Essential Skills in Postgraduate Medical Curriculum of Community Medicine

Introduction

Based on the principles outlined at Alma-Ata in 1978, there is an urgent call for revitalizing primary health care. India is not only committed to strengthening primary care but is already well aware of the means to achieving this goal (1). The National Rural Health Mission (NRHM) is a great testament to the determination of the Indian government to deliver universal primary health care and it has had impact also (2). However, there are a number of operational issues that need to be addressed to ensure that primary care is delivered effectively. And, some of the major problems in implementation and practice of primary health care relate to training and capacity building of health service providers in foreseeable future (3). It is suggested that human resources with requisite knowledge, skills, attitudes, values and responsiveness to people's health needs and health promotion are needed.

Community-based education has been considered a suitable approach for health promotion and for requisite skill development regarding primary health care (4, 5). In the current perspective, public health training and public health research, being two important aspects require immediate attention. The Task Force on Medical Education for the NRHM and National Health Policy 2002 have recommended increase in postgraduate seats in the discipline of Community Health/Public Health/Preventive, Social Medicine and Family Medicine (3). Thus, it is evident that in current scenario, public health specialists are the need of the hour in community health care.

The objectives and goals of Postgraduate (PG) Medical Education in Community Medicine are to produce competent specialists to manage the teaching departments in the Medical Colleges, or to manage health services and national health programs at various levels or to conduct biomedical research in the discipline of Community Medicine (6). During training, PG are expected to acquire a substantial knowledge and necessary skills in: concepts of health and illness and their determinants, methods in community health, health services organizations, community health programs and communication and advocacy (7).

There are regional variations in the way PG training in India is imparted by various institutions. There is no well defined curriculum worked out, if at all it is there, the methods of acquiring the desired competencies are vague or not at all stated (6). Though Medical Council of India has reiterated competency-based PG training in community health care, yet, detailed structured curriculum in PG training in Community Medicine is being followed in handful institutions only (8).

Considering the fact acquiring relevant public health skills during PG training is pertinent, the present study was undertaken to assess the skills of PG students in department of Community Medicine in four Medical Colleges of Delhi. This would also enable us to know the variations in PG training and evaluate whether the medical pedagogic approach is in line with objectives of such training.

Materials and Methods

Results

Out of the total 70 respondents, 58.6% were male and 29% were females. Large proportion of participants was between the age of 25-29 years. More than half of the participants had their undergraduation from a private college (51.4%). Majority of the students belonged to general category (n=49; 70%). There were 29 students who were in first year of postgraduation, 18 were in 2nd year while 23 students were studying in 3rd year. While 34.3% students had graduate mothers, half of the PG students had Fathers with professional education. Majority of students said that their mothers were housewives (87.1%) while half had fathers engaged in semi-professional occupation (Table 1).

There were 22 competencies that were self-assessed by the students. Most of the competencies did not show year of PG wise difference. However, ability 'to resolve conflict among the nurse at Primary Health Centre (PHC)', 'generate community participation', 'making thick and thin smear in case of fever', 'making a chart showing month-wise distribution of CuT', and 'calculating Chi-square of data', was found to be significantly higher in 2nd and 3rd year PG students than first year PG students (p<0.01). Only 27.1% of students felt that they could test water sample for microbiological aspects while only 47.1% said that they could examine an industrial worker for pre-placement examination. Ability to evaluative DOTS or any national health program and manage inventory of health centre was possessed by 48.6% and 54.3%, respectively (Table 2).

Univariate analysis of public health skills with socio-demographic factors showed that students who are females, having graduation from Government College, being in 3rd year of PG, aged younger, mother's and father's professional education and occupation, have higher skill score than others, though the difference was not significant (Table 3).

Discussion

The medical education regulatory authority Medical Council of India (MCI) has defined essential competencies to be acquired at the end of PG education in Community Medicine. These include managerial and epidemiological skills in health care delivery system and national health programs, skills to identify community health needs, research methodology and abilities to impart training to medical and paramedical personnels (9). The present study was undertaken to assess some of these skills among the PG students of four Medical Colleges in Delhi.

Self assessment of communication and counselling skills by the PG students revealed that majority of them considered themselves to be competent to communicate with a family member of a patient and motivate eligible couple for contraceptive use. This finding is in contrast to the findings of study by Avan et al in 2005 in Pakistan (10). These high proportions give some credence to recognition by PG students of the importance of effective communication with the community and their patients. Further, interaction with people and their organization in urban and rural settings offers a wonderful opportunity for learning from people (9).

Epidemiology is an important part of Community Medicine and acquiring epidemiological competencies is essential for community physician (11). In the current study, only 58.6% considered themselves skilled enough to investigate an epidemic. Outbreak investigation is an opportunity to contain the epidemic and prevent future occurrence and is the best example for participatory and active learning of epidemiology. The finding highlights the need to focus on this skill among PG students during their training in epidemiology. Similarly planning evaluation of national health program or carrying out surveillance of a vector borne disease are essential components of epidemiology that offer opportunity to learn multiple things.

It is a ritual to establish public health laboratory to meet the requirements of MCI. However, at many places the laboratories have not been developed. Due to lack of infrastructure in the field areas, the skills in laboratory organization for organisms of public health importance is mostly lacking among PG students as was evident in the current study as well. Even though, the students were posted in public health laboratory of MCD and Microbiology Department of their respective colleges, many students found it hard to make smears for malaria diagnosis (41.4%) or test water sample for quality (72.9%). This finding points to the fact even though knowledge can be gained, learning is best experienced by doing, skills need to be practiced repeatedly to develop perfection (9).

In India, the requirement of occupational health manpower is accomplished by medical graduates, community medicine specialists, and public health specialists working as industrial medical officers (12). Thus, it is evident that PG student of Community Medicine should be trained in occupational health. However, in the present study, little less than half felt that they can do pre-placement examination of an industrial worker. This is probably is due to the fact occupational health training in India is most neglected in medical curriculum.