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Indian Journal of Community Medicine

Vol. 25, No. 1 (2000-01 - 2000-03)



The new regulations of Medical Council of India on graduate medical education 1997 have posed several challenges to the field of medical education in general and to the discipline of Community Medicine in particular. These regulations have been adopted all over the country in phased manner and various departments are adapting themselves to modify the programme of teaching and training in the set up of medical institutions to translate these regulations into action.

Critical review of these recommendations and their application to the discipline of Community Medicine in the prevailing conditions unfolds several practical problems and it becomes Herculean task to implement these regulations in letter and spirit.

Medical Council of India has earned the credibility to the extent that it could spell out clearly the national goals and objectives of graduate medical education programme explicitly in terms of "Health for all" and "National Health Policies". In consonance with the national goals each medical college is required to evolve institutional goals with a view to clearly define the kind of trained manpower they intend to produce. These recommendations reiterate that the graduates be familiar with the basic factors which are essential for the implementation of the National Health Programmes including practical aspects of family welfare, maternal and child health, sanitation, water supply, prevention and control of communicable and non-communicable diseases, immunization and health education.

Though the teaching and training of community medicine permeates throughout all the three phases of education but it has been systematically degraded over the past years. The educational experience based on the model of regulations will have over emphasis on orientation towards disease and hospital.

Teaching and training of "Community Medicine" has to be in the "Community". Larger share of time should be spent in the community. The time allocation during different phases of the programme as indicated below goes against this laudable principle.

Phase I 60 hours 30 Lectures and 15 visits of 2 hours each
Phase II 200 hours 8 weeks posting of 3 hours each
Phase III 50 hours 4 weeks posting of 3 hours each

During the first phase, 30 hours are to be devoted to lectures, demonstrations and seminars and 15 visits of two hours each to cover the relevant part of introduction to humanities and community medicine; including demography, health economics, medical sociology hospital management, behavioural sciences inclusive of psychology. In practice, this programme posed several practical problems. Most of the times the teaching and training got confined to class room settings and the community exposure and contact with the community was of limited nature. Ideally, whole of the first phase should be devoted to community contacts to learn the community anatomy and physiology in sequential manner. Most of the departments of Community Medicine do not have adequate and well developed urban and rural field practice areas to accomplish these cherished regulations and hence the implementation tends to be a mere compliance. The resources of transportation of students to field practice area, ensuring meaningful and adequate preparedness beforehand (preparing the communities, preceptors and demonstration material etc.) is seldom undertaken as a serious endeavour. Time of two hours to accomplish a meaningful visit in our experience becomes quite taxing and appears to be Herculean task in many situations. To obviate this situation a rapid field visit exposure programme was evolved at Medical College, Rohtak. Model of this exercise is detailed hereunder. This was possible on account of several improvizations. Luckily the urban field practice area is in proximity of 1-2 Km. distance from the medical college institution. Advance preparedness is ensured. The visits are purposive with objective clearly defined and methodology to achieve the objectives are specified and account of visit is recorded by each student on the same day, which forms the basis for the student's internal assessment. Through these visits community contacts are maximized. However, the situation cannot be replicated in many other areas, this may be exception rather than a rule, hence the challenge is formidable and solutions are not easy to work out. The design in fist phase in our situation was to have the total class of 115 students for ten working days and then dividing the class into 3-4 batches for demonstrations on rotational basis.

Phase I (60 Hours)

Subjects/Areas Lecture/discussion and seminar Practicals-2 hours each observations, interview, demonstration
A. Introduction of discipline of Community Medicine
Demography and Population
Population Composition, distribution,
Population trends and dynamics
Population problem
Vital statistics
Economic surveys
10 Hours 1. Present population trends, demographic gap, Population distribution statewise
2. Composition of Population, age and sex pyramid its interpretation
3. Organization of urban community (slums and well to do) their resources, institutions. Rapid assessment
4. Organization of rural community their resources and institutions. Rapid assessment
5. Water supply in urban community
6. Water supply in Rural community
B. Medical sociology
Community structure and functions-economics.
Family-function, composition, types.
Groups/Leadership in community
Community development
Community health problems
Urban slums
10 Hours Family Study - allotted families
1. Composition, characteristics
2. Physical, biological and social environments
3. Qualitative and quantitative
Dietary intakes
C. Behavioural sciences
Cultural practices, customs
Health practices, personal hygiene
Personal habits
8 Hours Observe health practices
1. Age of marriage, birth interval, contraception practices.
2. Immunisation practices Feeding and delivery practices.
3. Child rearing practices, hygiene practices
4. Excreta disposal, garbage and waste disposal in allotted families
D. Hospital Management
Hospital organization and services.
Preventive services
Promotive services
Curative services
Rehabilitative services
2-4 Hours Visit to Hospital
Hospital waste disposal, central seterilization and supply department
Hospital records
Total 30 Hours  

During phase II and III (from third to ninth semesters) four weeks clinical posting of three hours in three spells of 4 weeks each has been suggested. In practice, the posting is variable and on each day a student becomes available for 2-4 hours a day. This has been evolved on hospital design and experience of taking a case in the OPD/indoor. How to fit this into clinical practice of community medicine in community settings? This is a big challenge indeed. One has to take a lot of initiatives to set up clinical practice of community medicine in the vicinity of the institute in urban slums or rural community. Deptt. of Community Medicine at Medical College, Rohtak could do it in a magnificent way by establishing the office of ICDS in the Deptt. of Community Medicine itself. We have developed strong linkages with ICDS system and with that innovative strength we are able to demonstrate the practice of community Medicine within the allocated time of 2-4 hours. We have developed improvised urban health centres and satellite centres in collaboration with ICDS infrastructure in urban slum population of 25000 in the vicinity of medical college. The model for three spells of clinical posting in Community medicine is presented below for replication in situations wherever feasible. Learning in theory lectures and clinical posting should be dovetailed and integrated in such a manner that leaning experience becomes a comprehensive endeavour. Medical Council of India accords clinical status to "Community Medicine" and it is highly appreciable and right thinking. Department of Community Medicine has to establish practice of Community Medicine within the hospital and in the Community on sustained and regular activity basis and taking responsibility for primary health care services.

Phase II & III (3rd to 6th semester)

Clinical Postings - 3 hours each day for 4 weeks

Area Time Resource material
A. Statistical exercises (mortality, morbidity, fertility) of rates, ratios of live and current data of district, state and country.
Data presentation in tables, diagrams and maps-drawing inferences.

Averages, Measure of dispersion, normal distribution
20 Hours Census data
National health and family welfare programme - Reports, National family health survey data
Distt. health survey data, Hospital, health centre and state published data.
B. Epidemiological exercises based on case studies/ caselets/ outbreaks - Data of health facility, routine reports, special surveys - National, State & local level surveys or service data.
1. Disease pattern and major morbidities in the state, country or district - diseases of infants, pre-school children, reproductive period, old age.
2. Incidence of common diseases in different age and sex groups.
3. Prevalence of common diseases, endemicity of disease (weekly- monthly- yearly incidence)
4. Distribution of diseases, geographically pathology of HIV, Endemic Goitre, Filariasis, Tuberculosis, Malaria
5. Disease trends - Seasonal variations, cyclical variations and secular trends.
6. Disease surveillance data of Malaria - API-SPR, fever rate, vivax and falciparum proportion. Spray data.
7. Causes of deaths statistics (Rural), infant mortality and preschool age and maternal mortality trends and causes.
8. Malnutrition in children, risk factors
9. ARI, diarrhoea and ORS use rate.
10. Planning and management (microplanning) - based on birth rate, disease burden and death rate.
Requirement of vaccines, supplies and materials.
11. Risk ratio, attributable and relative risk.
12. Sensitivity and specificity of test.
13. Life tables
14. Contraception Prevalence rates.
30 Hours Health Information India
Registrar General data.
SRS data
NFHS data
CSSM Modules
AFP alert
NICD data
NNMB data
other surveys, coverage evaluation surveys.
ICDS and social welfare.
World bank reports
C. Family studies on allotted family in urban slum. Follow up for outcome of pregnancy, growth and development of child, events: disease, disability and death, service utilization, home management and problems and health related practices, home visits of functionaries. 40 Hours  
D. Exposure to special drives - compaigns and mass operations and massive drives like outbreaks/ immunisation/ census/ spray/surveys 10 Hours  
E. Hospital situations - like immunisation clinic, antirabic clinic, hospital records and statistics, international classification of diseases, hospital central sterilization, health education booth, post-partum programme, sentinel surveillance, hospital waste management. 10 Hours  
F. Urban health centre and other urban settings.

1. Health services in slum areas
2. Outreach session of immunization.
3. Cold chain system
4. Iron-folic acid and vit. A prophylaxis.
5. Antenatal services
6. Services for young children
7. Growth monitoring-session
8. Supplementary nutrition session
9. Breast feeding practices
10. Non formal pre-school education.
11. Essential medicine kits
12. Demonstration on ORS and home made sugar salt solution
13. Home based records for immunization and antenatals.
14. Contraception practices.
15. Iodized salt - consumer level monitoring by kits. Salt storage and preferences.
16. Birth and death registration system and certification in urban area.
17. Urban malaria control - Larvicidal operation.
18. Entomological exercises - larvae and adults.
19. Urban waste disposal and hazards.
20. Initial training of health workers - Male and female
21. Food adulteration act, food sampling
22. AFP surveillance, stool samples
23. Laprosy colony,
24. School health check-up and services including health promotion.
25. Occupational/railway/defence services.
30 Hours ICDS/ESI Municipal health services. NGOs, Private hospitals, Practitioners.
G. Accessible rural health centre or subcentre or village

1. Rural community - village panchayat
2. Traditional birth attendant, delivery practices
3. Subcentre-health team and its functions/activities-demonstration.
4. Anganwadi-institution.
5. Malaria surveillance
6. Water chlorination - sample collection and bacteriological standards of drinking water.
7. Outreach session of immunization
8. Primary health centre/CHC organization and functions
9. National health programmes
- Family planning/contraception services
- Maternal health services
- Child health services
- School health services
- Diarrhoeal diseases and ARI
- Essential drugs and ailments
10. Records of subcentre/PHC
11. Repots of subcentre and PHC
12. Disease notification
13. Mosquito and fly breeding places - collection of larvae and adults.
14. Spray operation and other mass operations.
15. Bacteriological standards of drinking water - sample collection and testing.
30 Hours  
H. Assessment 10 Hours  
I. Open sessions 10 Hours  

The statistical and epidemiological exercises should be prepared well in advance and these should be simple but meaningful for learning experiences. Emphasis should be laid to pick up exercises which have relevance to national health problem and priority. As far as possible data collected by the students themselves or a situation seen by the students should be picked up and given an exercise for identification of problem and probable intervention and solution thereto. Data bank on these exercises and continuous updating can go a long way in development of faculty of the departments as also sustaining the interest of students in participatory learning. This could be the sound basis of interactive learning. Involvement of district health organization/state health organization can enhance and enrich the learning of epidemiology and science of biostatistics. Further, it is suggested that several medical colleges on regional basis can prepare and pool such data based exercises for development of learning material and model for better learning. Feed back generated from such exercises can be a further stimulus for better learning. Computer compatible models of evolved exercises can disseminate rich experiences for self learning.

Faculty members in Community Medicine need to be oriented towards these changed regulations and they should take responsibility to evolve practical and feasible package of Community Medicine exercises for effective demonstration to students. All these practical exercises need to be evaluated carefully on the basis of feed back, in order to improve and enrich these further with growing experiences. Use of modern educational technologies for better learning should be exploited to derive maximum advantage. State govt. and the institute is required to ensure adequate transport facilities for mobility of staff and students as also establishment of urban and rural health centres in close proximity to medical college; with full administrative, financial and technical control and responsibility of primary health care on sustained basis, with adequate funding.

The system of evaluation is considered to be an essential evil; but it has to go on. Weightage for internal assessment and day to day performance in the present system deserves credit. Only those will qualify for university examination who score 50% of marks in the internal assessment, it is a measure to ensure regularity in academic persuits. The timing of final examination in the Community Medicine in 7th semester appears to be a retrograde step and in a way it undermines the discipline of Community Medicine. To understand and develop full comprehension of the prevention and promotion one needs to learn full spectrum of essential medical sciences, in order to select best possible alternative for interception and interruption of disease. Examination in Community Medicine should be held in the final year or preferably at the end of internship period as Community Medicine skills are best learned during internship. Under the present system, the interns are hardly bothered to acquire essential skills as they strive for competitive examinations for residency system.

Regulations have created more confusions for internship training in Community Medicine. Three months resident period in primary health centre or community health centre is good enough to acquire necessary skills. Comprehensive list of skills recommended for Community Medicine are far too inadequate for graduate medical education and it needs a thorough revision and clarity.

At present the role of Medical Council of India is to prescribe a curriculum to achieve uniform standards but it is quite insufficient and incomplete, unless it makes assessment and evaluates the implementation of whatever has been prescribed, the things would not change much. Periodic inspections done by the council for according and renewing the recognition of the institutes offers no solution for improvement of standards and quality of medical education. Research in the area of medical education is awefully lacking. Research projects in the vital area be initiated and funded by the council on regional basis to have a meaningful feedback to evolve the future set of regulations. The present and past recommendations of the council had no basis of evaluation and are not borne out of hard research data, these were evolved by the wisdom and whims of learned members based on the amount of pressure a group could exert. Feed back and reactions of the teaching faculty were seldom incorporated in these regulations. It is high time that a we start evolving on the basis of operational research and hard data.

Sunder Lal
Prof. & Head
Deptt. of S.P.M.
Pt. B.D.S. PGIMS, Rohtak.

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