There were two things that dismayed me at the BEmOC (Basic Emergency Obstetric Care) training session for medical officers that 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 such training programs. There were no organised lectures or demonstrations, and nothing was done to ensure that its purpose was met. The second rather shocking aspect was 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 in such a fundamental area of rural medicine.
I was dismayed by the thorough casualness and out and out lack of discipline with which the session was conducted — a feature common to most such training programs.
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 who practice indigenous systems of medicine), and paramedical staff such as nurses and pharmacists. The study concluded that Rural Medical Assistants performed similarly to MBBS physicians, with only 61 percent 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 Chattisgarh, I believe we can justifiably extrapolate these trends to most 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 worth noting that MBBS physicians sampled in this study had, on average, multiple years of experience in rural service. In an earlier piece, I had argued that fresh MBBS doctors usually come with a very limited practical approach and need more years of supervised training to be able to practice 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.
It is 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 will agree that the importance of periodic training programs for medical officers is badly needed. There is a palpable lack of rigour and stringency in the implementation of such programs and participants can often get away easily with absenteeism. The programs are held on random topics at random intervals at random points of one's tenure. Many a time, such programs are nothing more than mere token gestures organized to achieve targets on paper. Lastly, most of these programs hardly go beyond the scope of classroom teaching, lacking in practice-based learning and assessment.
Training programs for medical officers need to focus on practice based instruction in the prime areas of rural medicine.
There is an urgent need to realise that the purpose of such training programs 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 programs 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 participant involvement in these programs.
2) Comprehensiveness: Programs 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 programs 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 programs for medical officers can be made into an efficient, cost-effective tool for improving health outcomes in rural settings in India.