirty-six months of undergraduate doctor but there is more in pediatrics than
clinical training only three months are just curing a disease, and that is main
allotted to pediatrics. This is often split taining the child in normal health. For
up into two terms of six weeks each. This this, a student should know a normal child,
breaks up the continuity of teaching. In his growth, development, nutritional and
some institutions a junior batch is attached emotional needs. This picture is seldom
to a senior batch. If the number of teachers presented to the student and, even if
in the department are few it becomes presented, it is only in a very sketchy
difficult to allot separate sessions for these manner. We need a few orientation. Our
batches. Teaching them together in a pediatric department should be planned to
single class is, I think, highly unsuitable. provide more time and facilities for this
You cannot draw up a three-month pro approach. Its main emphasis should be on
gramme ; it has to be a six weeks’ programme. this service of looking after a child in such
The terms are separated by long intervals in a way that he grows into a healthy and happy
which the student has to appear for a child, well-protected against disease and
university examination. Therefore, it is accident and with minimal chances of an
easy for the senior batch to forget the illness. A service of immunisation, assess
elements they were taught in the first six ment of physical and mental fitness and
weeks; in reality, they are now as new as the aptitudes, advice and aid to the handi
capped and retarded child should be in
junior batch.
cluded in this. For this approach all our
Another disquieting feature is the sche institutions and teachers are not yet
dule of lectures, demonstrations and practi equipped. While we can use a certain amount
cal which barely leave a couple of hours in of international data we have to collect the
the morning for clinical work. It seems the .. material and facts of our children, scrutinise
student comes into the department only to it and then absorb it in our teaching. This
move out again.
will take some years.
The interns attend the pediatric de
Another aspect of our teaching is that
partment for one month and are expected to the student is exposed to mainly one stratum
share in the routine working of the ward. of society in our teaching hospitals.
If they were assigned responsible duties, Seventy per cent of the patients in these
even this one month could be turned into institutions come from the very poor.
account but unfortunately, quite often, they Outside among the clientale of the general
are wasted in assisting in research pro practitioner the position is reversed. The
grammes. Since many of them will enter new doctor faces a different parent-child
general practice and some may take up relationship in his practice. The parents
pediatrics as a speciality, could not the of his patients are concerned even with small
intern be given the freedom to spend a ailments to which he paid no attention as a
longer period in the subject, if he so chooses. student, as they were considered ‘un
Except those that want to take another important’, and demand more from him
speciality all interns should spend atleast than the parents in the hospital did. There
422
INDIAN JOURNAL OF MEDICAL EDUCATION
VOL. IX, JUNE-JULY 1970
bare mention, of positive health, little
contact with other strata of our society
are continued in our post-graduate training
because they are now trained in the same
institutions. The new orientation of greater
emphasis on positive health and contact with
a wider spectrum of our society should be
presented to our post-graduates imme
diately along with early changes in the
structure of our departments.
The Indian Association for the Advance
ment of Medical Education has a part to
play but the initiative must be taken by the
pediatricians themselves and it is they who
should pursue their drive through their
Academy and Conference.
The Child’s Year and Medical Training
By
H. Dhillon
Director.
B. Cowan
Professor ofMedicine & Joint Director.
H.N.S. Grewal
joint Director.
Community Health Department. Christian Medical College, Ludhiana.
ABSTRACT
The International Year of the Child and tha genera! theme chosen by the country
“reachingthe deprived child” raises the question, “how many are deprived, where are
they and how can deprivation be prevented” ? They will certainly not “come" to
programmes organised for children. However, all who are concerned with health care
.want them to be found and further deprivation prevented. India’s medical educators
want to train doctors, who will be community team leaders. India’s doctors are reluc
tant to commit themselves to a career for which they feel untrained and in which they
may become the professional “drop out". It is suggested that no time could be more
opportune than the present, to make changes which bridge this gap. Medical Colleges
have to take responsibility for 3 blocks. We should recognise that faculty members
need training so that their contribution is effective, and make community medicine a
postgraduate specialty for which the “wards” are the blocks, recognition by Medical
Council of India being required for this specialty, as for any other. Training in field
research, detecting target groups which are at risk such as the deprived child, is as
important as any piece of laboratory based research. It is the medical teachers who
can do most to effect this change by proving that they regard field research as a top
priority. The simple, yet scientifically designed methodology of reaching those in
need, employed by the Department of Community Medicine, Christian Medical
College, Ludhiana, has been shown to be not only effective, but professionally
satisfying the doctors employed in this programme.
Will India’s medical graduates be able to
make a significant contribution to the Inter
national Year of the Child fl.Y C.) and to
child care in the rural areas, after 1979 ? The
general theme chosen for the year by the
country is “reaching the deprived child" and
the Central Department of Social Welfare
proposes to undertake the preparation of a
review document on the status of the child in
India. This document should reveal, not only
the size of the “deprived 1 group in India,
but the etiology of “deprivation”, so that
effective remedial and preventive measures
may be found and implemented.
Speaking at the world's first international
conference on Primary Health at Alma-Ata,
Russia, in 1978, the Director of W.H.O. Dr.
Helfdan Mahler (1) said that nations must
give top priority to allocating health resources
58
rue INDIAN JOURNAL OF MEDICAL EDUCATION
for the benefit of the most needy communities
Even if these resources are allocated for this
purpose in India, how will the needy com
munities be reached, their needs identified and
met ? The needy will certainly not come
spontaneously to centres where programmes
are organised for their benefit. Already, there
have been many gatherings of children to
inaugurate the I.Y.C. and, before the year is
out, many more will share in similar pro
grammes. However, the marasmic, the pot
bellied, the deprived, have been conspicuous
by their absence in pictures of such gatherings,
and they are rarely seen at clinics organised for
the welfare of children.
If we in India are serious in our desire to
reach those in the “weaker" section, to identify
their problems and. raise their standard of
health, we can no longer rely on schemes
. which succeed only partially because their
implementation has been put into the hands
of those who have not been trained for the
task. At the same conference, the Executive
Director of UNICEF, Mr. Henrv Labouisse,
said that the problem was not to extend
existing health services outward, but to begin
building at the other end, in villages and city
slums, mobilizing the people themselves to
improve health standards.
VOLUME XVII Ao. 1
JAffUARTIJUNE 1978
THE CHILD’S YEAR AND MEDICAL TRAINING 59
loss of child life in
will bridge the gap between the planners and
the people ?
relevance to India's health needs today than
the problem of reaching the deprived child.
India’s medical graduates are the obvious
choice. A large proportion of today’s medical
graduates will find their way into the
country's health service, but there appears to
be some doubt in the minds of the health
planners regarding the ability of these graduate
doctors to meet the health needs of the com
munity. Some have even suggested that the
graduate should be •‘by-passed" and the
responsibility for care should be put into the
hands of lesser trained medical personnel.
Surely this is a policy of defeatism for a country
which spends so much on the training of
doctors. Moreover, on the part of the doctors
themselves, there is a reluctance to commit
themselves to community service.
With good reason, therefore, many graduates
feel that, having been highly trained in
scientific methodologies, they will be unable
to use these skills if they do not remain in
large hospitals or training centres. Their skill
will be “wasted” in villages since the diagnosis and children, under five, will die this year for
of the community and plans for its treatment lack of health care, and 15 million will be in
appear, of necessity, to be based on vague developing countries. “Government would
impressions, hard to accept by a graduate have to drastically re-ordcr their priorities" if
trained in a precise methodology. Few are nation-wide health care was to become a
familiar with the concept of a community reality. This change would have to begin at
diagnosis, still fewer trained to make such a
the top level of • Government and national
diagnosis and, therefore they are unable to
find out the community's problems and how leadership. We suggest that this change of
to deal with them effectively. Moreover, they attitude could result in the mobilisation oi
see their colleagues moving ahead towards India's doctors for community health service,
residency programmes, postgraduate degrees not as reluctant “conscripts” but eager
and research fellowships, with financial “volunteers". Gan we, the medical collegr
rewards as well as promotion, academic teachers, show them that the challenge d
attainment, and, for some, a reputation for reaching the deprived child is as important at
expertise. It is, therefore, hard for them to finding a cure for cancer ? Can we changi
contemplate a life of struggle with a commu our teaching methods so that graduates become
nity they do not understand, for which convinced that we mean it and that this netunderstanding there appears to be no guide approach is not just another “gimmick" t<
lines, a people who do not value their services, get them into a Primary Health Centre ? Cai
and whose problems they are unable to we show them a methodology which we hav
identify. Naturally, graduates would prefer tried out ourselves ?
to treat patients who flock to large centres
and who are willing to undergo all manner
The Department of Community Healt'
of investigations in order to obtain relief,
Christian Medical College, Ludhiana, uses
rather than to spend their lives in uncongenial
simple and scientifically designed methodolo1
surroundings, treating patients who do not
In the Republic Day issue of the Indian
Express, a reference was made to the fact that
the post of Paediatrician, created specially to
intensify the Integrated Child Development
Scheme in Nurpur Bedi, Punjab, has been
vacant since the inception of the scheme three
years ago. It was stated that, “in spite of this
having been declared an A-grade project, by
the Union Social Welfare Department, the
medical officer posted invariably managed to
“wriggle" out of a tenure at Nurpur Bedi".
Who w ll begin this building process in the
Why should this happen ? Do doctors feel
villages of India ? The Health Planners or
Village level Workers ? The former, having that they have not been trained for this work
expertise and an over-view of the problem, and that they will quickly lose touch with
can plan, but are inevitably remote from the “academic" medicine. Are they afraid that
their contribution will be regarded as of less
areas where the plans have to be implemented.
The latter, village dwellers, with excellent importance than the contribution of their
acceptance by the people, lack the over-view colleagues whose careers lie in large teaching
and, therefore, are unable to see any need to hospitals or in research laboratories ? Many
change situations which they have come to problems which receive a large share of the
accept with a fatalistic attitude. Who then country's budget for research have much less
the socio-economically
deprived section of the community, and the
cost to country of the morbidity of this section
of the people, however, is almost as great as
the cost of war. Drawing special attention to
the urgent health needs of the world's children,
Mr. Labouisse said that 15.5 million infants
want their services and who, in fact, hold the
local hakim in higher esteem.
which leads us to all the “at risk groups
Mobilization of a country's resources and
rigorous training to a high degree of compe
tence, is the only course open to any country
when threatened by war. The toll taken by
set goals and evaluate success or failure. Sc
The doctors working in our programme soi
learn to use it in order to identify problen
they learn that vague impressions are as r
of place here as in a research laboratory.
januart/june 197a
60
THE INDIAN JOURNAL OF MEDICAL EDUCATION
In addition to family folders and a diary
for each worker, there is, for each area, a
comprehensive master register for maternal
and child health and family planning. These
are all the records that are required and, in
fact, permitted since it is well recognised that
a multiplicity of recording by many different
people in many registers results not only in
waste of time and money, but lack of clarity
in definition of the goal. The data, obtained
in the course of delivering comprehensive
health care, provides an almost limitless pool
of useful information about the community
and indicates areas of maximum need. In
this way, we identified the child in need, one
example of an “at risk" group. They are the
children of the socio-economically under
privileged, between 6 and 36 months of age,
with need for special concentration on the
females, especially of high birth order, more
so if there is no male in the family, the mother
illiterate and out working for most of the day.
Neary 50% of such female children have
severe malnutrition.
Is it possible for us to convince young
doctors that we, the medical teachers, mean to
make community medicine one of the ‘prestige’
specialities in India ? All our assurances,
however, will lack conviction unless we
emphasise that a new type of training is
mandatory for this speciality. No time could
be more opportune than the present to make
this change. Medical colleges are each taking
up for care, three blocks of the District in
which they are situated. What kind of care is
envisaged ? Those of us who have heen engaged
in academic medicine, within the wallsofa
hospital, know that, without some training
and guidance, the only care we could provide,
as a faculty, will be by means of clinics in
rural areas, teaching under-graduates, in a
village, exactly the same kind of facts that we
THE CHILD'S YEAR AND MEDICAL TRAINING 61
VOLUME XVII No. 1
would have taught in the hospital ward. Some
departments might take responsibility for an
academic term and might even live for part
of that term in the rural area. Those patients,
who attend the professor's clinic might well be
impressed with the seniority of his doctor, but
the Government Health Service doctor will be
made more aware than ever of the gulf which
separates the academic from the community
based doctor. The latter has to fulfil to his
communities and to his superiors certain
responsibiiites about which the college
teachers know little.
Will visits from the staff of a medical
college help him ? Perhaps, but there is a
possibility that these visits may even be a
hindrance. There is no medical college depart
ment in the world today, which would under
take a new speciality, for example, renal
transplantation, without years of preparatory
training of staff, and gaining experience from
earlier workers in the field before setting up
such a unit. Has it ever been suggested that
faculty members of medical colleges might
need training before taking on responsibility
for Community Health ? India's health needs
are great. Most are in rural areas. Few
medical college staff know anything about the
problems in those areas. A great opportunity
is being given to colleges to make an impact
on the health needs of the country. Is this not
the time for the college staff to ask “what are
the needs" ? What does Government expect
from the colleges ? Who will teach us how
to know a community and make community
diagnosis, mandatory if we are to make
effective
treatment
policies ?”
The
reluctance of some medical colleges to
commit themselves to Block involvement, stems
froms the fact that few, experts in their own
field, know what to do in a village and, if they
do not know how' will they teach others ?
The leaders in the field of medical education
must recognise the need for such training, find
centres where it can be given, teachers who
can give it, and formulate guidelines for the
functioning of college departments in a Block.
Community Medicine, practised in 3 Blocks
by each medical college, should become a
recognised discipline of the college, with a
training programme which must have, as other
departments of medical schools, the approval
and recognition by the Medical Council of
India. Graduates will then have the oppor
tunity to apply for posts in residency
programmes leading to post-graduate degrees
in this discipline. When this happens, there
will be at least some “volunteers”.
“Conscripts" will not become “volunteers”,
however, until they see that their teachers are
behind them and that, instead of becoming
“drop-outs" in a rural setting, they will be
accorded as much, if not more, in terms of
respect and financial gain than the hospital
based specialist. There must be no question
of two “streams” of doctors in Blocks which
are attached to colleges, one the medical
officers with obligations to the Government
Health Service, regarded as second-class
physicians by the medical college staff, who
are happy to leave the administrative problems
to the former. The scheme will not work
until the Government and college staff function
as a team.
India has inaugurated the I Y.C. with
many laudable aims. Bold and drastic
reorganising of priorities is needed so that
Indian doctors are channelled into the immense
task, not only of identifying and rehabilitating
those deprived of health, including children
but preventing deprivation by medical and
social change.
REFERENCE :
1. The Alma-Ata Conference
32: 409—430 (1978).
on
Primary
Health Care,
WHO
Chronicle,
Child Welfare Centre A Concept in Undergraduate
Pediatric Education
By
Harjit Singh
&
P. S. Bhatt
Department of Pediatrics, .Medical College and Hospital, Rohta/.,
Haryana.
Introduction
There are over 10 milllion severely mal
nourished children the world over and India
one of the major contributors to this ominous
reality. Closely linked to malnutriton are child
hood infections and diarrhoeal disease, and
these together account for the appalling morbi
dity and mortality rates. While all medical
educationists are unanimous on a need-based
undergraduate curriculum (Duraiswamy, 1970;
Srivastava, 1973), no concrete steps have been
taken in this direction, with the result that the
training of our ‘basic doctors' penaining to
child health care remains far short of the
desired standards inspite of the fact that
approximately 40 per cent of patients in gene
ral practice belong to the pediatric age
group.
It has been stressed that highly specialized
nature of work done in the hospital militates
against training for medical practice in the
community (Patel, 1973; Wahi, 1973). This
has been an important factor in producing a
severe imbalance in the availability of health
and medical resources between rural and
urban areas. There is, thus, an urgent need
to re-orient undergraduate pediatric education
in a manner so as to make it more rational
and practically more useful to the require
ments of a basic doctor. The Medical
Education Committee of the Govt, of India
(1969) i ecommended that the internship
training should not be confined to the teaching
hospitals alone but should include a supervised
training at the primary health centres. To
evolve an effective approach in this direction
the priority areas of child health care at the
primary level must be defined. The W.H.O.
Ad Hoc Committee on pediatric curricula
summarized the objectives of undergraduate
training thus :
“The object is to ensure that the student at the
end of pediatric posting has a firm grasp of the
major principles of child health necessary for a
doctor working in a Health Centre or in general
practice. His learning will be concentrated on
growth and development, on prevention and
effective care of common illnesses of infancy
and childhood and on the relationship of
environment to health”.
Infants and small children in the age
group of 0 to 5 years constitute 15 per cent of
the country's population and mortality is 4 to
5 times compared to the developed countries.
In an effort to provide basic health care to
this vulnerable segment a concept of UndorFives’ Clinics originated (Morley, 1966, 1963
and 1973 ;King. 1971 ; Cutting, 1972). These
Clinics require minimal staff, involve active
participation of the paramedical staff and aim
J ULT-DECEMBER 1978
CHILD WELFARE CENTRE A CONCEPT...
at a comprehensive approach in the form of
curative, preventive and promotive care.
Doctors who could be most involved in these
clinics are those working in the Primary
Health Centres or attached to Maternity and
Child Welfare Centres, However, few doctors
working in these situations have either the
comprehension or the practical background
to properly utilise the available resources and
paramedical staff to best advantage.
comprehensive health delivery to the masses .
102
(i)
To implement a health team concept,
training and education of all workers
should be together as far as possible.
(ii)
The curriculum should be so designed
as to meet the social and educational
objectives and needs of the society.
To this one may add that training pro
gramme should include a rural setting as the
place of instruction.
Diarrhoeal disease due to infections, faulty
feeding techniques, unhygienic living condi
Mobile training-cum-service hospitals were
tions and rampant malnutrition is still the conceived as a need-based programme for
number one killer in early childhood years. providing training in comprehensive medicine
Operational research all over the world has to the interns and undergraduates in rural
demonstrated that patiants are unlikely to areas under supervision of the Medical College
travel more than 5 to 8 Km to seek medical staff. There have been several functional
care and for the toddler who needs to be variants of this scheme. The authors are
carried, the distance may be reduced further. familiar with one in which they have
Therefore, the probability of rural population participated during the last five years. This
seeking advice in towns and bigger city ‘Mobile Hospital' is being run by the Medical
hospitals is meagre, Establishment of . College, Rohtak, and provides intensive com
‘Rehydration Therapy Centres' in rural areas prehensive care in all specialities for a period
has been recommended (Sack, 1972). The of 3 to 4 days (active phase) followed by a
selection of a suitable site which will be two week consolidation phase. Approximately
heavily used is very important. Such a site, 10.000 patients get medical benefit. Only
ideally, should be readily accessible to the interns participate at the undergraduate level
faculty members who would serve as and professional leaning opportunities available
supervisors, while most of the responsibilities to them at these camps are difficult to assess.
*
medical
can be delegated to Interns and paramedical At best these camps provide ‘instant
aid to the masses for a transitory period of
personnel.
time. Organisation of these camps involves
Rao (1973) pointed out that the present an enormous cost, which is perhaps a luxury
unsatisfactory situation of rural health services at the present point in time. Requisitions of
is explained, in addition to lack of resources, each camp is estimated to cost Rs. 8j,000/- to
by the failure to use auxiliary and paramedical
personnel through proper delegation of res
ponsibility, administrative inexperience of the
medical officers and inadequate and faulty
education of health personnel.
the
following
guidelines
He laid down
to
achieve
Rs. 100,000.
Child Welfare Centre :
A Child Welfare Centre (CWC) has been
conceived incorporating priority child health
care areas. These Centres should be esta
blished at the Primary Health Centres attache
103 THE INDIAN JOURNAL OF MEDICAL EDUCATION
to Medical Colleges, so that the interns and
paramedical
staff can gain a first hand
experience in working as a team in providing
basic health care to the children. The design
of CWC (Fig. 1) incorporates the basic design
of the Under-Fives, clinic, with addition to
provide for the extended needs of the
Rehydration Centre. Applied
Nutrition
VOLUME XVII Bo. 2
Comments:
Social health goals will vary from country
to country in accordance with social and
economic development. But an effective
delivery of health care in any society must
include total care of children including
nutritional guidance to ensure effective utiliza
tion of locally available food, immunization
against major infections and elementry cura
tive care.
JULT-DECEMBER 197S
CHILD WELFARE CENTRE A CONCEPT...
under constant review. It is inevitable thus
that the role of CWC would change in times
to come. But whatever the situation, the child
would always get top priority in health care
and the Child Welfare Centre would serve as
a constant reminder to the medical graduate
of his responsibility to the community's
children.
TABLE I
Staff Input
A.
Economy and health manpower resources
would always be the deciding factor in health
care delivery. Developing countries have
abundance of neither. Effort, therefore, has
to be made to devise the most economical
solution. With limited number of qualified
doctors available to man the Primary Health
Centres, an effective utilization of paramedical
staff becomes essential. The extent of involve
ment of paramedical staff depends upon the
administrative skill and experience of the
medical officer in team leadership.
child Welfare Centre
Programme and facilities of managing rela
tively serious illnesses
with
minimal
resources. Staff inputs, establishment costand
• recurring expenditure are shown in Tables I,
II and III. Annual expenditure on staff and
equipment is estimated at Rs. 3 lacs, which
would mean an additional expenditure of
Rs. 2,500/- per intern. Each intern would
spend, out of his three months' posting in the
Health Centre, one month at the CWC, where
he would be expected to work directly with
the paramedicos with minimal supervision and
amenities A graduate thus trained would be
better equipped and confident in dealing with
the health problems of community’s children
when he works in the field.
A fresh graduate exposed to the commu
nity for the first time finds it difficult both to
weave a well-knit team with effective
participation of the paramedical staff as well
as to provide the child health care require
ments of the community. A period of one
month which the Intern would spend at the
CWC is aimed at giving him a first hand
experience in both. He would, during this
period, work in association with paramedical
staff and have the primary responsibility in
providing primary health care to children
under minimal supervision of senior staff.
One is aware of the fact that with economic
progress the quality of health care even in the
developing countries would improve. Afterall
health care is ever-changing and must remain
104
B.
C.
Supervisory
Resident :
Trainee :
(1) Pediatric Consultant
(2) Consultant, Preventive and
Social Medicine
)
)
) Medical College
)
(1) Registrar Pediatrics
...Two
(2) Staff Nurses
....Two
(3) Radiographer
...One
(4) Clerk-cum-storekeeper
(5) Laboratory Attendents
.... One
...Two
(6) Bearers
(7) Sweepers
...Two
Six
(1) Interns
...Ten
(2) A. N. Ms.
...Six
TABLE II
.
.
Investigative Facilities
1.
2.
3.
‘
4.
5.
Routine Hematology
Urine and Stool examination
Arrangements for Microscopy, Gram staining,
Albert's staining (for G. Diphtheria)
Radiology : Chest and Abdomen
CSF for Cytology, Protein and Sugar
Zeil Nielson Staining and
Equipment :
1. Microscope
2. Hand Centrifuge
3. Electric Centrifuge
4. Routine Laboratory Glassware
and Chemicals
...One
-..One
....One
VOLUME XVII No. 2
105 THE INDIAN JOURNAL OF MEDICAL EDUCATION
TABLE III
Establishment Cost
1.
Building
Rs.
...
7.00 lacs
2.
Equipment
Rs.
...
3.00 lacs
3.
Total
Rs........10.00 lacs
Recurring Expenditure:
(A)
Salaries
Rs.
_.
1.00 lac
(B)
Drugs, Equipment, etc.
Rs.
.._
2.00 lacs
REFERENCES
1. Morley^ D.C. : The Under-Five's Clinic, in Medical Care in Developing Countries,
M. H. King, Edit., Oxford Univ. Press, 1966.
2.
King, M. H.: Clinics for Under-Fives in Zambia and Malawi, Tropical Doctor,
1(1): 36.1971.
3.
Cutting. W. A. M. : The Under-Fives’ Clinic. J. Christian Med. Assn. Ind. 47(4) :
160,1972.
4.
Morley, D. C.-: Pediatric Priorities in the Developing World. Quoted in Health
Care of Children Under Five. Tata McCraw-Hill Publishing Co. Ltd. Bombay,
1973.
5.
6.
Morley, D. C. : Tropical and Geographical Medicine' 20 : 101, 1968.
Sack, R. B : W. H. O. Report on a Course on Rehydration Therapy Centres.
SEA/Cholera/23, 1972.
7.
Duraiswamy, P. K.: Need-based undergraduate medical education, J. Med. Ed, 9 :
1970.
8.
Srivastava, R. N. : Teaching of Medicine in the community through field practice
areas-Some considerations, Ind. J. Med. Ed., 12 : 31. 1973.
9.
Wahi P. N.; Rural Health Services-Their implications for Medical Education.
Ind, J. Med. Ed., 13 : 144, 1973.
10.
Patel, T. B. : Proceedings of the 12th Annual Conf. I. A. A. M. E. Ahmedabad;
Ind. J. Med. Ed. 12: 141. 1973.
II.
Rao. K. N. : Implications of Rural Health Services of Education and Training of
Medical Personnel. Ind. J. Med. Ed.. 12 : 183. 1973.
JANUARY-JUNE, 1973
Concept Of Preventive and Social Pediatrics
by
(Miss) S. Gupta, frcp, dch.
Professor & Head of the Deptt. of Pediatrics, Maulana Azad Medical College & Associated, Irwin &
G.B. Pant & Hospitals, Pfew Delhi-I,
The purpose of Preventive and Social Pedi
atrics is to provide each child optimum oppor
tunities for optimum physical, emotional and
intellectual growth arid development. Such
opportunities are not considered luxuries today
or the right of a few previleged ones, but are
necessities of child health care service.
The idea of preventive pediatrics is not new.
The main concern of all parents is for-the wel
fare of their infant growing from one of the
deepest instincts in all animal species, nourish
ment, protection against heat and cold, and
warning of danger constitute the primitive
form of prevention and advances that have
taken place are due to handling down from
generations to generations of actions and
methods found by experience to be the most
efficacious.
Pediatrics being perhaps the most compre
hensive and complete branch of medicine, it
was only natural that several modern trends in
medicine originated or developed in its realm ;
preventive pediatrics is not only indebted to
many eminent pediatricians for the establish
ment of a large part of its formation, but as
child health science, it has become completely
integrated with the diagnostic and curative
aspects of child medicine.
The emergence of Social Science with their
improving methods has opened up new ap
proaches to the study of medically important
aspects of human society, and of its organised
life. Indeed there seems to be no less a reason
for a physician to know about the human com
munity life than about the life of bacteria and
viruses. For these reasons medicine is some
times called a social or socio-biological service.
chapters to Preventive Practice in his treatise
on children called the ‘ultratantra’. These
chapters devoted to (a) nursing and healthy
upbringing of infants and children and (b)
purification and improvement of breast milk
found deficient in quantity and quality, brings
forward the fact that prevention was practised
even in the ancient medical system of India.
In the present day medicine, preventive and
social medicine had its origin near about the
same time when methods to sterilize milk were
devised. Later milk banks and dispensaries
were started (1894). Well baby Clinics were
started around the same time as well (1892).
Then came the era af Pasteur and Jenner.
Mass innoculation against small-pox became
popular in early 20th centuary but the final
achievement in this field could be called the
post world war I era when M.C.H. bill was
passed by the British parliament which made itobligatory for the state to look after the mother
and her new born baby. This was especially
important for India since British rules applied
to us and passage of this rule was suceeded by
the starting of a number of M.C.H. Centres in
this country. The important realization that
children and particularly infants are not merely
manikins and they differ anatomically, physio
logically, pathologically and immunologically
from adults did not come till some people
devoted time to the child and its ailments to
wards the close of 19th centuary. Since then
pediatrics has developed very considerably,
the study of heredity and environment have
led the pediatricians to extend their activities
not only to the moment of conception, but
even before that up to post puberty when
reproduction starts.
A study of old system of Indian medicine
The practice of pediatrics may be divided
reveals that ‘ Susruta the senior ’ devoted two in three branches.
CONCEPT OF PREVENTIVE AND SOCIAL PEDIATRICS
45
4. Protection against accidents involving the
a. Clinical Pediatrics: dealing with the sick
child or child affected by trauma in the widest security of the child on the road, at home, and
sense of the word, and hence deals with etio at work. This last would go a long way in
avoiding
morbidity and mortality in no small
logy, pathology, treatment etc. b. Preventive
Pediatrics: is concerned with all ills physical measure.
and mental which may threaten the child and
5. Protection against congenital malforma
secondly with all endeavours aimed at safe tion and hereditary defects: Much is still
guarding for each child optimum growth and shrouded in mystery as regards congenital
helping him in every respect to reach the malformation, but avoidance of the known
maximum of his potential abilities, c. Social factors, like infections affecting the foetus,
Pediatrics: Comprises the whole group of maternal radiation etc. is important. Preven
collected endeavours favouring the young age. tion of obstetrical accidents, and provision of
It is difficult to isolate preventive from social good antenatal, natal and postnatal care are
since they are often bound upto the point of important steps in this direction. Genetic
fusion.
advice against consanguinity should be a regu
What then is the sphere of preventive and lar feature in prenatal clinics. This later is
social pediatrics ? Below are listed a number of not only the field of obstetricians but pedi
important considerations:—
atricians must take responsibility of the foetus
1. Protection of child against infection : By from conception onwards.
this, I mean not only specific immunization
6. Provision of services to children suffering
against disease for which specific immunizing from diseases which handicap the child in one
procedures are avilable but also infection with
way or another (e.g. blindness, deafness,
parasites like round worm, hookworm etc.
orthopedically handicapped chronic neuro
Streptococcal infections and repeated respira logical disorders and other chronic illnesses
tory infections are also very important since like Rh. fever.) These underprivileged
they may lead to permanent cardiac or renal children are in great need for help not only
damage and hence health education and other for their own treatment and rehabilitation
general measures to improve general standard but also require a lot of help for their families
of living, water sanitation etc. are important.
for social adjustment, adaptation and rehabili
2. Dietetic Errors and Insufficiencies:—Pro tation.
vision of balanced diet including proteins and
7. Legislation and'observance of laws relat
vitamins and help in terms of grow more, con
sume more, and train more para medical nutri ing to children: are absolutely essential in
tional worker for health education and hygiene preventing child labour, both in domestic as
of good stuffs available locally as far as possible. well as in commercial circles, further laws
Many of these insufficiencies are due to igno relating to adoption, provision of basic facilities
rance, customs and habits rather than due to like education, nutrition etc. are also impor
non-availability. The importance of proteins tant.
in the diet of vulnerable group cannot be over
8. Promotion of positive health in normal
emphasised in developing countries tvhen one children : By providing the basic requirements
considers its impact on brain development like food, shelter, education, fresh air, exercise,
right from foetal life onwards.
optimum facilities for physical and mental
3. Noxious effects of social environments : development and satisfying the emotional needs
In this, I should like to include serious psycho so as to allow and aid the child in developing
logical impacts due to deprivation of maternal at his most optimum level physically, emotio
care, broken families, extreme poverty and nally and socially and hence compete at his
also to include the effects on abandoned and most effective level.
neglected children. Besides this to counteract
9. Preconception and prenatal assistance:
the risk which threatens the child in a morally
abnormal family. The last named implies Preventive pediatrics for children should start
not only protection of the child against juvenile before conception. Adolescents should be
delinquency but more than that positive steps given advice on sex education and sex hygiene.
to avoid mental trauma and antisocial orienta Assistance to unmarried mothers in all its
entirety must be provided.
tion from a very early age.
46
THE INDIAN JOURNAL OF MEDICAL EDUCATION
FOL. XII
NOS. 1 & 2
10.
Emotional guidance: Prevention of with all aspects of administration and planning
emotional illness is the most difficult and time pertaining to mothers and children’s health.
consuming area. Modern living, strife for
Control of environment eventhough difficult
better standards of living, working mothers,
and disintegration of multigeneration family should be attempted as far as possible especially
units has compounded the problem of adjust in children with poor social backgrounds, and
handicapped
children.
ment. The symptoms of emotional instability
are many and even if diagnosed and assessed,
And lastly it is necessary that good records
the quantum of advice to be given and its are kept. These should include morbidity,
acceptance is always problematical.
mortality and vital statistics in that particular
11.
Social Health; previously considered a community. Besides these records of growth
concern for parents, clergy, school teachers and and development, incidence of handicapped
state, is now suggested as one of the areas for children and services available and rendered
activity for Pediatricians. Stealing, Drug must be documented, if further assessment is
abuse, School drop outs, premarital inter to be of value.
course etc. are the problems that might involve
Many allied services are important for car
the pediatricians caring for the youth. It rying on the task of preventive and social
seems obvious the physician must acknowledge pediatrics. These include milk banks, where
the impact that poverty and social ills have on any child can walk in and demand a glass of
children.
good wholesome milk, foster parents, chronic
12.
Family Planning advice is most essential sick homes, homes for children with sick or
in developing countries and countries with disabled parents, summer homes for healthy
poor economy. Not only advice on limitation children and homes for handicapped children.
of the family but on spacing as well should be
Physicians dealing with children should keep
given. Someone may say that this is the field in touch with various organisations working
for obstetricians. I believe that Pediatricians towards the same end. These include parent
since they are family physicians should be associations, adoption societies, youth organisa
more responsible for it than even the obstetri tions, cultural centres, sports clubs, and other
cians.
organisations for children and young people.
Now once we have defined the scope the Voluntary organisations and social welfare
next step would be planning for achieving agencies merit a special place among these.
these. The basic sen-ices needed are, well
So, it becomes necessary for anybody wish
baby clinics, both in urban and rural areas. It ing to practise pediatrics that he or she should
is unnecessary to elaborate on their importance have the ‘social sense’, besides his professional
and I shall not dwell on this familiar topic capability. By this I mean the capacity to
except to mention their value in health understand others, the capacity to guide and
education of the mothers and the family, instruct. Preventive and social pediatrics must
and in impressing about the preventive sendees permeate the curricula of all future teachers,
from an early age.
administrators, town planners, community
School and University health services which workers, agriculturists and all child health and
should supervise the child from a very early care workers, for whom it is essential to know
age with full time staff are indispensible for the all aspects both physical and mental health of
establishment of a sound preventive pediatric the child entrusted to them.
services. Sex education, health and hygiene
are important aspects to be impressed and References :
explained, and thirdly establishment of a
1. Acta Pediatrica. Supplement 151. 1963
national organisation at the level of Central (Symposium on preventive pediatrics in the
Government, State Government etc. to deal undergraduate curriculum).
Population Education
The Changing Status of Pregnancy TerminationImplications for Medical Education
*
by
Donald H. Minkler M.D., M.P.H.
I have the temerity to appear on this program continuing education of those who were trained
not as an expert in Indian Medical Education, in an era in which abortion -was virtually taboo
but rather in the spirit of sharing experience and medical practice generally isolated from
which is the hallmark of international coopera the social concerns expected of today’s commu
tion. The State of California has since 1967 nity minded health worker. Not only the
undergone a liberalization of its abortion law philosophy, but also the technology of abortion
similar in many respects to that which India has undergone revolutionery change calling for
now faces. We were, as you are, faced with training of those who now face a rapidly grow
the necessity on the one hand of adaptation to ing demand for this procedure in the new
an abrupt change in the supply : demand situa techniques of suction-aspiration, amniocentesis,
tion involving an important medical transac and the management of the inevitable compli
tion, and on the other the need to train physi cations of induced abortions.
cians and their co-workers in the provision of a
Fortunately, the need to impart the necessary
highly sensitive procedure with profund emo judgement and skills required for the care of
tional and religious overtones. It was my pri growing numbers of women requesting aborvilege to serve as Medical Director of an ex ■ tion coincides with the new emphasis given to
periment in the team approach to abortion reproductive biology and fertility control as
service,1 conducted by an affiliate of Plan high priority subjects in medical education.
ned Parenthood - World Population in coopera Last year’s tenth Annual Conference of this
tion with the University of California School association1 is testimony to this emphasis.
of Medicine. This paper attempts to adapt a As the Medical Colleges address themselves to
philosophy of abortion service growing out of needed modifications of curriculum, training
that experience to the educational require in management of problem pregnancies will
ments of India’s current situation.
hopefully reflect the interdepartmental coordi
The emergence of abortion in recent years nation that the technical, sociological, and
first as an increasingly accepted therapeutic psychological aspects of abortion care require.
modality, and now as a legally sanctioned pro
cedure with added humanitarian and eugenic
justification poses an immediate and compell
ing challenge to institutions engaged in the
training of health workers at all levels. Opinion
surveys, such as that conducted by Israel in
Bombay in 1969 indicate the wide variance of
attitudes of physicians as to the proper place
of abortion in medical practice. Clearly, we
face an educational task, not only at the under
graduate level, but also in the re-education and
In the 1969 survey of the curricula of ninety
three medical colleges in India reported by
Rice,8 practical experience in specific FamilyPlanning related procedures was reviewed.
Most colleges did not allow students to insert
IUD’s, deferring this experience to the intern
ship year. Very- few permitted assists in tubec
tomy and experience in vasectomy, with a
single exception, was not regarded as an under
graduate requirement. Clinical experience in
abortion was not surveyed in these question-
• Paper Presented at the XI Annual Conference of IAAME at AFMC, Poona, Feb’72.
Concept Of Preventive and Social Pediatrics
by
(Miss) S. Gupta, frcp, dch.
Professor e? Head of the Deptt. of Pediatrics, Montana Azad Medical College <3 Associated, Iruiin (3
- G.B. Pant & Hospitals, Hew Delhi-I.
WUART-flJNE, 1973
fusion.
The purpose of Preventive and Social Pedi
atrics is to provide each child optimum oppor
tunities for optimum physical, emotional and
intellectual growth and development. Such
opportunities are not considered luxuries today
or the right of a few previleged ones, but are
necessities of child health care service.
The idea of preventive pediatrics is not new.
The main concern of all parents is for the wel
fare of their infant growing from one of the
deepest instincts in all animal species, nourish
ment, protection against heat and cold, and
warning of danger constitute the primitive
form of prevention and advances that have
taken place are due to handling down from
generations to generations of actions and
methods found by experience to be the most
efficacious.
Pediatrics being perhaps the most compre
hensive and complete branch of medicine, it
was only natural that several modern trends in
medicine originated or developed in its realm ;
preventive pediatrics is not only indebted to
many eminent pediatri'-1 .is for the establish
ment of a large part of its formation, but as
child health science, it has become completely
integrated with the diagnostic and curative
aspects of child medicine.
The emergence of Social Science with their
improving methods has opened up new ap
proaches to the study of medically important
aspects of human society, and of its organised
life. Indeed there seems to be no less a reason
for a physician to know about the human com
munity life than about the life of bacteria and
viruses. For these reasons medicine is some
times called a social or socio-biological service.
A study of old system of Indian medicine
reveals that ‘ Susruta the senior ’ devoted two
CONCERT OF PREVENTIVE AND SOCIAL PEDIATRICS
a. Clinical Pediatrics', dealing with the sick
child or child affected by trauma in the widest
sense of the word, and hence deals with etiologv, pathology, treatment etc. b. Preventive
Pediatrics: is concerned with all ills physical
and mental which may threaten the child and
secondly with all endeavours aimed at safe
guarding for each child optimum growth and
helping him in every respect to reach the
maximum of his potential abilities, c. Social
Pediatrics : Comprises the ' whole group of
collected endeavours favouring the young age.
It is difficult to isolate preventive from social
since they are often bound upto the point of
45
4.
Protection against accidents involving the
security of the child on the road, at home, and
at work. This last would go a long way in
avoiding morbidity and mortality in no small
measure.
5.
Protection against congenital malforma
tion and hereditary defects: Much is still
shrouded in mystery as regards congenital
malformation, but avoidance of the known
factors, like infections affecting the foetus,
maternal radiation etc. is important. Preven
tion of obstetrical accidents, and provision of
good antenatal, natal and postnatal care are
important steps in this direction. Genetic
advice against consanguinity should be a regu
lar feature in prenatal clinics. This later is
not only the field of obstetricians but pedi
atricians must take responsibility of the foetus
from conception onwards.' •
What then is the sphere of preventive and
chapters to Preventive Practice in his treatise
on children called the ‘ultratantra’. These social pediatrics ? Below are listed a number of
chapters devoted to (a) nursing and healthy '■ important < ousiderations :—
upbringing of infants and children and (b)
I. Protection of child against infection : By
purification and improvement of breast milk this, I mean not only specific immunization
found deficient in quantity and quality, brings against disease for which specific immunizing
6.
Provision of services to children suffering
forward the fact that prevention was practised procedures are avilable but also infection with " im diseases which handicap the child in one
even in the ancient medical system of India.
parasites like round worm, hookworm etc. way or another (e.g. blindness, deafness,
In the present day medicine, preventive and Streptococcal infections and repeated respira orthopedically handicapped chronic neuro
social medicine had its origin near about the tory infections arc also very important since logical disorders and other chronic illnesses
same time when methods to sterilize milk were they may lead to permanent cardiac or renal like Rh. fever.) These underprivileged
devised. Later milk banks and dispensaries damage and hence health education and other children are in great need for help not only
were started (1894). Well baby Clinics were general measures to. improve general standard for their own treatment and rehabilitation
but also require a lot of help for their families
started around the same time as well (1892). of living, water sanitation etc. are important.
for social adjustment, adaptation and rehabili
Then came the era af Pasteur and Jenner. 1 2. Dietetic Errors and Insufficiencies :—Pro tation.
Mass innoculation against small-pox became vision of balanced diet including proteins and
popular in early 2()ih ccntuary but the final 1 vitamins and help in terms of grow more, con
7.
Legislation and observance of laws relat
achievement in this field could be called the sume more, and train more para medical nutri ing to children : are absolutely essential in
post world war I era when M.C.H. bill was tional winker for health education and hygiene preventing child labour, both in domestic as
passed by the British parliament which made it of good stulls available locally as far as possible. well as in commercial circles, further laws
obligatory forthestate to look after the mother Many of these insufficiencies are due to igno relating to adoption, provision of basic facilities
and her new born baby. This was especially rance, customs and habits rather than due to like education, nutrition etc. are also impor
important for India since British rules applied non-availability. The importance of proteins tant.
to us and passage of this rule was sucecded by in the diet of vulnerable group cannot be over
8.
Promotion of positive- health in normal
the starting of a number of M.C.H. Centres in emphasised in developing countries when one
this country. The important realization that considers its impact on brain development children : By providing the basic requirements
like food, shelter, education, fresh air, exercise,
children and particularly infants are not merely right from foetal life onwards.
manikins and they differ anatomically, physio
3. Noxious effects of social environments: optimum facilities for physical and mental
logically, pathologically and immunologically In this,.I should like to include serious psycho development and satisfying the emotional needs
from adults did not come till some people logical impacts due to deprivation of maternal so as to allow and aid the child in developing
devoted time to the child and its ailments to care, broken families, extreme poverty and at his most optimum level physically, emotio
wards the close of 19th centuary. Since then also to include the effects on abandoned and nally and socially and. hence compete at his
pediatrics has developed very considerably, neglected children. Besides this to counteract most effective level.
the study of heredity and environment have the risk which threatens the child in a morally
9.
Preconception and prenatal assistance:
led the pediatricians to extend their activities I abnormal family. The last named implies
not only to the moment of conception, but not only protection of the child against juvenile Preventive pediatrics for children should start
even before that up to post puberty when ! delinquency but more than that positive steps before conception. Adolescents should be
given
advice
on sex education and sex hygiene.
reproduction starts.
. to avoid mental trauma and antisocial orienta- Assistance to unmarried mothers in all its
The practice of pediatrics may be divided 1 lion from u very early age.
entirety must be provided.'.
in three branches,
& - dM
*
46
THE INDIAN JOURNAL OF MEDICAL EDUCATION
10. Emotional guidance: Prevention of
emotional illness is the most difficult and time
consuming area. Modern living, strife for
better standards of living, working mothers,
and disintegration of multigeneration family
units has compounded the problem of adjust
ment. The symptoms of emotional instability
are many and even if diagnosed and assessed,
the quantum of advice to be given and its
acceptance is always problematical.
11. Social Health; previously considered a
concern for parents, clergy, school teachers and
state, is now suggested as one of the areas for
activity for Pediatricians. Stealing, Drug
abuse, School drop outs, premarital inter
course etc. are the problems that might involve
the pediatricians cari: b for the youth. It
seems obvious the physician must acknowledge
the impact that poverty and social ills have on
children.
12. Family Planning advice is most essential
in developing countries and countries with
poor economy. Not only advice on limitation
of the family but on spacing as well should be
given. Someone may say that this is the field
for obstetricians I believe that Pediatricians
since they are family physicians should be
more responsible for it than even the obstetri
cians.
Now once we have defined the scope the
next step would be planning for achieving
these. The basic services needed are, well
baby clinics, both in urban and rural areas. It
is unnecessary to elaborate on their importance
and I shall not dwell on this familiar topic
except to mention their value in health
education of the mothers and the family,
and in impressing about the preventive services
from an early age.
School and University health services which
should supervise the child from a very early
age with full time staff are indispensible for the
establishment of a sound preventive pediatric
services. Sex education, health and hygiene
are important aspects to be impressed and
explained, and thirdly establishment of a
national organisation at the level of Central
Government, State Government etc. to deal
^OL. Xll
NOS. I & 1 '
with all aspects of administration and planning |
pertaining to mothers and children’s health.
Control of environment eventhough difficult \
should be attempted as far as possible especially j
in children with poor social backgrounds, and ’
handicapped children.
And lastly it is necessary that good records I
are kept. These should include morbidity, '
mortality and vital statistics in that particular i
community. Besides these records of growth E
and development, incidence of handicapped
children and services available and rendered |
must be documented, if further assessment is t
to be of value.
Many allied services are important for car
rying on the task of preventive and social
pediatrics. These include milk banks, whert
any child can walk in and demand a glass of
good wholesome milk, foster parents, chronic s
sick homes, homes for children with sick oi ;
disabled parents, summer homes for healthy ,
children and homes for handicapped children, j
Population Education
The Changing Status of Pregnancy TerminationImplications for Medical Education
*
by
Donald H. Minkler M.D., m.p.H.
I have the temerity to appearon this program continuing education of those who were trained
not as an expert in Indian Medical Education, in an era in which abortion was virtually taboo
but rather in the spirit of sharing experience and medical practice generally isolated from
which is the hallmark of international coopera the social concerns expected of today’s commu
tion. The State of California has since 1967 nity minded health worker. Not only the
undergone a liberalization of its abortion law philosophy, but also the technology of abortion
similar in many respects to that which India has undergone revolutionery change calling for
now faces. We were, as you are, faced with training of those who now face a rapidly grow
the necessity on the one hand of adaptation to ing demand for this procedure in the new
an abrupt change in the supply : demand situa
Physicians dealing with children should keep i tion involving an important medical transac techniques of suction-aspiration, amniocentesis,
in touch with various organisations working I tion, and on the other the need to train physi and the management of the inevitable compli
towards the same end. These include parent cians and their co-workers in the provision of a cations of induced abortions.
associations, adoption societies, youth organisa
Fortunately, the need to impart the necessary
tions, cultural centres, sports clubs, and other highly sensitive procedure with profund emo judgement and skills required for the care of
tional and religious overtones. It was my pri
organisations for children and young people
growing numbers of women requesting abor
vilege
to
serve
as
Medical
Director
of
an
ex
Voluntary organisations and social welfare I
periment in the team approach to abortion tion coincides with the new emphasis given to
agencies merit a special place among these.
service,1 conducted by an affiliate of Plan reproductive biology and fertility control as
So, it becomes necessary for anybody wish ned Parenthood - World Population in coopera high priority subjects in medical education.
ing to practise pediatrics that he or she should tion with the University of California School Last year’s tenth Annual Conference of this
*
is testimony to this emphasis.
have the ‘social sense’, besides his professional of Medicine. This paper attempts to adapt a association
capability. By this I mean the capacity U, philosophy of abortion service growing out of As the Medical Colleges address themselves to
understand others, the capacity to guide ant ■ that experience to the educational require needed modifications of curriculum, training
>n management of problem pregnancies will
instruct. Preventive and social pediatrics muc ments of India’s current situation.
—.pefully reflect the interdepartmental coordi
permeate the curricula of all future teachen
The emergence of abortion in recent years nation that the technical, sociological, and
administrators, town planners, community
workers, agriculturists and all child health an< first as an increasingly accepted therapeutic psychological aspects of abortion care require.
care workers, for whom it is essential to knov modality, and now as a legally sanctioned pro
In the 1969 survey of the curricula of ninety
all aspects both physical and mental health o cedure with added humanitarian and eugenic three medical colleges in India reported by
justification poses an immediate and compell *Rice, practical experience in specific Family
the child entrusted to them.
ing challenge to institutions engaged in the Planning related procedures was reviewed.
training of health workers at all levels. Opinion Most colleges did not allow students to insert
References :
surveys, such as that conducted by Israel in
1. Acta Pediatrica. Supplement 151. 196 Bombay in 1969 indicate the wide variance of IUD’s, deferring this experience to the intern
(Symposium on preventive pediatrics in th attitudes of physicians as to the proper place ship year. Very few permitted assists in tubec
tomy and experience in vasectomy, with a
undergraduate curriculum).
of abortion in medical practice. Clearly, we single exception, was not regarded as an under
face an educational task, not only at the under- graduate requirement. Clinical experience in
; graduate level, but also in the re-education and abortion was not surveyed in these question• Paper Prcicntcd al the XI Annual Conference of IAAME at AFMC, Poona, Feb‘72.
VOLUME 18—OCTOBER 1981
UNDERGRADUATE
PEDIATRIC EDUCATION
IN INDIA
K.K. Kaul
of internal medicine at par with system
specialities, such as cardiology and neuro
logy. As late as 1955, no department of
pediatrics in the country was autonomous.
Indeed the first chair in pediatrics was
established in 1948, by 1965 fifty two, 6y
1968 sixty four and by 1971 seventy five
departments were functionally independant(4) (Table). Even until recently, not
all departments of pediatrics enjoyed auto
nomy. A glaring example in this regard is
a premier postgraduate institute whose
department of pediatrics remained for
long a subdepartment of internal medicine.
Another major factor that adversely
influenced the development of under
graduate education in child health was the
rapid expansion of medical colleges from
17 in 1947 to over a 100 at present. This
expansion together with lack of facilities
for postgraduate education in pediatrics
in the initial stages resulted in considerable
difficulties in provision of suitably quali
fied and trained teaching staff to depart
ments of pediatrics. With increase in the
number of colleges the student intake in
each college also increased(5). Since major
efforts were chanelled into expansion, the
Teaching and services of no other
discipline of vital national importance and
priority have suffered as much as that of
child health. Despite much lip service,
concern about health of children and
appreciation of its direct relationship to
Maternal and Child Health/Family Plan
ning, child health enjoys a lower priority
in both services and training of a basic
physician. For instance, in hospitals dis
tribution of beds and consequently of
staffing, drugs and equipment continues to
remain in striking contrast to the sick
child population needing curative services.
Not more than 10-15% of total beds are
allotted to children’s wards in spite of
over 40 % population comprising children
below 14 and higher sickness rates in them.
In a routine day’s work of a general duty
medical officer, 40-70 % of all patients are
children below 14 years, yet only 10%
of the total clinical teaching time is allotted
TABLE—Number of medical colleges &
to pediatrics(l,2).
Training and assessment of students autonomous department of pediatrics after
independance
in child health have suffered for a number
of reasons. Historically, medical education
in India, as in some neighbouring count Year No. of medical No. of autonocolleges
mous Deptt. of
ries, was founded upon the British pattern,
Pediatrics
but remained nearly static after independance(3). It has not undergone any I 1947
17
—
substantial change in response to the needs [1955
32
4
and aspirations of the masses. Older and 1965
85
52
established disciplines continued to exert 1968
92
64
their pressure and consequently delayed 1971
100 (Aprox)
75
the progress of pediatrics—a relatively
new subject and considered then a branch
course content and curricular organization
From the Smt. Patel Pediatric
Centre, Govt. did not undergo any extensive revision to
keep pace with social change and the
Medical College. Jabalpur 482003 (MP)
695
KAUL
UNDERGRADUATE PEDIATRIC EDUCATION
resultant changing health needs of vulner coordinated and not all teaching need be
able populations, particularly women and done by those working in the departmeni
children. Most departments of pediatrics of pediatrics(5,6).
The inclusion of pediatrics in the final
are directly involved in national health
programmes including MCH, EPI, Post MBBS examination by the Medical
partum programme, I .C.D.S. etc, to name a Council of India continues to face severe
few. Together with responsibility for rou opposition from certain sections of the
tine teaching and services it amounts to a college medical faculty, some members of
heavy work load for a small number of which take greater pride in ‘loyalty’ to
faculty members not exceeding five in an their own subjects than to medical edu
average medical college, yet proposals cation at large or merely tread the path of
for expansion of pediatric departments least resistance by opposing any change.
do not receive the consideration they It is argued that introduction of pediatrics
(or other essential matter relating to other
deserve.
Old curricula in most medical colleges subjects) will increase the burden of the
in the country suffer from the traditional already over-burdened student. The ans
separation between pre-clinical and clinical wer to this is not exclusion of clinical
teaching and the expectation from the disciplines essential to the graduate doctor
student to assimilate a large amount of in conducting his day to day practice but
factual information. The teaching of pre- indeed inessentials in the vast undefined
and para-clinical sciences generally remains course that have for long harassed the
confined to the fully grown and mature student in established disciplines like
adult as though what applies to an adult internal medicine and surgery. Medical
could automatically apply to a child on a science is ever expanding and unless the
smaller scale. Teaching of pediatrics has course content of each subject parti
remained heavily curative oriented and cularly internal medicine and surgery is
institutional. Severe constraints of time clearly defined (not merely as a ‘syllabus’
have prevented introducing to the student but a clearly spelt out course-content)
the bare concepts of child health parti and the student is made aware of essen
cularly in the area of growth and its tials that he must know and the skills he
variations and its determinants from birth must be able to perform, his ‘burden’
to adolescence, preventive and promotive will never cease to grow. The Medical
child care, economic cultural and demo Council of India, universities and Medical
graphic factors influencing child health Faculties need to engage in the exercise of
and the need for education of parents, removing what is unnecessary and pre
teachers, paramedical staff, social workers paring precisely defined curricula for each
and others towards better ultimate health subject based on essential requirements
care of children. These aspects of teaching of a general duty medical officer in his
require to be done with the agreement and daily medical practice. This will doubtless
cooperation of other departments espe focus the students’ attention to essential
cially Obstetrics and Preventive & Social knowledge and skills resulting in better
Medicine. Inter departmental cooperation performance not only in- the examination
is being increasingly recognised as essential but indeed also in general practice. If
for effective teaching and for setting a this Tact is appreciated and put into
necessary example to medical students. practice there should be no difficulty in
Besides, the total teaching should be implementing the revised directives of
696
INDIAN PEDIATRICS
VOLUME 18—OCTOBER 1981
Medical Council of India relating to late sixties (9-12). To that end WHO has
student assessment. The role of the gra supported the work of a committee of
duate doctor in providing health care to medical educators which has studied the
children as a priority has recently been teaching of child health and has published
appreciated by Medical Council of India. an experimental curriculum suitable for
As a result the requirements of the under use in medical colleges in India (12,13).
graduate curriculum have been revised The first objective of the ‘Ad hoc’
and adopted in 1977(7) to include pedia committee on education and training in
trics at the final MBBS examination as a Pediatrics in designing the curriculum was
section of internal medicine and to provide to see that it has relevance to the needs
3i months clinical posting in the children’s of the country and to the development of
wards. It is unfortunate however that medical services. It was clearly realised
Jwpite of clear directives of the Council, that such a curriculum must necessarily
wnich have become an act of Parliament, observe realities of conditions and work
Medical Faculties of universities have been within the limits and constraints existing
slow to implement them thus delaying or in teaching hospitals in the country. The
denying the nation’s over 270 million experimental, ‘remodelled’ curriculum thus
children their right to appropriate health prepared took into account the heavy
care through medical graduates properly clinical work in the wards and the OPD,
its workability in an average sized depart
equipped to provide such care.
In 1970, 90% institutions provided ment of pediatrics with material resources
less than 300 hours of teaching time for available in such a department, acceptabi
pediatrics and it seems the situation has lity to the college teaching faculty without
not since changed substantially. A foreign disturbing the overall curriculum and
visiting team that came to India in the 50’s working within the directives of Medical
stated that the undergraduate curriculum Council of India. This remodelled curri
seems to have been prepared as if to culum has been operating at two medical
deliberately belittle it in the eyes of the colleges in the country(13) which serve as
student. A WHO Committee in 1957(8) demonstration centres for this curriculum.
agreed that without a minimum of 300 A WHO fellowship scheme enables pro
hours it was impossible to do justice to a fessors and senior teachers of Pediatrics
pediatric curriculum. For adequate cover from other colleges to observe and parti
age more hours were thought necessary cipate in teaching this remodelled curri
and an allocation of one quarter of the culum at the two colleges. From available
clinical time to pediatrics was envisaged reports this has been a useful experience
as a reasonable proportion. These require both for the teaching staff of the two
ments are nearly met if the directives of centres and over twenty professors who
the Medical Council of India providing have so far participated in teaching at
3i month’s clinical posting are imple these centres.
Since MCH care at the block (PHC)
mented and at least 50 lecture hours are
allotted to pediatrics in the undergraduate level is delivered by the same doctor, it is
necessary that every student should observe
course.
The Ministry of Health Government how such care is delivered by the PHC.
of India and WHO have been consistently Such an opportunity arises during intern
working in collaboration towards streng ship when the intern is resident for a
thening of pediatric education since the period of 3 months in a rural field practice
697
KAUL
UNDERGRADUATE PEDIATRIC EDUCATION
area attached to the medical college. To merely because they are available with
this end a curriculum has been developed out careful selection and planning can
by a WHO ad hoc committee and is in be worse than a carefully prepared lecture
operation at two centres in the country(14, delivered without such aids.
15) where departments of Social and
As stated earlier, inadequate teaching
Preventive Medicine, Obstetrics and Pedia time, lack of appropriate curriculum
trics are jointly responsible for the working planning and the absence of student
of the curriculum. Fellowships available assessment in Pediatrics at the final MBBS
from the WHO on nomination by Govern examination have turned out medical
ment of India enable senior teachers of graduates poorly equipped in the health
these three disciplines from other colleges care of children(15). Refresher courses
to visit these demonstration centres for 6 and continued education in child health
weeks and participate in teaching the for those who have been in practice there
curriculum as a team.
fore assume an importance greater than
A long felt need in the field of pediatric that of any other clinical discipline.
education in India has been suitable text Planners of medical education and health
books for students and practitioners avai services need take note of this urgency.
lable at low cost, dealing with prevention
In conclusion health services for chil
as well as cure, descriptive of common dren and Pediatric undergraduate edu
diseases and symptom complexes, infor cation have thus far, undergone a painfully
mative on nutrition, growth and develop slow metamorphosis to the detriment of
ment and related to economic facts, des proper development of human resource
criptive of practical techniques in common material and of consequent national pro
use, suitably illustrated and descriptive ductivity. These errors and omissions need
of the clinical approach to the sick child to be remedied and personel gains sacrificd
and his parents. A handbook on child in the larger National interest by those
health care based on these parameters is responsible for implementing policies in
under preparation by the WHO and is medical education.
likely to be available soon. Several books
written by Indian authors are also now REFERENCES
available and one by the Indian Academy
1. Kaul KK. Editorial. Undergraduate teaching
and general practice. Indian Pediatr 1973;
of Pediatrics is under preparation. Many
10:203-206.
more books on various aspects of Pedia
2.
Kumar RC, Kaul KK. The pediatric compo
trics and relevant to the national needs are
nent of practice in Jabalpur. Indian Pediatr
required to enable students and practi
1973; 10:103-110.
tioners a wider choice of subject matter.
3.
Kaul KK. Notes on Pediatric undergraduate
teaching in Europe & East Africa. Indian J
With no further increase in number of
MedEdn 1967 ;6:1-10.
medical colleges it is now possible to
4.
Rao MN, Harish Chandra. Present statin of
strengthen and improve undergraduate
pediatric undergraduate education in India.
medical education generally. Government
Indian Pediatr 1973; 1:121-124.
funds and assistance from UNICEF/
5.
Miller FJW. Present status of undergraduate
education in India. WHO Report of the meet
WHO have enabled provision of audio
ing on pediatric education in India. Document
visual aids to institutions. While these
SEA/MCH/49,1969.
aids are very useful it is necessary that
6.
WHO Report of a meeting on pediatric edu
teachers understand the skilful use of these
cation. Document SEA/MCH/61 (SAE.'
aids and their maintenance. Utilising them
Medical Education/130) 1970.
698
INDIAN PEDIATRICS
VOLUME 18—OCTOBER 1981
Education and training in Pediatrics. Docu
Medical Council of India. Recommendations
ment SEA/MCH/74, 1971.
on Undergraduate Medical Education 1977.
WHO Report of a meeting of the ‘Ad hoc’
8.
WHO Report of a study group on Pediatric 12.
Committee
on Postgraduate Education in
Education. WHO Technical Report Scries No.
Pediatrics in India. Document SEA/MCH/101
119, 1957.
(SEA/Medical Education/249), 1975. .
9.
Govt, of India Ministry of Health & Family 13.
Kaul KK. The teaching of child health in a
Welfare, Deptt. of Health. Report of Medical
medical college in Central India. Brit J Med
Education Conference, New Delhi. July 6 & 7,
Edu 1978; 12:413-416.
1971.
14.
Philip E. Development of MCH curriculum for
10.
WHO Report of a meeting of the ‘Ad hoc’
undergraduates in medical colleges. Indian
Committee on Pediatric Education and Train
Pediatr 1981; 1:429-433.
ing during the Internship and Postgraduate 15.
Desai AB. Teaching of integrated MCH/
study for the Diploma of Child Health and the
Family Welfare programme. Indian Peditr
Doctorate of Medicine. Document SEA/
1981. 18:435-442.
_ MCH/FP/30, 1974.
16.
Pohowalla IN. A note on Pediatric Under
^PwHO Report of a meeting on Postgraduate
graduate Education. Personal Communication.
7.
699
SOCIAL PEDIATRICS AND INTERDISCIPLINARY APPROACH
TOWARDS COMMUNITY AT HYDERABAD (A.P.)
YOURAJ CHANDRA MATHUR
*
Clinicians throughout India are now
fully aware of the enormous responsibility
due to the 2.5% growth rate resulting in
an annual addition of above 13 million
babies in this country. As Pediatricians, we
responsible for the health aspects of the
Sffmunity which we are serving and there
fore the aim should be to minimise the
mortality and morbidity amongst children
and also to lay down priorities in the pro
gramme. No doubt, limitation of the family
is extremely important but it is quite vital
for all health workers to also see that the
children who are born should survive longer
and grow into a healthy adult. An analysis
of the mortality figures shows that 4’3% of
the total deaths are in the pediatric age
group and a further break down shows that
31% of the deaths are in children under
5 years. 16% die in the neonatal age group
and another 15% die before they reach the
age of 5 years. Therefore unless this is
efficiently looked into, on a mass scale, the
t^Bers cannot get convinced for family
planning, only on the demographic, social
and economic arguments, specially the less
educated ones.
means of hospital data or much better, by
a door to door survey This will give the
top ten diseases and therefore it will help
in carefully planning preventive programmes
in the community. Like all the developing
countries of the world, in India too, nutri
tional problems, gastroenteritis, respiratory
problems and infectious diseases top the
list. There is a little bit of regional variation
in our country but by and large similar
problems are confronted by health workers.
Problems
1.
Before planning an effective health pro
gramme for any group of population it is
imperative on the part of a clinician to
know the mortality and morbidity pattern
of the community. This can be done by
Asst. Professor of Social Obstetrics, Post
graduates, Lab technician, Health
Visitors.
2.
Asst. Professor of Social Pediatrics,
Nutritionist, Postgraduates doing
M. D. & D.C.H., Health Visitors.
The Institute of Child Health, Osmania
Medical College, Hyderabad has undertaken
the task of reducing the mortality and
morbidity by the following ways.
Prevention of Infections
1.
2.
3'
4.
Immunization.
Nutrition and vitamin supplements.
Nutrition and health education.
Environmental sanitation.
These four ways of preventing infection in
the community is done by the Department
of Social. Pediatrics. This team, headed by
Addl. Professor of Social Paediatrics, consists
of:—
* Addl Professor of Social Paediatrics, Institute of Child Health, Hyderabad.
6
IND. JOUR. PREV. SOC. MED.
3.
Asst. Professor of Social & Preventive
Medicine, Health Educator, Social
Worker, Postgraduates, Interns &
Undergraduates.
VOL 3, MARCH, 197
sive survey and after studying the commit
nity, the maternal and child health tea
started their action programme. Weekl
clinics are conducted wherein the mothers an
4.
Local resident staff of the Primary or children are examined for whole day. Duripj
the first year, only six villages within 3 mil
Rural Health Centre or Institute.
radius of Shankerpally were selected. Th
Thus, this team of Social Pediatrics has all total child population under six years wa
the three important disciplines—the S. P. M., about 2,000 and expectant mothers were 50(
Obstetrics and Pediatrics, and through this Thus, the team concentrated in the I yea
team an interdisciplinary approach has been on preschool children and pregnant mother!
planned in the following three areas :—
The field unit provided the evaluation of th
I. RURAL :—Chevella block under the programme. In the II year 2 more village
Indo-Dutch Project for were added to Primary Health Centrq
Shankerpally and two more sub-centr^
Child Welfare.
Pattancheru under the Maharajpet and Dhobipet were opened ti
covert-he- Northern part of the Chevellt
Osmania Medical College'.
block. The whole of the Northern part c
II URBAN :—Puranapul Centre - Under
the block is covered now. Since it is at
the Municipal Corpora
eight year project, every two years the tear
tion of Hyderabad.
will move to other main centres. Trainihj
III. Institute of Child Health, Niloufer is given to the local doctors, health visitor
Hospital, Hyderabad.
and other paramedical personnel. It 1
This team works in all these areas during expected that in 7 years time, the mortality
and morbidity will be brought down.
the week. Background and baseline data
for all the areas was collected before the
Emphasis is on the total care of tb “
actual action programme was started.
child.- Good and efficient curative treatmen
The Indo-Dutch Project for Child Welfare — At
the Chevella block under the Indo-Dutch
Project for Child Welfare, an eight years
programme has b£en started in January, 1970.
Initially, a survey of the entire block was
done by the survey team from Social
Pediatrics Department and the National
Institute of Community Development. This
survey by SPM Asst. Professor and his team
and the N. I. C. D. was carried out to know
the population structure, beliefs and taboos,
child rearing practices, socio-economic
conditions, cultural and feeding practices,
morbidity and nutritional assessment and
environmental factors. After such an inten-
is given to all children to gain the confidence |
of mothers and to minimise admissions >
hospitals Every child on arrival is given ,
token number and a weight card. Th 11
child passes through six places wherei
*/-!
he is weighed, height and circumference
taken, examined, immunised and then he '
goes to nutrition and health education
clinic and finally for getting drugs if requiredThus all aspects of child health are covered
*
There has been a good community response
to protein supplements. The villagers are,
themselves preparing the protein packets with.bengal gram and groundnuts. The produq
tion of ground nut has increased by 3 time
*
Social pediatrics an^nterdisciplinary approach towards c^munity
Anthropometrically, the children
have
attained better heights and weights and their
nutritional status is very good. Due to this
comprehensive care, the mothers who were
previously reluctant for family planning
measures are now voluntarily and willingly
coming forward for tubectomies. The inci
dence of neonatal tetanus has come down due
to immunisation of the mothers with tetanus
toxoid. The morbidity pattern has changed.
Protein Calorie Malnutrition, which was
topping the list of diseases, has come down to
thi^kdace now. The local dais who were
pr^musly conducting the deliveries at home
are now trained and they have thus brought
down the neonatal and maternal deaths. The
survey revealed that every 3rd child in the
preschool age group has vitamin A deficiency
and therefore all children in this age group
are now receiving Vitamin A supplements.
Two lakh units of vit. A are given every
6 months for 3 such doses.
Evaluation is
done, time and again, about the whole pro
gramme and its benefit to the community.
Thus, this combined team of obstetrics, pedia
trics and social and preventive medicine has
started paying its dividends. Andhra Pradesh
is the first State in our country to start a
department of Social Pediatrics and it has
already shown its good results in the commu
nity. Therefore even if a separate depart
ment of Social Pediatrics is not formed, it is
our plea that similar programme can be
undertaken throughout the country by full
co-operation of all these three departments.
ROLE OF SOCIAL PEDIATRICS IN THE INTERDISCIPLINARY
APPROACH TO COMMUNITY HEALTH CARE
AJIT KUMAR
*
The role a pediatrician can play in
community health is very important and it
is interesting to note what he has been doing
all these years with regard to the problems
d how -they could be solved with the
se co-operation of other departments.
The team of social pediatrics has members
from different disciplines namely, obstetrics,
pediatrics, social & preventive medicine, and
nutrition. Thus it is an interdisciplinary
approach towards the comprehensive care
of the child in relations to his family ahd
environment. We have a clinical and a
All along, the emphasis in medical care
field division. Field programmes are carried
has been to treat the physical illfiess of the
out by a survey team. The home visits,
individual patient. Advances in public health,
psychiatry and social sciences have given wider besides offering an opportunity to work
outlook of comprehensive medical care in within the community, provides a realistic
contrast to fragmented specialised one. Yet picture of peoples health problems as they
this concept of total care has not been widely exist in the community which would help
practised, perhaps
because ‘laboratory in developing comprehensive service pro
medicine’ has paid more dividends and grammes for mother and child. Secondly,
prestige to the research workers. The pedi the survey team through its movement within
atrician must be able to discuss the social, the community serves as a liason between
educational and cultural factors that lead the people and the clinical team which
to conditions like anaemias, protein calorie mainly engages itself with immunisation,
malnutrition, toxaemia and others. He, in nutrition, therapeutic and anthropometric
collaboration with the obstetrician and social work at particular place. There has been
d preventive medicine specialist, needs a tremendous reduction in the incidence of
understand the causal relationships different diseases specially those of infectious
between socio-economic status of women and nature in the developed countries. This is
episodes of premature births, low birth because of the advent of different immuni
weights and high perinatal mortality. Andhra zation agents and an improvement in the
Pradesh is the first State in our country to socio-economic status of these countries.
start an interdisciplinary approach towards To plan any programme for the improvement
the total child care in a community as a of health of a particular community or
pilot project, at the Institute of Child Health,
country it is essential to know the pattern
Niloufer Hospital, Hyderabad within the of morbidity and mortality in that area.
department of social pediatrics under the Indo This in turn would help us to know the
Dutch Project for women and child welfare. need for medical and paramedical staff to
«
•
Apst. Professor of Pediatrics, Niloufer Hospital, Hyderabad.
role of social pediaWics in the interdisciplinary approach
provide nation-wide health care of abetter
quality.
Our Set up - At the Shankerpally P.H.C.
in Chevella block of Hyderabad district,
our team of social pediatrics visits every
Wednesday and Saturday and conducts an
obstetrics and pediatrics clinic. The pro
gramme undertaken mainly relates to —
I. Clinical evaluation of children under
5 years and mothers in child bearing age.
2. Evaluation of nutritional and growth
statuiof children and mothers.
Immunization of children against
communicable diseases.
4. Supplements of vegatable protein
mixtures to the home diets of pre-school
children.
4. Iron and folic acid and other supple
ments to antenatal mothers. This is under
taken by the social obstetrician.
6. Concentrated Vit. A supplementation
to pre-school children.
The centre was opened under the Indo
Dutch Project for child and women welfare
in February 1970. During the first six
months a study of 450 children attending the
clinic showed the following disease pattern.
P. C. M.
Resp. Tract infections
Gastroenteritis
Vit. deficiency (Vit. A & D etc.)
Skin diseases
Eye. E. N. T. Dis.
Infectious diseases
Tuberculosis
Total
128 cases.
112 cases.
92 cases.
74 cases.
32 cases.
6 cases.
4 cases.
2 cases.
450 cases.
Protein calorie malnutrition topped the
list followed by the respiratory infections and
gastro-enteritis. Therefore, under this pro
gramme we are emphasising on the most
W
9
commonly observed problems like P. C. M.,
Vit. A. deficiency and anaemias rather than
the rare clinical entities like congenital heart
and other rare syndromes. The economic
implications of such an approach are well
known to all of us.
The protein calorie malnutrition was dealt
with by vegetable protein packets whose
formula is given below.
Wheat
35 gms.
Groundnuts
6 gms.
Bengal gram
11.5 gms.
Skim Milk Powder
6 gms.
Sugar
11.5 gms.
70 gms.
Calories
Proteins
Cost
250
10 gms.
12—15 Paise.
These packets are prepared in Niloufer
Hospital and are based on locally available
foods. They are given free to children
suffering from protein calorie malnutrition
for first 3 weeks and when the child shows
signs of improvement (disappearance of
oedema; alertness in child) then the
mother is told by the Nutritionist about
the contents of protein packets.
The
mother is encouraged to make such packets
at home. There has been a very good
community response
to this nutrition
programme. Many of the mothers have
started making these packets at home and
bringing them to centre. Advantage is
taken of such-enlightened and enterprising
mothers and they are made to speak to
the ladies in the nutrition room. Thus this
feed back technique not only encourages
mothers but also gives confidence to them.
The very fact that the P. C. M. has become
number 3 in the incidence of the disease
pattern in the study of 2,030 children after
10
IND. JOUR. PREV. SOC. MED.
VOL. 3, MARCH, 1972
dJ years of starting the clinic proves the
success of this programme The study of
2,000 children at Shankerpally after 1J years
revealed the following disease pattern.
Respiratory infections
...
Gastro-enteritis
...
Protein Calorie Malnutrition ...
Vitamin Deficiencies
...
Skin Infections
...
Eye and E. N. T. Dis.
...
Infectious diseases
...
Tuberculosis
...
Miscellaneous-Cong. Dis.,
P. U. O. etc.
...
For immunisation.
...
Total
480
430
370
340
200
62
26
4
40
48
2,000
The second great task is of conquering the
killing infectious diseases. This can be met
with the active immunization programme
throughout the country. When our scheme
was started only 60% of the children were
immunised against small-pox. Now 95% of
the children of the area are immunised
against smallpox, B, C. G., D. P. T. and
Polio.
Unfortunately, in our country smallpox
vaccine is the only one which is easily avail
able followed by cholera and T. A B. The
vaccines like D. P. T., Polio and Tetanus
toxoid are not available free in all the hospitals
and health centres. B. C. G. vaccination
is possible only if team is operating in the
area. Even if the medical officers and general
medical practitioners want to do immuni
sation, they are not available freely. Pro
viding immunisation definitely works out
much cheaper than treating the disease.
During the survey in a sub-centre
(DhobipetJ and surrounding villages, many
cases of leprosy were found in children. This
lead to the study of incidence of leprosy in
the pediatric age group. The study was
conducted by house to house survey by this
integrated team.
Alternate houses were
surveyed and the coverage is as follows
Total number of houses in the village
739
Total number of houses surveyed
370
Total population
4,0.’5
The survey team consisted of Asst. Prof.
of Social Pediatrics, Asst. Prof, of Social and i
Preventive Medicine, Health Visitor, Health 1
Educator and two Leprosy Workers from Hind 1
Kusht Nivaran Sangh, a local guide and a j
local village headman. 103 cases of leprosy
in the pediatric age group could be detected
by the survey which would have been other
wise gone un-noticed.
Age Incidence
Rural.
Urban
0-5 Yrs.
8% .
8%
6-10 Yrs.
56%
38%
11-15 Yrs.
36%
54%
History of contact was present in 50,31
of cases. To compare this data a study was I
also conducted at an urban centre (Dhoolpet •
in Hyderabad city) where only referred |
cases attended daily.
Socio-economic Conditions—The peo- g
pie in the village live in a single room •
thatched house with poor ventilation, hud
dled together with leprosy cases and animals |
tied in the same premises. Now we haveg
started B. G. G. against leprosy to all the ■:
children in the area though the preventive^
role of B. C G. against leprosy is stillg
doubtful. A future survey may confirm ilsE
utility.
4
This clearly shows that all cannot b«:done by a pediatrician alone. Such comm»nity problems cannot be solved by a single
person or a single department. A team work
with an interdisciplinary approach is the
real answer for such community problems4
‘ ROLE or SOCIAL PED^TRICS IN INTERDISCIPLINARY APPROACH
11
Types of Leprosy
Lepromatous.
RuralUrban.
12%
2%
Non-Lepromatous
Tuber
Maculo
Poly
Anaes
neuritic.
culoid.
thetic.
16%
34%
28%
38%
Border
line.
—
—
4%
14%
N ? L
Indeterminate.
44%
8%
Every department should consider it their asion in introducing bengal gram and
duty to work in close collaboration and co groundnuts in their daily food. Nutritional
operation with the members of the team. problems can be solved by explaining about
every medical college has all—these_ the correct method of weaning. A social
departments in the college they could work obstetrician can help the pediatrician in
hand in hand towards the care of commu cutting down the incidence of neonatal
nity. All the assistant professors, postgradu tetanus by giving tetanus toxoid to the
ates and undergraduates should be posted pregnant mothers and explaining to the
by rotation atleast for six months to one mothers about the necessity of cutting the
year, so that all should become aware of cord with a sterilised knife.
what is meant by Preventive and Social
The average pediatrician is now so comple
Pediatrics. When posted outside they can tely occupied in curative practice that he is
implement such programmes and give a unable to devote enough time to preventive
practical approach towards the care of the pediatrics, particularly child nutrition. The
block for which they are responsible.
pressure of work in the General O.P. Depart
A similar study about child rearing and ment does not permit him to advise the
weaning practices in 500 mothers was carried mother about the feeding. In our hospital,
out at Shankerpally. It was found that the fortunately, we could succeed in opening
mothers commonly applied tile paste on
(1) Nutrition clinic where the pediatricians
small-pox vaccination which is the main refer all nutritional problems. The dietitian
caq^kof tetanus in infants. They apply and the nutrition research assistant help the
counter irritants on forehead or temple mother in solving their nutritional problems
region in case of convulsions, cut the umbili apart from teaching undergraduates and
cus with the sickle, do not give ground-nuts postgraduates in this clinic. (2) Immuni
with the belief that it causes nausea, late zation clinic, where all the children are
weaning practices, not using bengal gram immunized against D.P.T., Polio, Smallpox
as it causes formation of pus etc. They and B.C.G. (3) Child guidance clinic, where
threaten the children with dire conse children are referred for any behaviour
quences by taking the names of wild animals, problems. (4) Well baby clinics, where the
ghosts, old ladies and beggers if they did newborns are taken care of regarding growth
mischief or refused to take food. Such taboos feeding and weaning practices. (5) Clinicoat>d beliefs can be overcome by this team social conferences are held every month
approach. We could succeed by our persu wherein undergraduates study a problem
12
ind. Jour.
w EV. SOC. MED.
regarding their clinical, environmental, socio
economic and related maternal problems
in the hospital.
In a poor country like ours there are many
diseases prevalent but in any programme top
priority should be given to the most common
prevalent conditions.
Our problems are
mainly malnutrition and vitamin deficiencies,
where much can be achieved with minimum
expenditure and genuine effort. Unfortu
nately emphasis in postgraduate and under
graduate teaching has been always towards
1 diseases and the treatment and complications.
Not much emphasis is given towards the
prevention and nutritional aspects with the
result that the medical student during the
undergraduate and postgraduate training
today does not attach much importance to
learning
about
vaccination,
nutrition
(common food values) and health education
and carries out these activities with great
reluctance. It is considered to be a job for
Nurses, Health Visitors, Public Health Nurses
and Social Workers.
A modern medical
student would- not know the common food
values but will be expert in all the rare
syndromes which is not useful for him in a
rural P. H. C.
Family Planning and Pediatrics
Portman (1971) at the Second National
Pediatric Conference at Bandung, Indonesia
in April 1971 has correctly explained the role
of pediatrician in Family Planning.
Family Planning—its implementation and
success is not the sole responsibility of an
obstetrician. The department of obstetrics
and gynaecology cannot meet this challenge
alone. Much can be achieved by close
collaboration of all the three departments
of obstetrics, pediatrics and social and
preventive medicine.
Wol. 3, MARCH, 1972
The role of pediatrician in the promotion
and acceptance of family planning is very
important as he comes in close contact with I
mothers and children than any other medical I
specialist and he will have the full confidence
of the mothers after he has demonstrated that
the health, and if necessary the cure of their
children, “are main concern. Therefore they
will listen more carefully to any advice that
he will give them. This approach is followed
by our team at the centre. During filling the }
card of family and their income, the mother
with large family and poor income is |
immediately interviewed and referred to the |
social obstetrician in the opposite wing. The '•
response to the family planning has been very
encouraging at Shankerpally due to the joint ’•
effort.
According to Dr. Beasly “The principle reason why family planning is not practised
among the poor is lack of knowledge and :
lack of adequate service” and such a team ;
as that of ours at Niloufer Hospital not only gives the service to the child and the |
family but also helps greatly in giving g
clients the necessary knowledge about family g
planning.
According to Dr. Helen Wallace “Com- :
bining maternal and child health and family ;
planning may have a better chance of impro- ■
ving the quality and paiental care in .
present society” but also improvement ofhealth services for mothers and children is ’
a pre-requisite for family planning. Oneof the reasons for having many pregnancies f
was the fact that parents knew, from pastj ;
experience, that high percentage of their|
children would die, so that it was necessa ry
to produce more children to have thedesi-L
red family size. But before we can convinced
the parents that they should limit the
number of pregnancies, we must be able
ROLE OF SOCIAL OBSTETRICS IN THE INTER DISCIPLINARY
APPROACH TOWARDS RURAL HEALTH CARE
SALEHA QURESHI
*
Obstetrics relates more closely to public
health than does any other field of medical
practice. Medical institutions have failed
to give sufficient impetus to the teaching of
social obstetrics. Social aspects in the
teaching of obstetrics and gynaecology
are defined as those aspects of personal and
community life which have a bearing on a
women’s reproductive life.
The purpose of medical education is to
prepare a good general physician who is
able to serve the community as well as the
individual.
The ethos of family care, and the accept
ance by the rural people of a continuing
doctor-family relationship makes combined
obstetrics and pediatrics work more desirable.
Postnatal care and family planning naturally
harmonize with initiation into the immuni
zation programme, and with supplementary
feeding of the pre-school group. Domiciliary
visits will also provide opportunity for a
linear study of relationship between infant
morbidity and preceding birth events.
The trend in modern medicine should
be more towards coalescence than compart
mentalization of departments.
The Social Pediatrics department of
Osmania Medical College has taken the
lead in unifying the three related disciplines
of Obstetrics, Social & Preventive Medicine
and Pediatrics. This department represents
an
integrated
approach to teaching of
community medicine to the students. For
the teaching of community health, colla
boration with government health services
is required, like maternity and child welfare
centre for urban and primary health centre
for rural field practice area. This colla
boration has a two way benefit. It gives an
opportunity to avail the building and services
of the medical and para-medical staff an !
in return the public can avail “on the spot”
specialist advice and consultation.
In this paper the rural health care under
taken at the primary health centre at
Shankerpally, by the social obstetrics team
has been summarised.
Rural Health Care Programme at Village
Shankerpally
Shankerpally is one of the big villages
of Chevella Taluka, belonging to'Hyd.erabad
district of Andhra Pradesh. It is situated
about 26 miles away to the north west of
the city of Hyderabad and is connected by
road as well as by railway line. This
village along with the surrounding six
villages with a total population of 8,400 was
the area of operation for the year 1970-71,
and for the subsequent year two more
subcentres, Maharajpet and Dhobipet were
added, making a total population of 13,104
as the field practice area.
Asst. Prof, of Social Obstetrics, Osmania Medical College, Hyderabad.
ROLE of social obstetrics in the inter disciplinary approach
A regular maternity and child health
clinic was conducted at these places with
the help cf local medical and para medical
staff.
A preliminary survey was conducted in
this area, before starting these clinics, to get
the background information of the village.
This was done with the help of Assistant
Prof, of Social & Preventive Medicine. This
survey helped us in understanding the socio
economic and cultural behaviour of the
ple which has a bearing on the obstetric
blems of the community. Based on this
information the community health services
were formulated.
15
All the pregnant women of the area
under study were registered and were called
to the clinic for regular antenatal checkup.
Iron and folic acid supplements were given.
Nutritional status of these mothers were found
to be low. The reasons being poverty, igno
rance and certain prejudices due to cultural
factors. It was noted that no extra or special
diet was given to pregnant or lactating
mothers. Dietary intake studies made on 30
subjects gave the following results (table 1}.
«
The poor nutritional status of this commu
nity may be one of the contributing factors
to the low birth weight of the babies (the
Work done at the Clinic
usual birth weights falling between 5-6J
1. Conducting ante-natal and post-natal lbs). Protein and calorie' supplements are
being given to the mothers during preg
clinics.
2.
Giving prophylactic tetanus toxoid nancy and birth weight studies are under
way.
during pregnancy.
3.
Sorting out cases for hospital and
The poor nutritional status may also
home confinement.
be responsible for the high incidence of
4.
“Well women’s clinic ” ■
premature births in the community. Most
5.
Gynaecological clinic
of the mothers are not sure of their dura
6 Training of traditional dais.
tion of pregnancy, so many babies termed
7. Family planning clinic and conducting
“premature” might actually belong to the
periodic tubectomy camps.
so called category of “small for date”
8 Training of local medical and para
babies.
medical staff.
;
e 1
Number
Surveyed.
Non-preg
nant Women
Pregnant
mothers.
Lactating
mothers.
10
Recommended Allowance for Indians
(N I.N. 1968)
Total calories
Proteins
Total calories
Proteins
per day.
Gms/day.
per day.
Gms/day.
38
1600
45
2200
10
42
1800
55
2500
10
40
1800
65
2900'
16
ind. Jour. Wev. soc. med.
Incidence of Tetanus in the Community
Animal sheds were found in close vicinity
of the living rooms. At some places animals
and human beings lived under one room.
The practice of applying cow dung to the
umbilicus of the pewborn was also com
mon. Immunization of pregnant mothers
was adopted as a routine measure against
neo-natal and postnatal tetanus.
Analysis of the survey data indicated
that 27% of the infant deaths, before the
start of the programme, were due to neona
tal tetanus.
Out of 481 mothers who
received tetanus toxoid during pregnancy
under this programme, there was not a
single case reported of tetanus nor was there
any case of congenital malformation. Only
three cases of neonatal tetanus were repor
ted in this area during the preceding two
years. These cases did not belong to the
area and were not immunised.
>L. 3, MARCH, 1972
•_________________ Table 2
_________
Home P.H.C. Referal Total
Hospital
Normal
Forceps
Caesarean
Section
Tola!
264
—
24
—
6
4
294
4
—
264
—
24
2
"12
2
300
Before our programme started in this area,
hardly any deliveries were being conducted
at this primary health centre.’
Well-Women’s Clinic and Gynaecological
Clinic
Routine gynaecological clinic was conduct
ed and minor treatment like cauterization,
D. & C. were carried out at the P. H. C.
itself. A “Well-Women’s Clinic” was conduct
ed and cytological screening for cancer was
done for suspicious cases.
Training
Dais
Programme for Traditional
Chevella block has an area of 961.9 sq.
Sorting out Cases for Hospital and Home
kilometers and a population of I lakh 12
Confinement
thousand with only one primary health centre,
(a)
Cases
expected to have normal one civil hospital .and one civil dispensary.
There is a great scarcity of even trained
delivery were encouraged to have home
midwives (one midwife for every 8 to 10
deliveries.
___
thousand population). Rural India is still
(b)
Problem cases such as mild toxaemia, one of the most “under doctored” areas—
anaemia, twin pregnancy etc., were advised 90% of the deliveries in this area are being
to have medically supervised delivery at the attended by untrained barber midwives. It was
P. H. C. hospital.
decided to give training to these indegenous
(c)
Cases of gross cephalo-pelvic dispro barber midwives as they form a useful mem
portion, malpresentation and position, cases ber of the medical community. So far 40
of previous caesarian section were all shifted dais have been given, training to conduct
to institutions for institutional care and delivery in an aseptic and antiseptic manner
and also to detect cases requiring referal
confinement.
services.
They
were
provided
with
Table 2 shows the mode and place of UNICEF delivery kits and were paid
delivery of 300 cases which were analysed at incentive of rupee one for reporting each
delivery conducted by thcnq. This helped
the end of 1J years.
Wol. 3, MARCH, 1972
I^V. SOC. MED.
16
IND. JOUR
Incidence of Tetanus in the Community
Animal sheds were found in close vicinity
of the living rooms. At some places animals
and human beings lived under one room.
The practice of applying cow dung to the
umbilicus of the ijcwborn was also com
mon. Immunization of pregnant mothers
was adopted as a routine measure against
neo-natal and postnatal tetanus.
Analysis of the survey data indicated
that 27% of the infant deaths, before the
tetart of the programme, were due to neona
tal tetanus.
Out of 481 mothers who
received tetanus toxoid during pregnancy
under this programme, there was not a
single case reported of tetanus nor was there
any case of congenital malformation. Only
three cases of neonatal tetanus were repor
ted in this area during the preceding two
years. These cases did not belong to the
area and were not immunised.
_________Table 2
, ■
Home P.H.C. Referal Total
Hospital-
Normal
Forceps
Caesarean
Section
264
—
—
—
2
2
Total
264
24
12
300 ~
24
—
6
4
1
294
4
Before our programme started in this area,
hardly any deliveries were being conducted
at this primary health centre.Well-Women’s Clinic and Gynaecological
Clinic
Routine gynaecological clinic was conduct
ed and minor treatment like cauterization,
D. & C. were carried out at the P. H. C.
itself. A “Well-Women’s Clinic” was conduct
ed and cytological screening for cancer was
done for suspicious cases.
Training
Dais
Programme for Traditional
Chevella block has an area of 961,9 sq.
Sorting out Cases for Hospital and Home
kilometers and a. population, of 1 lakh 12
Confinement
thousand with only one primary health centre,
(a)
Cases
expected to have normal one civil hospital and one civil dispensary.
There
is a great scarcity of even trained
delivery were encouraged to have home
midwives (one midwife for every 8 to—10
deliveries.
thousand population). Rural India is still
(b)
Problem cases such as mild toxaemia, one of the most “under doctored” areas—
Anaemia, twin pregnancy etc., were advised 90% of the deliveries in this area are being
to have medically supervised delivery at the attended by untrained barber midwives. It was
P. H. C. hospital.
decided to give training to these indegenous
(c)
Cases of gross cephalo-pelvic dispro barber midwives as they form a useful mem
portion, malpresentation and position, cases ber of the medical community. So far 40
of previous caesarian section were all shifted dais have been given training to conduct
to institutions for institutional care and delivery in an aseptic and antiseptic manner
and also to detect cases requiring referal
confinement.
services.
They
were
provided
with
Table 2 shows the mode and place of UNICEF delivery kits and were paid
delivery of 300 cases which were analysed at incentive of rupee one for reporting each
the end of 14 years.
delivery conducted by therq. This helpe4
role of social obstWrics in the interdisciplinary approach
us to maintain accurate birth records in the
area of operation. It is also hoped that this
training to some extent will bring down
maternal morbidity and mortality and will
bring down the incidence of puerperal sepsis
in the community.
Family Planning Programme
It was found that the family planning
drive was more successful under this pro
gramme because of the combined obstetric,
paediatric, nutritional and preventive services
made available. Because of these above
sc^^bes the mother has a sence of security
for the welfare of the living children and
shows willingness to limit the family. It is
3
17
the personal belief that this approach is likely
to evoke better response from the community
than the mass tubectomy camps which lack
“doctor-patient relationship”.
Thus the obstetrician working in close
collaboration with the paediatrician and
social and preventive medicine department
will be in a better position to appreciate the
problem of community as a whole. This
awareness on the part of the obstetrician is
expected to go a long way in motivating the
students of medicine to put into practice the
concept of preventive and social obstetrics in
day to day life which is, and should be, the
aim of medical education.
—
—~---- ■-
ROLE OF SOCIAL AND PREVENTIVE MEDICINE IN AN
INTEGRATED TEACHING OF SOCIAL PAEDIATRICS
N. PRALHAD RAO#
The method- is Today, Social & Preventive Medicine in medical education.
(SPM) does not lack in statistics to snow that ‘subject-centred’ rather than ‘problemthe environmental hazards like bad housing, oriented’, is ‘curative-based
*
rather than
poor nutrition, improper sanitation and ‘preventive-based’ and is often taught
hostile social milieu are responsible for high as blocks of information more or less inde- •
proportion of diseases and premature deaths. pendent of one another with least involveBut it certainly suffers in providing evidence ment of community.
to prove that the proper attention is paid to
Secondly, the SPM“which bears relevance
the social and preventive aspects of medicine to almost all the medical specialities has
in teaching of medical sciences.
inadvertantly been dubbed as a non-clinical
During past two decades, many medical department in the complex of medical
colleges in India have established the depart education with the result it has unwittingly ~
ment of S.P.M. as an independent discipline, dissociated itself from the teaching progra
in line with other major disciplines like mmes of clinical departments, consequently
Internal Medicine and Surgery. In some it the teachers of SPM often taught the lessons
has been upgraded from part-time to full- of Social and Preventive medicine in isolation
fledged departmental status so that adequate without clinical and curative material around
stress could be laid on these two neglected them. As a result, the sense of service and
but important aspects of- medicine. But prestige (and also research) which is usually £
neither of the above steps taken by the associated with practice of clinical medicine »
Medical Faculties seems toTiave succeeded did not find place with social and preventive
in providing preventive and social concepts medicine.
of medicine to the students. It appears, as
Under these compartmentalised system of
though, the traditional academic distinction medical education in our medical colleges,
accorded to it as an independent discipline the role of Social and Preventive Medicine in
tended to foster separation of medicine into an integrated teaching . situation such as
two compartments viz, curative and preven social paediatrics is difficult to define. But,
tive medicine, at academic level and further having had an opportunity to work in a
the isolationist trends between clinicians and set-up which brought .together the three
public health workers at executive level.
disciplines of Paediatrics, Obstetrics and
This unfortunate situation is mainly due Social & Preventive Medicine, perhaps for
to conventional methods of teaching practised the first time under one canopy as a viable
Assistant Professor of Social & Preventive Medicine in Social Paediatrics Programme, Osman ia
Medical College, Iljderabad.
SPM IN INTEGRATED '^CHING OF SOCIAL PAEDIATRICS
teaching unit, we would prefer to describe
the way we went about in realising the
objectives of SPM in particular and medical
education in general, with respect to
paediatric teaching.
£
19
involved in studying a problem case from
clinical, social, economic and nutritional
angles. The ‘total’ study is accomplished
usually in 3 to 4 teaching sessions conducted
by the team.
(i)
In the first session the students are
Resetting of Priorities
Like other major clinical disciplines briefed about the broad aims and objectives
paediatrics also presents a wide-sp’ectrum of of the exercise to be undertaken by them.
clinical conditions requiring serious attention The students are also told about the major
in the teaching programmes of under-gradu public health problems that pertain to the
ates. But considering the morbidity pattern field of paediatrics. Stress is invariably laid
problems of pre-school
of local paediatric population and also the on nutritional
amiability of resources of men and material children in relation to their diet and feeding
tl^^ibject of Nutrition and Infection have habits, belief system with respect to child
been chosen as the areas to be dealt in depth feeding and child rearing habits of the local
by the department of Social Paediatrics. And community. The importance of anthro
taking into account certain organisational pometry in the evaluation of children’s
and other constraints which are likely to be growth status and the use of weight-charts
met with any institution of professional are explained in a general way.
education wishing to introduce major innova
(ii)
In the second session students are
tion into the curriculum and teaching encouraged to discuss the plan of investi
methodology, a workable teaching ‘plan ops’ gation. Usually during this session students
was drawn, in conformance with the ongoing are helped to evaluate the child’s clinical,
programmes of SERVICE, TRAINING and nutritional and socio-economic status. A
RESEARCH in and around the Institute of detailed account of the child’s feeding and
Child Health, Hyderabad. It is too well dietary habits (prior to hospitalization) are
known that unlike service, training and obtained from the mother. An assessment
research aspects do not become automatically 'of the mother’s health and nutritional status
an integral part of an action programme is made and her previous obstetric history is
ui^gs specifically developed. Hence, special obtained.
at^P.ion is devoted to develop these two
(iii)
The second session is followed
aspects in all the programmes undertaken by by visits to the home of the patient.
[the department. The main purpose of these The students and staff members jointly
[programmes is to discern the social, educati visit the family to observe for themselves
onal and cultural factors that lead to anaem the physical and social environments- of the
ias, toxaemia, PCM and other forms of family. During the visit the key members
common diseases in the area of maternal of the family arc interviewed by the students
fend child health (MCH).
in an informal way and assessment is made
[Training of Medical Students
with regard to family income, educational
I The under-graduate medical students status and cultural and behavioural pattern of
rho arc posted to Paediatric wards in the family. Dietary intake figures are obtai
Patches of tens and fifteens every month are ned by employing a questionnaire method
r
20
3, MARCH, 1972
IND. JOUR. PREV. SOC. MED.
(with the help of standardized cups when
ever necessary). Once complete information
is obtained, students are helped to critically
evaluate the child’s health and nutritional
status with respect to his home environment,
family’s socio-economic status, dietary and
feeding practices. At this point they need
guidance for doing library work, which
becomes necessary especially when they
wish to compare the anthropometric measure
ments and nutrient intake figures with the
^standard norms and offer comments on their
"observations.
■
Thirdly, he has to help the student to |
visualize the impact of his advice on the |
personal commitments and the extent to |
which these commitments will interfere with ■
the treatment.
Field Research Work
Evidently field-work forms the main-stay
of the programmes of Social Paediatrics.
The SPM has a leading and predominant
role in assisting the clinical departments to
initiate and implement field-based studies
on the problems of public health importance.
a
|
|
I
This is really a difficult job to accomplish I’
Finally, the case is presented in an in
because it involves a near herculean effort I
formally conducted clinico-social conference
to get a clinician interested in field oriented :
under the supervision of staff members of
projects. It really requires a lot of convincing •
the department, wherein the students are
to “convert” a hard-core, hospital-bound
encouraged to discuss the case in a compre- .
physician to see one good point in laborious, '
hensive manner.
time consuming and un-rewarding public .
During the investigative procedure that health undertaking. The reluctance of the '
is initiated at the bed-side in the hospital clinician to participate in field-based pro- ■
and is carried through the study of home grammes also stems from the fact that it calls
environment and socio-economic and socio forth the doing of his “specialised job” at '
cultural milieu of the patient, the teacher the ‘people’s door-steps or ‘beneath the i
of SPM has to address himself to the follo banyan tree’, as it is called.
wing tasks.
Fortunately now, it is increasingly realized i
Firstly, he has to introduce the students by the leaders in clinical medicine that
to to the methods of observing and communi exclusive emphasis on cure has never reduced
cating with his patients that would enable the amount of sickness in a community ;
a good personal relationship to be estab unless followed up by a massive preventive
lished between them. This means to train and'wealth promotional action and clinical
the students to hear his patient’s points of departments are slowly but surely teaming
view, to listen to what he has to say and up with SPM for carrying out their work ’
to observe and interpret his “non-verbal” in the fields.
behaviour.
Secondly, he has to provide the student
with an integrated understanding of be
haviour that takes account of his patient’s
physical, physiological, psychological, social,
cultural and educational status.
Following is a brief resume of the field ’
projects which the department of Social
Paediatrics has undertaken. We do not
claim that these works, which we have
carried out as a team, are a piece of original
research, because our objective is not always
22
IND. JOUR. PREV. SOC. MED.
Our brief but significant experience in
the area of Team-Teaching suggests that
the teacher of SPM has a multifaceted role
to play in developing the concept of comp
rehensive medicine through inter-disciplinary
approach.
In a sense he has to be a “crusador” for
the people in rural and urban slum areas
without being a fanatic, a “converter” for
his clinical colleagues without being a
vW. 3, MARCH, 1972
missionary and a “co-ordinator” for diverse
set of professionals and paraprofessionals
without becoming a politician. In addition,
he has to be a social scientist and a public
health physician with a basic understanding
of applied sciences such as epidemiology,
human behaviour and statistics so that public
health work acquires
an element of
research and service in it.
Associate Trof.of Social Science
National Institute of Health
Administration and Education
New Delhi.
I.
WIDENING SCOPE OF PAEDIATRICS - INTEGRATION OF
CURATIVE, PREVENTIVE aND REHABLITATIVE ASPECTS:
Paediatricians were among the first to extend paediatric care
services, beyond the four walls of hospital wards and clinics,, to the
child's family; they also added a preventive dimension to the purely
clinical approach to their patients by developing immunization units
within their own organizations.
Shifting of focus from the individual
child and his family'to the community as a whole, leading to the develop
ment of an integrated community level approach to the preventive, curative
and rehablitative aspects of. child health problems is a logical extension
of this trend (1).
Even the old approach to paediatric care services to individual
patients has bad a particularly important social dimension.
With the
phenomenons1 widening of the scope of paediatrics, the role of the social
considerations has become even more crucial and pervasive.
As a result,
increasing attention is being paid to the new discipline of Social
Paediatrics.
II • A WORKING DEFINITION FOR SOCIAL PAELIATRICSl
Because of the comparative newness of the discipline it is not
surprising that different workers have used different definitions of
social paediatrics, depending on their.perception of its role in their
aprroach to practice of paediatrics (see, for instance,-2, 3 and 4).
For the purpose of this presentation, it is intended to adopt a definition
which covers as wide afield as’possible.
Gade (5) has ' of fered'suth-a:
definition:
The "social paediatrics" keeps' to emphasize that the child is an
integral part of the family and of society at large and that environmental
<. 2 )
factors, i.e,, social as well as economic, physical and biological det< : ine to a large extent, the pattern of a paediatric disease. At
the
time, the term denotes the need to give due consideration to
the growth and development process of rhe child in the epidemiological
interpretation of causes of childhood illness. 3y drawing attention to
the considerable extent to which a disease has a social origin, the
practice of social paediatrics ensures that social remedies are taken
into account in a comprehensive treatment programme.
in. aspects ■-?? social paediatrics:
The following is a very brief outline of some of the areas that are
covered within Gade's comprehensive definition of social paediatrics:
(a)
Social etiology of paediatric disorders:
Such social considerations
as infant and child feeding and other child rearing practices, commu
nity norms concerning sanitary practices, family size norms, food habits,'
economic status and the influence of the overall sodal and cultural
milieu on the growth and development of the personality of children are
known to play an important role in the etiology of some of the major
paediatric'^sroblems in developing countries.
(b)
Comirnity beliefs, attitude and practices concerning paediatric
disorders:
This includes such considerations as perception of the
states of health or sickness in children by the parents, their beliefs
concerning causes of various childhood disorders, their attitude towards
various folk medical practices and towards services offered by physicians
and paediatricians and the level of awareness of the childhood disorders
within the community as a whole.
(c)
9
Social orientation of paediatric services:
As has been brought out
earlier, a number of .social factors have influenced the approach to
problems of child health.
In the context-of developing countries, there
are four additional considerations which have major bearing on practice
of paediatrics:
(i) The overwhelming size and extent of the paediatric problems in
the community - for instance, mal-nutriti.on and under-nutrition,
various communicable diseases &gastrp-intestinal disorders.
(11) Even greater relevance of social and economic considerations to
etiology of major problems.
(ill) Compared to the more industrialised countries, in these countries
the social and cultural factors that are of relevance to health
fields are often significantly different.
(iv)
The very limited availability of resources, in terms of personnel,
funds and equipment, for providing paediatric services to the
community’.
3.
( 3 )
Orientation of the principles of practice of paediatrics to these
factors is essential to ensure that they are applicable on a community
wide scale in developing countries.
Hugh R. Leavell (personal communication) has underlined the
significance of taking into account these factors in the formulation
of health programmes in developing countries.
He has pleaded for se
paration of what he calls "the natural science essentials" of health
procedures that have proved useful in scientifically advanced count
ries from what he designates as the "socia-cultural overcoatings"
which have unconsciously got mixed up with such procedures in the
course of t eir growth and development in these advanced countries.
these "overcoatings", Leavell goes on to say, have little relationship
to the "natural science essentials".
For the developing countries these
socio-cultural overcoatings of western countries could be detached from
the core formed by the "natural science essentials" and the latter can
be inserted into a new "envelope" or "coating" that will harmonize
w
better with the. socio-cultural environment of the developing countries.
(d)
Developing skills of com'.uni cat! ng with the parents and imparting .
health education:
In order to establish a communication link with the
parents of the children, a paediatrician is required to have an under-:
standing of their "cognitive frame".
This is particularly important in
developing countries as very often there is wide gulf-between the
socio-cultural background of the physicians and. that of the parents
of the children. . He is a.lso required to motivate the, parents to
accept the prescribed measures,which include curative, preventive and
rehabiitative aspects, by explaining to them their importance in the
context of their own needs and problems.
He thus plays the role of
a health educator here.
(e)
Contributions of paediatric services to the promotion of small
ramily norms:
There is now widespread recognition of the impli
cations Of the problem of rapidly rising population in developing
countries. ' Encouraging acceptance of small family norms in the
community forms a key-stone of programmes for controlling this rapid
population growth.
Practice of effective paediatrics in these
,
( 4‘)
countries can m=ke substantial contributions in promoting small
family norms by ensuring normal growth and development of the child
ren that are already born.
Practice of good paediatrics should,
therefore, become an integral component of the community-wide pro
gramme for population control.'
IV. SOCIAL SCIENCE AND SOCIAL PAEDIATRICS:
In the above elaboration of. the field of social paediatrics, there
have been frequent references to such terms as "child rearing practices",
"folk medical concepts", "community awareness of child health problems" and
"cognitive frame" of individuals.
Study of these various aspects of the
community and the family and of the.influence of the community on the be
haviour of individua.ls come within the purview of social science.
Knowledge
from the field of social science thus forms a major constituent of social
paediatrics.
This knowledge is mainly derived from the three major components of
social science:
social or cult’>ral .anthropology, involving the study of
the culture or the way of life of a community; sociology, related to struc
ture and functions of group life; and, social psychology, interested in
studying how behaviour of individuals is determined by social and cultural
considerations.
i
The relevant aspects from all these three components are ;
to be included in the teaching of social paediatrics,
V. A?-?F 'ACH TO TEACHING IF S~CTAL SCIENCE CONCEPTS IN SOCIAL PAEDIATRICS:
Social paediatrics should be considered as a component of the wider '
discipline - Social Medicine, which also includes social dimensions of
.
such other disciplines as internal medicine, geriatrics, obstetrics and
gynaecology, surgery and ophthalmology.
There has been
;
growing recognition of the importance of social
medicine in the teaching of medical sciences (6),
I
With this recognition,
social science is now considered as science basic to the education of
doctors.
It is, therefore, desirable that students are acquainted with
these basic elements of sod al sciences along with the teaching of such
other basic sciences as biochemistry, microbiology, protozoology and bio
*
statistics.
.
For teaching these aspects, it will be necessary to have social
. |
scientists in the staff.
'I
5.
Subsequently, while dealing with’such areas as social etiology,
social pathology and social orientation of practice of paediatrics, it
is necessary to blend the basic social science ele-ents with other clini
cal, considerations in .order to .present an integroted picture of social
paediatrics to students.
This crn be taught by ..cediatricl’ns who ate
well versed w th the social dimensions of their disciplines;
SlP-l'ARV;
The recent trend of bringing about integration of the curative,
preventive and rehnblitntive aspects of problems of child health has
further underlined the importance of tl.e social dimensions of paediatrics Social Paediatrics,
This includes such considerations as social etiology
of childhood disorders, the prev.n’linr beliefs, attitude and practices in
the conrr.unity concerning such disorders ’.nd considerations of communication
with parents and of imparting health education to them.
Certain epidemio
logical characteristics of problems of chi Id." health in developing countries,
the significantly different socio-cultural setting of these countries .and
the acute limitnt'ons in the availability of resources underline the im
portance of bring-ng about a suitable reorientation of the practice of pae
diatrics.
As practice of good paediatrics encourages small family nofms,
it should be an integral component o : family planning programmes.
Social science provides knowledge concerning various aspects of
con-munity one the family --nd the behaviour of individuals in a socio
cultural setting.
It thus forms
major constituent of social paediatrics.
k processional social scientist should expose the students to the basic
elements; a paediatrician, who is .’Iso well-versed with the social dimen
sions, should explain how social science ideas can be incorporated in the
practice of s'-cial paediatrics.
PETERTHCZf :
i
1.
Groegortewski, Edward (1963), Prevention in the Undergraduate
Hedical Curriculum, Act^ Paediatrics Supplement no. 151, p.5.
2.
D'-kshinemurty, S. (1961), Preventive and Social paediatrics,
I nd. Jour. Paediatrics, 28, 483.
6.
( 6 )
3.
Bose, S.X. -nd Dey, ; .K. (Ed;) (1964), .Asian Paediatrics,
'Bombay: Asia Publications.
4.
Patterson, Po'nald and McCreary, John F. (1956), Pediatrics,
Philadelphia: Liffincott.
5.
Gado, Anna Marie (1967), Social Paediatrics, Archives of
Child Health, £, 43.
6.
Banerji, D. (1968), Place of Social Sciences in Under
graduate Medical1 Education, NTHAE Builetin, JI, 25.
Undergraduate Teaching in Paediatrics
BY
Db. G. COELHO
Cambridge Court, Bombay
Material:
An independent department of
paediatrics of not less than 25
medical beds, 15 surgical
beds and 10 isolation beds.
A daily medical and surgical
out-patients department.
A service of the newborn.
A child guidance clinic tiiat
meets atleast twice a week.
Staff - Paediatrician :
• Two Assistant Paediatricians;
one Resident Registrar with
post-graduate qualifications
in paediatrics, two Resident
House Physicians.
Practitioners with paediatric
qualifications to assist at the
out - patient department they will attend fora limited
number of hours on specified
days of the week.
When the load at the out
patient increases, part-time
practitioners on the same
basis as above, are to be
increased.
One Child Psychiatrist, two
assistants, two Social Work
ers, Child Welfare trained
workers or Social workers to
help at the out-patients
department.
Facilities of a laboratory for
routine
and special work
with adequate personnel and
equipment.
Facilities of other auxiliary
departments - Radiology,
Physiotherapy, special clinics
for the handicapped.
Size of Batch of Students :
Not more than 15 for the unit
of the above size.
Period of Attendance :
One Surgeon, one Assistant
* Surgeon, one Resident Surgi
cal Registrar
with post
graduate qualifications, one
Resident House surgeon.
Three months - Two months
continuous under the Paedia
trician and one month under
the Paediatric Surgeon.
275
276
Indian Journal of Medical Education
Course of Instruction :
Newborn service - One
twice a week for 8 weeks.
hour
Out - patient Department - Two
hours on alternate days thrice a
week.
Examination of new cases
and a
follow-up
of old cases.
Teachers and practitioners will have
batches of five students. They will
check up the history, the physical
finding and teach briefly on each
case.
The batches should rotate
round the teachers each week.
Child Guidance Service - One hour
twice a week for 8 weeks.
This
should be on the same days as the
out - patient days and the Child
Guidance Clinic must be located in
close
proximity.
The
sessions
should be consecutive.
Vol. Ill, April & July, 1904,
Both at. the out - patient and the
in-patient departments the teaching
should be integrated. The anatomii
and physiologic norms must he
stressed in every case
and the
deviat ions from the norm demonstrat
ed on the patient through physical
examination, laboratory investiga
tion, other auxiliary aids and post
mortem material. Therapy must be
taught in all its aspects in its
application to the case presented.
Both in the out - patients and in
patients departments more patiente
must be followed up by the student
with the teacher. The presentation!
must be brief Case material must
be collected and fed so that as far as
possible the common conditions are
all dealt with in the period of the
course. In clinical teaching by the
bedside discourses must be avoided.
The student must supplement the
tuition by self education and of
these he should maintain note!
which must be inspected by the
tutorial staff.
Ward Attendance - For two hours
in the mornings on alternate days
thrice a week. The students must
finish their hour in the new born
department and then pass on to the
The Paediatrician and the Assist
wards. Ip the wards the students ant Paediatrician should give one
should be grouped in batches of hour lecture every day after the
three and cases allotted to the ward session, four times a week for
group, but each individual student 8 weeks.
should be responsible for every case.
The history and the examination notes
The child psychiatrist should give
should be written by them nnd the a lecture twice a week on the day he
routine
laboratory investigations has his
out-patient
department
carried out by them and repeated sessions and these should be given
frequently to learn the progress. for 8 weeks.
The patients of each batch must be
changed every week and in doing so
The students should meet in the
an attempt must be made to see wards every afternoon again to meet
that each student has had an oppor the parents of the children, to learn
tunity to learn the common condi of their home situations, to take
tions of the place. In these two charge of the new cases allotted to
hours the teaching must be conduct them and to examine other oases in
ed by the Paediatrician and the the wards. During this session, ths
Assistant Paediatricians.
Resident should check their findings
Undergraduate Teaching in Paediatrics
277
demonstrate physical signs, labora 3. Science of genetics and disorders
tory techniques, minor surgicil
of genetics.
procedures and assist in reading
skiagrams, studying
pathological 4. Disturbances
of good health
specimens and slides. The attend
caused by infection, environ
ance and teaching on the surgical
ment, physical agents, improper
side will be on the same pattern.
ance.
Content of Instruction :
1. Development and growth, physi
cal, mental and
social from
conception to adulthood and
deviations from normal, their
causes, effects and prevention.
5- Psychological development, diffiiculties in social adjustment and
abnormal behaviour.
The Objective of undergraduate
2. Nutrition - physiological princi teaching should be to equip the
ples - norms for different ages student to deal with the day to day
deviations from sound nutrition problems he
will meet in his
causes, effects and prevention.
community after graduation.
SOCIAL PEDIATRICS AS STEP TOWARDS PRACTICE
OF INTEGRATED TEACHING OF COMMUNITY
HEALTH
N. PRALHAD RAO
,
*
Y.C. MATHUR
**
The traditional teaching methods in al
most all the branches of learning, of late,
have been questioned by both the classes as
well as by the masses. Even the nature and
quality of medical education has come under
strict scrutiny in recent years. Medical
education, due to certain limitations imposed
on it by the conventional methods of teaching
of medical sciences, has failed in its basic
objective of producing a “good” physician,
who conforms to the ideals set by W.H.O.
study group on pediatric education (W.H.O.,
I957\ In other words, it has failed firstly,
to provide students an integrated concept
of medicine as a community science concern
ed with physical, mental and social well
being of men, women and children. Secondly,
it has delayed the development of an unified
medical and health services in many countri
es including European countries (Bozman,
1961). And thirdly, it tended to produce
more specialists than
good generalists,
in utter disregard to the needs of the
community.
The leaders in medical education, consci
ous of this serious situation, prevailing all
over, have expressed their concern through
national and international forums, which
has been documented in the reports of the
various seminars, symposia, expert committees
and study groups (WHO, 1959; WHO, 1964;
MCI, 1969; UGC Seminar, 1969). The
AND HARISH CHANDRA
***
medical educationists, besides recommending
measures like restructuring of curriculum
content, resetting of subject priorities and
reorienting of evaluation (examination)
system, have also suggested multidisciplinary
teaching approach in medical education
(WHO, 1970). So far much has been said
about the teaching of comprehensive medi
cine through interdisciplinary teaching but
little has been done in a practical way in this
direction. Even today, the trend towards
specialization and sub specialization with
consequent fragmentation of medicine conti
nues unabated which has resulted in the
decline of proportion of physicians who are
in general practice (W.H.O, 1963).
Limitations of traditional teaching and
its effect:
It is too well-known that owing to certain
facts of history, we in India, have inherited
the British system of education. Educational
curricula, including that of medicine
were mainly modelled to fit the finished
products of the Institutes into a narrowly
defined technical “service” role which their
parent country prescribed for them (King,
1969). Whatever might have been the broad
aims of the then medical education, the
teaching leaned heavily on the “disease”
rather than the “diseased”; it emphasised
more often the “diseased organ” rather than
the whole individual. In other words, it
* Asstt. Prof., P.S.M. ** Addl. Prof., Paediatrics
of Child Health, Hyderabad.
Director and Prof., Paediatrics, Institute
.
2
VOL. 3, MARCH, 1972
IND. JOUR. PREV. SOC. MED.
tended to be “cadaver-oriented” and “organcentred” rather than “man centred” and
isolated the students from the very commu
nity they were expected to serve later. With
the result, the “end products” of the medical
college happened to be better diagnostician,
able therapists and efficient “sole-practi
tioners” rather than good physician capable
of practising community medicine.
The discernible effects of traditional
teaching methods on medical education are
that the medicine as a subject got partitioned
into the two disciplines, namely curative
and preventive medicine. The partitioning
effect has been so complete that one finds
today these two aspects of medicine stand
separated into all too rival compartments.
So much so, that in actual practice, the
preventive medicine does not find its rightful
place in routine curative work of even
Pediatricians and Obstetricians, who realise
too well that their main chance and often
the only chance of helping many of their
patients in overcoming health problems, is
by prevention (WHO, 1964.) Secondly it has
led to the creation ot two distinct sets of
professionals, denoted by various nomen
clatures such as, clinicians and nonclinicians,
medical officers and health officers, para
medicals and health auxiliaries and so on.
In the context of their social role each one
fallaceously considered himself superior to
the other and struggled under artificially
seperated
department with
what was
fundamentally
one problem. It is our
common observation that higher the heir. archy level greater the rivalry.
In view of the fact that the trend for speci
alisation has to be continued in the interest
of advancement of medical sciences, and will
continue whether one likes it or not, the sure
way of ensuring a balanced knowledge of
medicine with respect to its clinical, curative,
social and preventive components to students
is through integrated teaching—the organisa
tion of which requires a bold, unconventionaland imaginative strategy from clinical and
S. P. M. departments of the medical colleges.
Social Pediatrics
department :
as
Interdisciplinary
In the light of thqpabove, emergence of
social pediatrics as a teaching sub-discipline,
within the frame work ,<of Pediatric teaching
could be considered as a step in the right
direction. In reality it represents a practical
approach towards practice of integrated
teaching. Since the department draws
teachers from allied disciplines of pediatrics,
obstetrics and S. P. M , one could reasonably
expect a balanced treatment to the speciality
with respect to its clinical, curative, social
and preventive components.
It not only
implements the interdisciplinary approach
in day to day teaching programmes of
medical students but also involves these
interrelated sciences in carrying out field
based scientific studies in
the area of
M. C. H. . Further, the arrangement reflects
not only the realisation of the relative
importance of the other two disciplines by
the pediatricians but also their honest will to
seek lasting solutions to some of their pernici
ous problems of infection, growth retardation
and malnutrition that dominate their clini
cal horizon, through multilateral approach.
Because the problems of pediatrics invariably
have their origin in obstetrics and defy
permanent
solution unless
approached
through social and preventive medicine angle,
coalescence of the three disciplines under
social pediatrics represents logical end
result of interdisciplinary coordination.
SOCIAL PEDIATRICS AS STEP TOWARDS PRACTICE OF INTEGRATED TEACHING
Advantages of Interdisciplinary depart
ments :
The trend towards establishment of
interdisciplinary departments on lines of
social pediatrics which envisage inclusion
(not a mere participation) of S.P.M. within
the frame work of hospital teaching, though
belated, is a trend away from disintegration
of medicine and needs fullest encouragement
from all, especially from those who matter
most in the realms of medical education.
The long-term beneficial effects of such
teaching situations, wien properly handled,
are likely to be on the quality and nature
of teaching of clinical disciplines themselves
but immediate gains are likely to be
registered by the teachers of S.P.M. who
hitherto have been and are still a part of an
isolated department dealing with theory
rather than the practice of community
medicine.
As far as the pediatric discipline is
concerned, the creation of social pediatrics as
a hospital based teaching unit which funct
ions as a viable, multiprofessional team un
der a unified command, represents a unique
experiment in the area of integrated teaching.
It has got a field practice area consisting
of a network of M.C.H. clinics, primary
health and rural health centres in and
around Hyderabad city. The organisational
set up which we have, at the Institute of
Child Health, Hyderabad, by no means
could be considered as ideal but under
existing conditions, might be regarded as
adequate. Our brief experience in the area
suggests that with such multidisciplinary
team with a teaching commitment in a
specified area of education, firstly, muchtalked of but less practised mutlidisciplinary
teaching could be made a matter of routine
rather than a specially organised inter
3
departmental co-ordinated effort in the
teaching programmes of the undergraduates.
The complexities of organising inter-depart
mental co-ordination, in a situation (like
ours) where different disciplines function as
seperate entities in a matrix of undergradu
ate medical education are too well known
(Udani and Paranjpe, 1966; Marwah et al,
1971). Secondly, S.P.M. could be actively
associated with programmes involving hospi
tal participation which would impart service
aspect (of the type which is valued more by
both the students and the community) hither
to the “preaching without practice” depart
ment. And
thirdly, the teaching of
S P.M. carried
with pediatricians and
obstetricians at the bed-side, in O.P.D. and
at the peripheral M.C.H. complexes, which
offer opportunities to practice “situational
approach” of teaching could be of immense
value to both the teachers as well as the
taught.
The benefits accruing from such joint
ventures, no doubt, are many but the most
notable are obviously two. In the first place,
it cuts across the artificial barriers inadver
tantly erected by a faulty system of medical
education between the teachers of clinical
and social medicine and secondly, it helps
the development of a meaningful service and
research aspects in S.P.M., the lack of which
constituted one of the serious defects in the
science of public health (WHO, 1959),
Hence the teachers of medical profession owe
a great responsibility towards the society,
since they are charged with the challenging
task of training the doctors of tomorrow.
Since a doctor of tomorrow is expected not
only to be a “physician but also a philosopher
and guide to his community”, a broad-based
medical education has to be tailored to
provide the concept of comprehensive care
4
IND. JOUR. PREV. SOC. MED.
of the community to the students. Evidently
this requires an intelligent integration of
curative and preventive medicine at the
academic level in the medical colleges irres
pective of the fact that the trend towards
polarisation still continues to be tremendously
strong amidst the teachers of medical sciences.
References
VOL. 3, MARCH, 1972
6. U. G. C. Seminar : Extracts from the
proceedings of the Institute for Teaching
of Social Sciences in Medical College
held in New Delhi under the joint
auspices of the University Grants Commi
ssion and the Delhi chapter of the Indian
Association for the Advancement of
Medical Education Oct, 6-11, 1969.
Ind. J. Med. Edu. 8,9, 1' 69.
1. Bozman, C. A. : “Reflections on tropical
hygiene” The J. Trop. Med. Oct.,
7.
W. H. O. : “The study group on Pedia
1961.
tric Education. Techn. Rep. Ser. No.
2.
King, A. D. ; “Behavioural Science and
119, 1957.
the Social Role of the Physician”. Ind.
8.
W. H. O : “Expert committee on pro
Med. Edu., 8, 399-405, 1969.
/jL/Marwah, S. M., Varma, A. K. and
fessional and technical education of
Medical and Auxiliary personnel.”
Tiwari, I. C. : “Family and community
Techn Rep. Ser. No. 159, 1959.
medicine in medical education”. Bharat
^Med.J. 3, 124-128, 1971.
W. H. O. : Techn. Rep. Ser. No. 257,
9.
<4J Medical Council of India : Report of
1963.
the review committee of Medical Council
of India on under-graduate Medical
10.
W. H. O. : “Promotion of Medical
__ Education on 13, 14th Oct., 1969.
Practitioners interest . in
Preventive
57Udani, P. M. and Paranjape, P. D. :
Medicine Techn. Rep. Ser. No. 269,
Collaboration of the development of
1964.
pediatric with preventive and social
W. H. O. Chronicle : New approaches
medicine for effective teaching of indi 11.
vidual and community health. Ind.
to medical teaching in Europe”. W.HO.
J. Med. Edu. 5, 600-603, 1966.
Chronicle 24 : 450-152, 1972.
I
VOL. VIII, MAY, 19^
■elcome, your dean, Profess,.
‘time and opportunity hat
or Varanasi’. To fill the
expectations and to train th,,
physicians, medical cducationging task.
'
Role of Hospital in Teaching of Preventive and
Social Pediatrics
*
BY
Dr P. M. Udani
REFERENCES
V. (1966), Environmental factor,
medical education in develop,-.,
A. Modern medicine and th,
:-dis^k pattern of overly trad,.
les; technologic misfit. J. mi
Jo. 9. Pt. 2, 137-162.
G. (1966). Operational resend
.isation of medical service. Ina
*
., S, 446-449.
(1968). Science policy in Ink
in Decision Making in Noli
**
cy. Edited by A. De Reuck. M
-nd J. Knight. (Ciba Found,
: of Science Foundation Sytnpv
archill, London.
■ni, V. (1967). Factors influence
mcnt of a curriculum, Bnt J
|
1, 251-254.
j
I. (1967). Medical education ad
»
nity. Perspect. Biol. Med.. U. C
I
:
PirectorlProfessor, Pediatric Centre, J.J. Group of Hospitals and Grant Medical
College, Bombay S. Immediate Past President, Indian Academy of Pediatrics
Introduction
In developing countries, there are many
hmrds in child health, like poor housing,
overcrowding, poor ventilation, poor sani
tation, flies, inadequate washing and clean
ing facilities, unhygienic and inadequate
Siter, milk and food containers, air polludon, human and other reservoirs of infectjoaj, .superstitions, traditions, false belidsy. apathy, lack of education, etc., all
related to social, economic and cultural
factors. Unless the health personnel con
sisting of teachers, students, nurses, para
medical personnel, social workers and others
are intimately aware of the above mentioned
problems of the community, they cannot do
justice to its health needs particularly for
the children. They have to learn the
demographic data, feeding practices, vari
* Vital statistics, like maternal, perinatal,
ed
Monatal, infant, toddler, and the child
mortality and morbidity; and cultural prac
tices in the community so as to understand
the impact of these factors on child health.
ftisonlythen that they can plan appropriate
erasures to solve the problems and give
?®PW practical advice to the family.
Irj??of Preventive and Social Pedia«>CS will have to be oriented to these social
economic and cultural background.
Hoepital Units
if
not be out of place to mention
^
*
*5
the units of a Children’s Hospital
Wftdiatric Department, where the empha* Preventive and social aspect for pediajj®
j^-Couid be laid in the day-to-day
"•Oung to the students. The usual units
are: (1) the medical wards for the care of
sick children, (2) isolation units for the
treatment of communicable diseases, (3)
neonatal and special care neonatal units for
the care of the healthy and sick neonates
and premature and low birthweight babies,
and (4) out-patient unit for treatment of
minor ailments and early diagnosis of
major ailments. Apart from the above
services, it is desirable to concentrate on
the teaching of preventive and social pedia
trics at some of the units like maternal and
child health centre, school health clinic,
and various follow-up clinics for newborn
and premature babies. For the proper
advice regarding the mental health problems
and their prevention, it is desirable to insti
tute similar teaching in the child guidance
clinic. The above mentioned various units
may exist only at a few big teaching pedia
tric centres. However, every teaching
pediatric department should try to develop
the above mentioned services so as to em
phasize many facets of training in child
health and care. This is particularly im
portant in developing countries, where the
emphasis on preventive and social aspects
of child health is of paramount importance.
However, even if the above mentioned units
are not developed and the pediatric practice
is at the level of hospital, or in an urban or
rural community, or in small dispensaries,
the practice of pediatrics should be an
integrated preventive, curative and promo
tional one. Pediatrics is synonymous with
child health and has the greatest scope of
prevention of disease and promotion of
health, physical, mental and social.
presented at the Seminar on Pediatric Education (Methods of Teaching with Special
to Preventive and Social Pediatrics) at A.I.I.M.S., New Delhi, February 7-8, 1969.
organized by International Children’s Centre, Paris, and Indian Academy of
(in co-operation with W.H.O., U.N.I.C.E.F. and Government of India).
149
150
INDIAN JOURNAL OF MEDICAL EDUCATION
In-patient Department
The usual or old concept of teaching
child health problems in the in-patient
department consisted in history taking, de
monstration of physical signs to students,
teach them how to elicit the physical signs,
their interpretation and finally their synthe
sis so as to arrive at a provisional diagnosis;
discuss differential diagnosis, treatment of
the condition and incidentally teach the
students how to deal with the child and
parents. Today with our changing philo
sophy about the teaching of child health,
we have revised our programme at every
level to emphasize social, economic, en
vironmental, nutritional and cultural fac
tors, for example, in the dietetic history
of the child, not only the quantitative and
qualitative aspects of the diet are studied,
but the students are taught to learn the
food habits of the family with feeding habits
of the child in particular, get mother’s ideas
and knowledge about foods, their values,
effects and traditional beliefs about them.
Also careful attention is paid to the available
foods to the family as this is often related
to the economic condition and cultural
beliefs. What is studied in the hospital
about the dietetic history of the child and
the family should be further extended to
the study 'of feeding practices and the
various reasons behind such practices in
the community. With this approach of
the teachers and students in the dietetic
history, there is much practical information
of the diet of the child in the family as
related to social, economic, and cultural
factors. Also this leads to the much more
practical advice to the mother about the
diet of the baby from the available foods,
and mother could be given dietetic educa
tion of practical value. Similarly when the
students take the social history he gives
proper attention to the size of the family, its
income, particularly per capita income and
then can explain the need of family planning
and planned parenthood to the family he
is dealing with and get himself enlightened
on these' aspects of the problem. Also
parents can be referred to the family plan
ning clinic for necessary advice and motiva
tion. In the in-patient routine history
sheet, there should be a special form to get
the detailed data on the social, economic,
vol. vin, may, 19w
■ T'^j'oF hospital in TEACHIF
environmental, cultural and dietetic asiw-i
of the family.
—ay out-patient departmen
■tegcountries should have phy
Ssormel and equipment so a
C^ide immunizations to
k,kh and nutritional educati
.r‘< Tferexpenses incurred in de'
programmes are of great bei
pterentive point of view and f
Ban of the students to praci
preventive and curative pedia
^'^■Swtheir lives. In this coi
■ ^stable to give special attent
uader five years where then
aortality and morbidity, and
could >e most benefited
approach. It is desirable
special card for every chi
mothers can keep with th
. bring during every visit to the
.'VthKgttd, there is informat:
progress of the child’s growtl1
CttdiWeight etc., details of i
rtattd of the common illness
CMUbunicable ones, the alle
special ndicaps. Such a
Kroplied to the family at a
Often the out-patient record
?
to'.maintain at the hospital
nth rcumstances, the ca
•pedal lue in improving t
Vulnerable children and mot
•tudents towards preventiv
Child health.
Out-patient Department
As mentioned before the out-paticla
department in developing countries 9
usually very much overcrowded and oftea
has poor physical and other facilities, Th,
out-patient department provides service,
to children mostly with minor illnessn
detect major illnesses at an early state
and is meant for the training of the student,
in making quick examination, quick diaj.
nosis and treatment. Often he has to
decide whether the apparent minor symp.
toms are of major disease, and thus th,
child requires either admission to the
hospital or requires special diagnostx
procedures. The out-patient teaching ■
very important for the students as aftn
their graduation, they are going to deal will
similar problems in their practice in a corn.
munity. Hence they need good training a
dealing with these types of problems. Ik
cause of heavy service load and overcrowd'
ing, often the out-patient service is m
properly utilized for teaching integrated
preventive and curative pediatrics. In spin
of these difficulties, we must find out wap
and means to convert the out-paticM
department into an integrated prevent!"
and curative pediatric clinic. We may rsrf
be able to provide preventive and promo
tional services to all the children who attend [■
Home visits of the Student
the out-patient department. However, dw k,
to the Child in the Hosj
students should be motivated towards the
* important to study the
integrated preventive and curative aspects« S v " ' Bl
child care so that he practices the same u* E j. "Which the child is broug
future basic doctor of the community. A*
~
under what cc
our out-patient department wc attempt “ B • -Sy-dcvcloped the disease.
preferably with his
immunize large number of children
KH^S^prtments of pediatric
usually attend the department for nun
*
social medicine shou
illnesses. In infants and children who"
*
not ill, direct B.C.G. vaccination is P™ gVdwRSP study the physical
"W. Ventilation, light, sat
and after assessing the immunization su i
milk
supply, etc., am
of the child we carry out all the
1
tions at the out-patient level. The mot“^ ] l'
money spen
■
Z*-*
food. Ay and other
could be given incidental teaching
immunizations when her child is o* & a MN^HS£.COntacts as for examp
■
jSJ®
0
*
08
’
8
,
and
also get t
immunized. Also the teachers m
|
T™?, number of people,
department have the practice of g'™J 1
JjM^tude towards child’s
incidental health education and n?tn'L(g j ‘
education to the mothers while discus
*"
’’
a—cj°°crn medicine, etc.
are later discussed
the care of the child. It is desirable
jfflB OF HOSPITAL IN TEACHING OF PREVENTIVE AND SOCIAL PEDIATRICS
VOL. VIII, MAY, 1%ij
iltural and dietetic aspeqi
tartment
before the out-patjcn!
developing countries i,
h overcrowded and often
and other facilities. Thr
rtment provides service,
:ly with minor illness^
esses at an early stated
he turning of the studenn
extirpation, quick diaK.
nent. Often he has ii,
he apparent minor sympor disease, and thus the
:ither admission to the
uires special diagnostic
e out-patient teaching n
ar the students as after
they are going to deal with
they need good training in
e types of problems. Ikrvice load and overcrowdut-patient service is not
for teaching integrated
rative pediatrics. In spitr
:s, we must find out wan
convert the out-patirr.i
an integrated prevents
atric clinic. We may not
e preventive and promo
ill the children who attend
;pai^pnt. However, thr
be i^ffivated towards thr
tiveand curative aspects™
or of the community.
lepartment we attempt 10
number of children who
re department for 0“*
ants and children who i"
C.G. vaccination is
|
g the immunization stJt“* I
irry out all the immune I
atient level. Themothc"
incidental teaching
j
vhen her child is
|
-o the teachers m
■
e the practice of gfv"”J I
education and num"0
,
mothers while discuss^ •
hild. It is desirable «“•
Kj'nut-patient department in developSg countries should have physical facilities,
Sjonnel and equipment so as to routinely
■ wHSwide immunizations to children and
Kith and nutritional education to parents.
expenses incurred in developing these
Djogrammes are of great benefit from the
preventive point of view and for the motivafen of the students to practise integrated
preventive and curative pediatrics through
out their lives. In this connection, it is
desirable to give special attention to children
•' gjrwter five years where there is maximum
mortality and morbidity, and which group
(juld-be most benefited by such an
approach. It is desirable to provide a
Special card for every child which the
mothers can keep with themselves and
bftlig during every visit to the hospital. In
thb tcard, there is information about the
progress of the child’s growth, both height
in£weight etc., details of immunization,
foedrd of the common illnesses particularly
communicable ones, the allergies and any
special handicaps. Such a card can be
Supplied to the family at a nominal cost.
Often the out-patient records are difficult
to maintain at the hospital level, and in
such circumstances, the card will have
Special value in improving the services to
Vulnerable children and motivation of the
Undents towards preventive aspects of
Child health.
Home visits of the Students (in relation
to the Child in the Hospital)
, It Is important to study the environments
» Which the child is brought up so that
■^now under what conditions the
developed the disease. Hence the
•waits preferably with his teacher from
ydepartments of pediatrics and preven-social medicine should make home
WBtS: to study the physical environments
Wffientilation, light, sanitation, water
milk supply, etc., and study details
■^mod intake, money spent on different
«ttlS of food, fly and other insect menace,
®^ey contacts as for example in a case of
^BR^llosis, and also get details of the
™uy, number of people, their health,
w®?1 attitude towards child’s illness, drugs
;3|S®Btodern medicine, etc. When these
* uDiema are later discussed, the teachers
■r
■
151
and students would be much better exposed
to the problems of the family and the
community, learn the place and conditions
in which the child got sick, and develop prac
tical human approach to problems and their
solutions. In the developing countries,
with a dearth of teachers, heavy service
load, it is not possible for the teacher to
accompany the students at home every
time.
However, for every batch of
students, a few exemplary visits are not
impractical.
Where to train Young minds in the
Hospital Campus?
As mentioned before, at every level, there
should be an emphasis in preventive and
social aspects of child health. However, a
concerted attempt should be made at some
of the places in the hospital.
1. Side-room Clinic: When the stu
dents are in the in-patient department, they
should have intensive case-study at least
twice a week. Such a case discussion can
be held in a side-room clinic of the hospital.
The clinic should last for 1| hours each
time. The common problems and conditions
should be discussed in such a session.
However, students should be active partici
pants throughout the session. The stu
dents will remember well what they them
selves have done and actively participated.
In such a session there is intensive case
study which not only emphasized the
clinical aspects, but equally emphasized
the social, economic, nutritional and cul
tural aspects of the problem. Such inten
sive 24 sessions in a three-month period
in the ward will go a long way in emphasiz
ing the study of the common problems of
the community.
2. Clinico-Social Conference: In our
experience, such a conference has proved a
very useful teaching method in emphasizing
the teaching of preventive and social aspects
of the child health problems to the students.
It has proved a great stimulus to them in
drawing their attention to these aspects of
the problems. The conference is organized
by the students with the guidance from their
teachers of pediatrics and preventive and
social medicine. One to two weeks prior
to the conference, a batch of three students
152
INDIAN JOURNAL OF MEDICAL EDUCATION
will collect the clinical data of the case in
the hospital and shall visit the home of the
patient to study the physical, social, econo
mic, cultural, dietetic, nutritional and other
data of the family. They will study the
income of the family, the expenses of the
family in detail, particularly find out hew
much amount is spent on food and health
and how much on various ceremonies. They
will get an idea of the food habits and the
way the food is prepared and taken by the
family members. In cases like tuberculosis,
they will study the family and contacts by
history, physical examination, tuberculin
survey, blood and sputum examination and
even take them for a mass miniature
radiography. The conference is started
with an introduction by one of the students
in charge, and later will be followed by
clinical data in brief. However, there will
be detailed presentation of the data of the
family pertaining to social, economic,
nutritional, cultural, environmental and
other aspects. After the presentation of
the full data, the students will actively
participate in the discussion. However,
often here the guidance of the teacher is
necessary. After the initial discussion by
the students, the teachers of pediatrics and
preventive and social medicine will give the
comments, and the conference is finally
summarised by the students and the teachers.
Often when a case of tuberculosis is
presented at the conference, there will be
discussion on the following aspects of the
problems.
VOL. VIII, MAY, 1969
in the community to know the extent of
the problem in the community.
At the subsequent clinico-social conferences the work done by the students
teachers, paramedical personnel and the
agency involved, e.g., health department
is reviewed to detect the difficulties en
countered at various levels, to find out what
has been successfully done particularly in
the fields of immunization of the family
and dietetic and health education. Also
advantage may be taken off and on to get
various non-medical personnel from the
university faculties, like the economist,
social scientist, nutritionist, demographers
and even agriculturists. Discussion of the
problems by such diverse specialists,
enlightens the minds of the students ami
teachers as the problems in a developing
country are so much related to these educa
tional fields.
It is usual to get the clinical material from
the low socio-economic groups, and hence
the discussion is predominantly limited to
the problems of low socio-economic group
of population. However, it is desirable to
select at times also other socio-economic
groups so as to study their problems which
are more likely to be presented to a general
practitioner. Moreover the different socio
economic groups provide good comparison
of the data obtained. Also the student
will learn that it is often easier w
implement the advice in the upper and
middle socio-economic groups and only
limited advice is followed in low socio
1. How did this child get the infection? economic groups.
2. From whom?
The common problems which we discuss
3. Could it have been prevented?
in clinico-social conferences are (i)
nutrition, (ff) anaemia, (t'n) other common
4. Why was immunization not given?
nutritional disorders like rickets, vitamin A
5. What were the attitudes of the and H complex deficiency, scurvy, (,r)
parents to immunization and what diarrhoeal disorders, (v) tuberculosis,
were the difficulties?
communicable diseases, diphtheria, whoop
6. Discuss the solutions to the various ing cough, measles, poliomyelitis, typhoid
fever, hepatitis, etc., and (tit?) parasitic
problems.
infestations, and
(tn'n) handicapped
7. The whole family is immunized if children, etc.
necessary, and chemoprophylaxis,
3. Neonatal Conference: This is another
primary and secondary is given,
if indicated.
teaching exercise held once in two wee"
for a period of 1J hours, in a three-mont“ L
term
of pediatrics. The idea is to stimu“" ,
During such a session there will be a
discussion on the incidence of tuberculosis interest in the newborn which is usua
*J
Tjg OF HOSPITAL IN TEACHING <
delected in the developing
' sEris on prevention of disease fr<
jiriod, bring about collaborate
yntK of pediatrics, obstetrics :
and social medicine, as w
foiihedical personnel like mid
jorker, public health nurse,
md others. This is a good
jjjfaudisciplinary teaching org:
"Wjhe programme of a neonata
consists of presentation of the
In brief and detailed data on
economic, environmental and
pects of the family. Initially
Scussion by the students and
don by the paramedical person!
followed by comments and di:
tnjichers of obstetrics, pediatri
tjntive and social medicine.
the session there is emphasis oi
of the disease, health educatic
lesser extent on routine treatme
6 neonatal conferences in a pc
of 3 months, care of the healtl
birth weight baby and comm,
and neonatal problems are dis
some presentation of the data
and perinatal morbidity and m
♦. M.C.H. Centre: One ol
nal and Child Health Centres i
pita! premises. In such a cer
Itetric staff members followup
from the antenatal period an
them during the intranatal ai
periods, while the pediatrician
the babies during the neonatal a
. periods. With such a collabo?
Departments of pediatrics am
raany useful sessions could be
i OBJ the various problems
ttbthtts, particularly affecting
1 '-'.POOe in three to four weeks
wussions could be held on th<
py the triple disciplines of
cs and preventive
e, "with active part
’•tudents.
are many areas in
could be trained will
t> ■enfs. pediatrics, pr
• taedicine and at times oJ
•talent of family planning
tthood. Other related
VOL. VIII, MAY, 1969
■ to know the extent of
community.
ent clinico-sociai confer.
done by the students
lical personnel and the
e.g., health department.
etect the difficulties cn'
unization of the family,
heti^h education. .Also
tak^n off and on to get
cal personnel from the
es, like the economist,
rtritionist, demographers
rists.
Discussion of the
ads of the students and
-oblems in a developing
eh related to these cducathe clinical material from
lomic groups, and hence
iredominantly limited to
w socio-economic group
so other socio-economic
dy their problems which
cover the different sori'
irovidc good comparisi
Ivic^Bt the upper and
lomic groups and only
followed in low socn>-
oblems which we discus'
mia, (Hi) other common
rs like rickets, vitamin-'
deficiency, scurvy, f,r)
rs, (u) tuberculosis,
•ases, diphtheria, whoops, poliomyelitis, typhon
tc.. and (w) parasiW
I (viii) handicapl
*®
nference: This is anotb
*
held once in two
hours, in a three-m®’
The idea is to stimub
wborn which is uiU '
HOSPITAL IN TEACHING OF PREVENTIVE AND SOCIAL PEDIATRICS
selected in the developing countries,
ZEon prevention of disease from perinatal
Sod, bring about collaboration of departKnts’of pediatrics, obstetrics and prevennd
**
ja4j
social medicine, as well as bring
U1 medical personnel like midwife, social
WOtker, public health nurse, nutritionist
.Withers. This is a good example of
^^disciplinary teaching organization.
^Hie programme of a neonatal conference
consists of presentation of the clinical data
Inibrief and detailed data on the social,
joiaomic, environmental and cultural as
pects of the family. Initially there is a
JJjcussion by the students and the discusife'hy the paramedical personnel. This is
followed by comments and discussions by
(lechers of obstetrics, pediatrics and pre
ventive and social medicine. Throughout
the session there is emphasis on prevention
of the disease, health education, and to a
laser extent on routine treatment. During
6 neonatal conferences in a pediatric term
of J months, care of the healthy child, low
birth weight baby and common perinatal
Uid neonatal problems are discussed with
MOO presentation of the data on neonatal
and perinatal morbidity and mortality.
♦i- M.C.H. Centre: One of our Mater
nal and Child Health Centres is in the hos
pital premises. In such a centre, the obMetric staff members followup the mothers
from the antenatal period and look after
•hem during the intranatal and postnatal
periods, while the pediatricians look after
•he babies during the neonatal and postnatal
*f° ds. With such a collaboration of the
P
apartments of pediatrics and obstetrics,
useful sessions could be held to dis^33 the various problems of pregnant
particularly affecting the child,
® three to four weeks and useful
®JCTssions could be held on these problems
Tvtiie triple disciplines of obstetrics,
P^&tacs and preventive and social
."““Oife, with active participation of
Mg^ents.
Me many areas in which the
could be trained with the help of
j^g^mients of pediatrics, preventive and
J^A^dicine and at times obstetrics and
’'■;Eg*™?snt
of family planning and planned
' V^'hood. Other related departments
153
can participate depending upon the subject.
However, the motivation of the students,
their knowledge, practical implementation
and success of the programme will depend
upon the stimulation by and participation
of the teachers. Students usually take the
example of the teachers and they will learn
what the teachers do. Hence active parti
cipation of the teachers in different depart
ments, particularly pediatrics and preven
tive and social medicine is vital to the
success of teaching of preventive and social
pediatrics. The participation of the stu
dents and teachers could be had at various
levels and units in health education, nutri
tional education of the mothers including
preparation of foods for infants, immuniza
tion teaching, family planning, etc., for the
proper training of students in these
aspects.
It may be emphasized that
curative pediatrics at any unit is only
an initiation to teaching of preventive
and social pediatrics.
Difficulties
There are bound to be lot of difficulties
in the organization of the teaching of pre
ventive and social pediatrics to the students.
Some of them arc: (1) heavy service load,
particularly in the out-patient department,
(2) lack of adequate number of pediatric and
other teachers and paramedical personnel
specially interested in preventive and social
pediatrics, (3) lack of adequate number of
teachers in departments of preventive and
social medicine, particularly those oriented
to M.C.H. problems in developing coun
tries, (4) lack of adequate training period in
pediatrics in undergraduate teaching. The
students usually attend the morning sessions
from 9 to 12, and it is very difficult to
squeeze in everything in this short period.
It is desirable to have a full-time posting
of students in pediatrics so that they are
able to spend the whole day in the depart
ment. This can only be done by a full
block teaching. (5) Often there is inadequate
evaluation of the teaching programme
either at the level of the department but
more so in the lack of assessment of the
students in pediatrics by the pediatricians
in theory and practicals in the final qualify
ing university examination. (6) Lastly not
254 . Indian Journal of Medical Education
The' experience of the faculty
seems to be that a close co operation
with the interns is required ; that
short-term programmes that can be
completed within a 2-month period
are essential for the group as a fini
shed programme leaves a feeling of
satisfaction among participants.
1. April, 1962
It is such survey that bring the
graduates into close relationship
with the rural people, produce an
understanding of the existing condi
tions and creating, it is hoped, a
sense of curiosity to fact finding and
research in years to come.
Paediatrics in undergraduate Medical Education
bz
DR. FRAN N. TANEJA> Professor of Paediatrics and
DR« OM. P. GHAI, Asst. Professor of Paediatrics.
Paediatrics is a branch of medical development of the habit to think
science which deals with child care, and self-education ; (3) to create
both in health and disease. Its scientific curiosity; and (4) to acquire
place in medical education varies specific knowledge and skills.
greatly in different countries of the
world. Because it is young as
Every general practioner, therefore,
compared to other disciplines, its must not only be alive to the special
entrance into the curriculum at the needs and health demands of the
undergraduate level has been more community in the country in which
by superimposition than by design. he lives, but also be able to dis
The inception of paediatrics in India charge them efficiently.
has only been possible since the last
decade and a half. With the chang
There are several . reasons as to
ing trends the movement has heen why paediatrics is most suited for a
away from ‘curative’ paediatrics i.e. proper place in the training of such
the one dealing with treatment of a general basic, doctor :
diseases of children to that of a
comprehensive subject in which the
(a) India is a large country with a
human being as a whole, during a
population of over 436 millions.
certain age group, in all its aspects
It has been estimated that
is the focus of attention.
children constitute as much as
160 millions. Their demands
The main objective of medical
need
special attention.
education should bo the preparation
of a good basic doctor who is able to
serve the community as well as the
individual. There are certain pre
requisites necessary to that end,
viz., (1) awakening in the student
an interest in the human being, the
family and the community ; (2) the
(b)
India still has a very high in
fant morbidity and mortality.
It need hardly be emphasised
that infant mortality of any
country is the index of national
health.
255
256 ^Indian Journal of Medical Education
VWl, April, 1962
Paediatrics cannot be defined as ing should include knowledge about
mental
and emotional
a speciality either of an organ, physical,
system, a technique, a function growth and development, genetics,
or a group of diseases. It is the infant and child nutrition, method
application of general medicine ology of examination and treatment
and perhaps much more, as app of children with emphasis on the art
lied to a certain period of life. of handling children and their
parents, supervision of the child in
(d) By no means of imagination is a good health and for the promotion of
child a ‘miniature adult’ or a positive health, problems of the
‘little man’. Childhood is a handicapped child - both physically
biological period of every human and mentally, problems of the foetus
being especially characterised and the new born including the pre
by continuous process of growth mature and lastly adolescents. Be
and development from birth sides, there are many other situations
with which a basic doctor has to be
through adolescence.
familiar such as marriage counsell
health programmes,
(e) There are many social, environ ing, school
mental and congenital disorders physical and emotional problems of
puberty and adolescence. The field of
■ peculiar to this age group.
prevention is specially applicable to
(f) Many disease problems of later children and immunization pro
life have their beginning in cedures and prevention of diseases in
childhood and a study of paedi general has its best application in
atrics
gives one the best this age period. The doctor has also
opportunity of studying the to be well acquainted with the special
services available for child welfare
natural history of disease.
such as baby welfare centres, creche,
g) Paediatrics is the only field in adolescent clinics, etc.
which the doctor gets an oppor
tunity of applying family care
It would thus be obvious that the
in its natural environment. The training of every medical under
student therefore is ideally graduate should include a substantial
placed, while studying paediat time spent in the learning of paedia
rics, to study the social and trics. It is a strange paradox that
environmental factors
which the discipline of paediatrics appears
influence human well being.
to be least developed where it is
most needed and the number of
quirements of Teaching of Paedi
paediatricians is the smallest where
atrics
problems of child health are most
pressing. Whereas 40^ of any
Besides the obvious need for doctors’ patients, time is occupied
truction in the diseases peculiar by the care of children, in the aver
children or of children in certain age medical training centre in this
•as or of diseases common to both country he hardly gets more than
ilts and children, there are certain 2% of his training perird for the
•cialised fields which are essential. learning of this discipline. In order
y programme of paediatrics teach to have an adequate coverage, more
(c)
Paediatrics in undergraduate Medical Education
time is necessary and the allocation
of at least l/4th of the clinical time
to paediatrics seems to be a reasonable
proportion. It is very bssential that
adequate personnel and facilities
must be available for the proper use
of such teaching time. Instructions
in paediatrics should commence with
the teaching of growth and develop
ment and should run throughout the
clinical years both independently
and in collaboration with other
departments. Further, there should
be a period of concentrated paediatric
training towards the last part of
medical studies. It is indeed sad
that the Indian Medical Council has
not realised the importance of this
discipline and has very often dubbed
it along with other organ specialities.
Even in its recommendations, the
Council states that every medical
stndent should spend a minimum of
one month in the paediatric wards.
It need hardly be emphasised that
paediatrics cannot be taught only in
the wards and one month is hardly
any time even to orientate a student
in this major discipline. The teaching
methods may include as few as
possible formal single or multiple
teacher lectures but more of semi
nars and a well organised paediatric
clinical clerkship. It is during this
period that the student is exposed
to the out-patients service, the
various welfare clinics and is also
acquainted with the immunization
procedures. He must also be made
to spend some time in the care of the
newborn and in the specialised care
of the premature.
The All-India Institute of Medical
Sciences, realising the necessity of
giving a rightful place to paediatrics
in the undergraduate curriculum, has
already evolved a programme which
257
goes a long way in meeting the
principles enunciated above. Paediat
rics forms at the Institute an
independent
discipline and has
approximately 12% of the total
clinical time. Its instruction starts
in the first year with growth and
development and goes through till
the end with an essential pre-registration internship of one month. The
department collaborates with all
other clinical disciplines in the
teaching of common problems sucl^as
clinical methods, infectious diseases,
etc. There are additional specific
paediatric topics. The total clinical
clerkship of every student works
nearly to 4 months in the depart
ment during which time he is rotated
through the various sub-sections of
paediatrics as already outlined.
Another feature of this training
programme is the day to day assess
ment which has a significant part tp
play in the final performance. The
students, of course, have to take a
separate examination both theoretical
and clinical in paediatrics.
Appeal to Medical Educationists
It is obvious that paediatrics is a
comprehensive discipline dedicated
to the care of the whole organism
and fulfil the basic aim of a rational
medical teaching ideally. It supple
ments rather
than takes away
anything from the teaching of .general
medicine in all its facets. It offers a
helping hand to the surgeon in
familiarising the students to the
management of water and electrolyte
disturbances, to obstetrics by colla
borating in the care of the newborn
and premature and other specialised
disciplines in fully co-operating with
them. If we have to reduce our
infant mortality, our poor nutritional
258
Indian Journal of Medical Education
standards
in
the
school-going
children and to prevent the communic
able diseases, we ought to train the
students in the right direction and
adequate time allotment for paediatrics
therefore becomes essential. It seems
odd to send out a qualified doctor
from a medical school without his
having any idea of how to deal with
40% of his clients.
«It is of fundamental importance to
realise that paediatrics is not a
speciality ; in fact, if there is any
generality it is paediatrics. It is
hoped that the medical educationists
will realise the changing times and
give adequate portion of the clinical
Vol. 1, April, 1962
teaching time to this very important
yet long neglected field of under
graduate medical training.
References
1. Interdepartmental Committee on
Medical School (1944) Report,
London. H. M. Stationery Office.
2. Robinson,
P. Undergraduate
Paediatric Education in South
East Asia. Acta Pediat. 50,
329, 1961.
3.
W. H. 0. Study
Group on
Paediatric Education, Report.
W. H. 0. Technical Report
Series 119, Geneva, 1957.
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