Skip to main content

Outreach programme in medical education: Band-aids for compound fractures

By Amitav Banerjee, MD* 
Recently, the National Medical Commission (NMC) of India, introduced two curricular changes in medical education, both at the undergraduate and the postgraduate levels, ostensibly to offer opportunities for quality medical education and to improve health care accessibility among the underserved rural and urban population.
At the undergraduate level, it introduced the Family Adoption Program (FAP), in August 2019 to be implemented for MBBS students from 2021-22 batch as a part of new competency based medical education (CBME) curriculum. The purpose is to provide community-based learning experience to medical students. The FAP starts from the first professional phase to be continued throughout the MBBS course. The NMC stipulates that each student will adopt five families in rural areas or urban slums, in the first year. The medical student will be responsible for monitoring the general health of the family members of the adopted families and advise them on health related issues, guiding and accompanying them to the hospital. The medical student is expected to follow these families till their final MBBS part one, under the guidance of a faculty of Community Medicine.
At the postgraduate level, the District Residency Program (DRP) was launched in 2020 by the NMC to be followed by students admitted 2021 onwards. This is a mandatory three months rotational posting for all post graduate (PG) students, or residents as they are called, in district hospitals.
A number of articles, in peer reviewed medical journals, praising the schemes while glossing over the drawbacks, have been written by academics, with their skin in the game. We require a critical appraisal of these community outreach activities, against the background of the current ethos of medical education and the needs of the underprivileged communities. The NMC enjoys immense authority over the Medical Colleges in India. By granting them recognition it can make or break them. Regular inspections for increase in seats keep the faculty and management on their toes perpetually. Any criticism of their policies is unlikely to come from them.
Anna Ruddock a medical anthropologist from Stanford University, carried out a detailed study of student doctors at All India Institute of Medical Sciences, (AIIMS) New Delhi. After studying the medical landscape and interviewing hundreds of doctors and medical students, she has penned down her deep insights in her book, "Special Treatment." 
As the AIIMS is the role model for all medical colleges in India, her findings describing the ambitions and aspirations of medical students in AIIMS have important take home messages for medical education. They are sobering. Her in-depth interviews with medical students revealed that almost all of them were focused in the future and their MBBS course was only a corridor to specialization and super-specialization. Wise beyond their years, the medical students demonstrated irrefutable logic in this approach given the current medical environment. As one student expressed, "MBBS has become just like a preliminary examination, it's a "pre." So the actual doctor should at least do a PG, otherwise you are not a doctor." Most echoed similar views, and beyond, a considerable number wanted to pursue super-specialization after their PG studies. According to them the medical students were on the cusp of a transition to the necessity of super-specialization without which they would stand no chance of a successful career.
Another articulated, "About 20, 30 years back just MBBS doctors were doing all these things, no PG qualification or anything. But now PG is everything, without PG we cannot do anything. At present if I am postgraduate, I will be just OK in medicine, but in my time in five-six years, I will be doing super- specialization."
Those who fail to secure a PG seat do not necessarily enter general practice by default. A large number keep on appearing and re-appearing in the entrance tests to secure a specialist branch. Dr Raman Kumar, of the Indian Academy of Family Physicians estimates that at any given time India has around 300,000 MBBS graduates who were not in full time work. And many who do not get their desired specialty again reappear in the entrance exam to get the seat of their choice.
This period of the past two or three decades coincides with India's flourishing corporate hospitals and driving health care from a calling to an industry selling a "five star" experience to patients. This transition is influencing the value of particular forms of medical practice in the eyes of patients and aspiring doctors.
The other aspect which the outreach programs purport to address is lack of access to health care by the marginalized population. The Bhore committee laid down the roadmap for health care around the time of our Independence. It envisioned a primary health centre for 10,000 to 20,000 people with a 75 bedded hospital staffed by six medical officers, including the broad basic specialities like surgery, gynaecology, medicine, and supported by other auxiliary staff. About 30 of these primary units were to be overseen by a secondary unit with a 650 bed hospital offering all major specialties. At each district level, it recommended a 2,500 bedded hospital providing tertiary care.
Over the years we have strayed further and further away from this roadmap which would have provided equitable health care to our vast population both at the rural and urban areas. By adopting families, (the very term "adopting" is patronizing), first year medical students without any clinical competence would not mitigate the medical needs of our neglected population overnight. Many would play truant to attend coaching classes for PG entrance as they are doing currently during internship training. They would of course, with a spatter of white coats in the community give an appearance of medical cover at the community level without going deeper than the surface of the malady, like misplaced band-aids over compound fractures. A compound fracture is one in which the skin over the bone is broken, and putting band-aid on the skin will not address the deeper fracture. And due to the commuting from college to community they will lose on precious time taken away from learning tough subjects like Anatomy, Physiology, and other basic medical sciences which is the foundation of a sound professional career.
But of course, these community postings and outreach activities help them pad up their CV enabling them to get admissions and jobs abroad. At the first opportunity for greener pastures in the West, having learned the tricks of the trade, rather than the trade, most fly over the cuckoo's nest instead of serving the community.
From the above dynamics, it would be obvious that the current ethos of health care and medical education does not harmonize with the concept of community outreach activities in medical education. The NMC, though well meaning, seems to be both insulated and permeated by social and health inequalities beyond its ivory tower. For the former it seems to be turning a Nelson’s eye to the deeper malaise in healthcare, while for the latter it is applying band-aids over compound fractures. The concept of FAP originated in Sewagram on the principles community service of Mahatma Gandhi. Given the lure, lucre and survival in the profession, only an occasional Spartan like the "Mahatma" may benefit from these outreach activities.
---
*The Author is a renowned epidemiologist, and currently is Professor Emeritus at DY Patil Medical College, Pune, India. Having served as an epidemiologist in the armed forces for over two decades, he ranked in Stanford University’s list of the world’s top 2% scientists in the year 2023 and again in 2024. He has over three decades of teaching experience including undergraduate and postgraduate courses

Comments

Anonymous said…
The combination of experience, keen observation and analytical abilities of the author about ground realities is evident in the article. DRP is academic wastage but a long merry time for residents. The residents would not learn anything better in DRP. They are just covering the deficiency of services in those hospitals or are relieving the existing working drs. FAP is not practical and useful and dangerous as well as it is taking a toll on UG students and Community Medicine faculty. NMC should consider taking the opinions of all stakeholders and ground realities before implementing any major changes in the system.
Anonymous said…
Thank you for your valuable feedback. Appreciate it.
Anonymous said…
I second the thought by dr Amitav Sir. Although FAP and DRP are supposed to connect our students to community , it’s becoming a tick mark activity to make institutions NMC compliant. We all know the problem, however we don’t acknowledge it , even if we acknowledge many of us don’t want to challenge the current system..
Anonymous said…
The sheer logistics of having medical students in large numbers , including from private medical colleges, roaming around in the community, virtually unsupervised is a recipe for disaster. Are 18 - 22 year old modern generation young people capable of independent functioning to this extent? Where will the supervisory faculty get a chance to guide them and influence their work, when there are not enough faculty in most medical colleges for routine work... this refers to the slew of new govt medical colleges that have been opened up in many Districts by transferring faculty from well established colleges. Spreading 20 gm of butter intended for one toast on five slices of bread doesnt help in anyway.
Anonymous said…
NMC must have done the home work first before launching both the programs
It is unscientific to bring change without doing a situation analysis
How many colleges are having adequate infrastructure , manpower and logistics to run these programs on regular basis . It is just like posting pics on social media and filling the forms . Neither the community nor the students are getting any benefit out of it . It is only a number game for the govt which an apex body like NMC is adhering too . I am not sure how many of NMC members have really worked in the field and how the insight is developed for launching the program on mandatory basis
Anonymous said…
The logistics of assigning three families to an undergraduate student, safely transporting them to the village, supporting and enabling them to interact with the villagers and then seeing they record the interactions - all take serious planning , logistical support and most importantly cooperation from the families who are "adopted". Medical colleges with 250 students intake require 750 "families" and all should be within a reasonable distance so that it becomes easy to reach - say after travelling 60 to 75 minutes one way. On any given working day, the children will be in school and the adults (barring the infirm and elderly) will be at work which make it difficult for the students to actually meet with all members of the family. Any teacher of community medicine at a medical school would have told them this - had they wanted to have a dialogue. Unfortunately they do not want to have a discussion.
Anonymous said…
Do we learn medicine by roaming arround in village streets and chitchating or by reading books, listoning , discussing and seeing patients under active guidance of clinical tutors in a conducive environment ? Can a 17 yrs old tweleve class pass student guide patients in villages on their diseseases and drugs ? Its a cruel joke on medical education and future doctors . Must be stopped forthwith !

TRENDING

Loktantra Bachao Abhiyan raises concerns over Jharkhand Adivasis' plight in Assam, BJP policies

By Our Representative  The Loktantra Bachao Abhiyan (Save Democracy Campaign) has issued a pressing call to protect Adivasi rights in Jharkhand, highlighting serious concerns over the treatment of Jharkhandi Adivasis in Assam. During a press conference in Ranchi on November 9, representatives from Assam, Chhattisgarh, and Madhya Pradesh criticized the current approach of BJP-led governments in these states, arguing it has exacerbated Adivasi struggles for rights, land, and cultural preservation.

Promoting love or instilling hate and fear: Why is RSS seeking a meeting with Rahul Gandhi?

By Ram Puniyani*  India's anti-colonial struggle was marked by a diverse range of social movements, one of the most significant being Hindu-Muslim unity and the emergence of a unified Indian identity among people of all religions. The nationalist, anti-colonial movement championed this unity, best embodied by Mahatma Gandhi, who ultimately gave his life for this cause. Gandhi once wrote, “The union that we want is not a patched-up thing but a union of hearts... Swaraj (self-rule) for India must be an impossible dream without an indissoluble union between the Hindus and Muslims of India. It must not be a mere truce... It must be a partnership between equals, each respecting the religion of the other.”

A Marxist intellectual who dwelt into complex areas of the Indian socio-political landscape

By Harsh Thakor*  Professor Manoranjan Mohanty has been a dedicated advocate for human rights over five decades. His work as a scholar and activist has supported revolutionary democratic movements, navigating complex areas of the Indian socio-political landscape. His balanced, non-partisan approach to human rights and social justice has made his books essential resources for advocates of democracy.

Four J&K MLAs visit Wular lake, pledge support to fisher community, environmental conservation

By Shamim Ahmed*   In a historic meeting that highlighted both environmental and social concerns, four Members of the Legislative Assembly (MLAs) visited Wular Lake to meet with the fisherfolk community, signaling a significant step in addressing their longstanding issues. This gathering, organized with the support of dedicated advocates, marks a strengthening of efforts to both safeguard the lake’s ecosystem and support the community’s welfare.

Supreme Court’s dismissal of PIL on Covid vaccine safety is counter to known science and mathematics

By Bhaskaran Raman*  On 14 Oct 2024, the Supreme Court of India dismissed a Public Interest Litigation (PIL) on the side-effects of the Covid vaccine. In 2021, the world saw the rollout of various Covid vaccine candidates. In India, Bharat Biotech’s Covaxin and Serum Institute of India’s Covishield were rolled out. Covishield was nothing but Oxford’s AstraZeneca relabelled in India. The importance of open-minded and scientific probe of Covid vaccine safety In 2020/2021, all Covid vaccines were authorized for emergency use, which meant that the necessary efficacy and safety follow-up was incomplete at that time. The originally approved trials – called randomised controlled trials (RCT) had a “vaccine” group and a “placebo” group for comparison. Such experimental comparison/control is the cornerstone of the scientific method – which even children learn in photosynthesis experiments in class-1. The vaccine trials were scheduled to conclude in late 2022/early 2023. For instance, Covax...

Swami Vivekananda's views on caste and sexuality were 'painfully' regressive

By Bhaskar Sur* Swami Vivekananda now belongs more to the modern Hindu mythology than reality. It makes a daunting job to discover the real human being who knew unemployment, humiliation of losing a teaching job for 'incompetence', longed in vain for the bliss of a happy conjugal life only to suffer the consequent frustration.

Buddhist shrines were 'massively destroyed' by Brahmanical rulers: Historian DN Jha

Nalanda mahavihara By Our Representative Prominent historian DN Jha, an expert in India's ancient and medieval past, in his new book , "Against the Grain: Notes on Identity, Intolerance and History", in a sharp critique of "Hindutva ideologues", who look at the ancient period of Indian history as "a golden age marked by social harmony, devoid of any religious violence", has said, "Demolition and desecration of rival religious establishments, and the appropriation of their idols, was not uncommon in India before the advent of Islam".

A Hindu alternative to Valentine's Day? 'Shiv-Parvati was first love marriage in Universe'

By Rajiv Shah  The other day, I was searching on Google a quote on Maha Shivratri which I wanted to send to someone, a confirmed Shiv Bhakt, quite close to me -- with an underlying message to act positively instead of being negative. On top of the search, I chanced upon an article in, imagine!, a Nashik Corporation site which offered me something very unusual. 

Right-arm fast bowler who helped West Indies shape arguably greatest Test team in cricket history

By Harsh Thakor*  Malcolm Marshall redefined what it meant to be a right-arm fast bowler, challenging the traditional laws of biomechanics with his unique skill. As we remember his 25th death anniversary on November 4th, we reflect on the legacy he left behind after his untimely death from colon cancer. For a significant part of his career, Marshall was considered one of the fastest and most formidable bowlers in the world, helping to shape the West Indies into arguably the greatest Test team in cricket history.

Will Left victory in Sri Lanka deliver economic sovereignty plan, go beyond 'tired' IMF agenda?

By Atul Chandra, Vijay Prashad*  On September 22, 2024, the Sri Lankan election authority announced that Anura Kumara Dissanayake of the Janatha Vimukthi Peramuna (JVP)-led National People’s Power (NPP) alliance won the presidential election. Dissanayake, who has been the leader of the left-wing JVP since 2014, defeated 37 other candidates, including the incumbent president Ranil Wickremesinghe of the United National Party (UNP) and his closest challenger Sajith Premadasa of the Samagi Jana Balawegaya.