There were two things to my dismay at the BEmOC (Basic Emergency Obstetric Care) training session for medical officers which I attended a couple of weeks ago. First was the thorough casualness and out and out lack of discipline with which the session was conducted — a feature common to most of such training programmes. There were no organized lectures or demonstrations, and nothing was done to ensure that its purpose was met. The second rather shocking aspect is that a colleague of mine, the only other participant, was receiving the training for the first time in his 20 year long tenure as a medical officer on such a fundamental area of rural medicine.
Allow me to cite a study conducted to assess the competence of rural medical practitioners, a term I’m using to cluster together MBBS physicians (those serving as medical officers in rural areas), Rural Medical Assistants (those trained specifically to practise medicine in rural areas), AYUSH doctors (those of indigenous systems of medicine), and paramedical staff like nurses and pharmacists. The study concluded that Rural Medical Assistants performed similarly to MBBS physicians with only 61% correct prescriptions for six of the most common illnesses seen in rural India. AYUSH doctors and paramedical staff had inferior competency scores. While the study was limited to the hinterlands of Chhattisgarh, I believe we can justifiably extrapolate these trends to most of the other states of India — also considering that studies conducted in some other settings have found the quality of care provided by primary care physicians to be only marginally better than quacks.
While qualified MBBS physicians performed better than AYUSH doctors and paramedical staff with 61% correct prescriptions, their score is nowhere close to exemplary, and leaves a lot to be desired. It is also worthy to note that the MBBS physicians sampled in this study had, on average, multiple years of experience in rural service. In a former piece, I had argued that fresh MBBS doctors usually come with a very limited practical approach and need further years of supervised training to be able to practise independently. Also, MBBS interns spend a majority of their internship year in tertiary care settings and hardly receive any orientation in rural healthcare. With this in mind, you can imagine the precariousness of the situation in which a fresh MBBS doctor is made in charge of a rural primary health centre. Add to it the common knowledge that, usually, those belonging to the lower belt of competency distribution and with limited prospects elsewhere opt for service in rural areas.
Those who’ve spent at least a year in rural service would agree that the importance of periodic training programmes for medical officers is largely understated. There is a palpable lack of rigour and stringency in their implementation, and participants can often get away easily with absenteeism. Programmes are held on random topics in random intervals at random points of one’s tenure — and are mainly intended to update medical officers about the current developments in the field. Many a time, such programmes are nothing more than mere token gestures organized to achieve targets on paper. Lastly, most of these programmes hardly go beyond the scope of classroom teaching, lacking in practice based learning and assessment.
There is an urgent need to realise that the purpose of such training programmes for medical officers needs to transcend that of just keeping them abreast of latest developments and achieving targets on paper. With the limited clinical experience fresh MBBS doctors possess, and with the glaring lack of orientation of fresh Medical Officer recruits in rural healthcare, training programmes for medical officers need to focus on practice based instruction in the prime areas of rural medicine. The potential reforms can be summarized under three heads:
1) Stringency: Excellent stringency and rigour needs to be observed in implementation, supervision, and ensuring the participants’ involvement in these programmes.
2) Comprehensiveness: Programmes need to be comprehensive, focussing on every major health/disease feature characteristic of rural areas.
3) Planning: A definite plan needs to be followed with regard to the scheduling of such programmes for new medical officer recruits — and most, if not all, of the important areas of rural medicine be covered within the first year of their service.
Given some proper direction, periodic, ongoing training programmes for medical officers can be made into an efficient, cost effective tool for improving health outcomes in rural settings in India.
The writer, Dr Soham D Bhaduri, is a medical doctor and takes keen interest in mental health and medical education. He blogs at The Free-Thinking Medic.
Note: An edited version of this article was first published in Huffington Post India.