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Indian Journal of Community Medicine

Whose Teaching Hospital, is it Any Way!

Author(s): D. Nandan

Vol. 31, No. 4 (2006-10 - 2006-12)

D. Nandan

I want to divert from the format of many orations. I am not therefore presenting any of my research findings – through my focus on action oriented research at the community level I would like to offer some valuable insights.

I want to discuss a broader concept as I feel that we the public health community must deliberate about where SPM/public health in this country is headed and the role we can play to make the health system more relevant to the needs of the nation and the immediate community around our medical colleges.

Teaching hospitals are no longer, only the places where monologues and dialogues take place. They have assumed a bigger role and a larger responsibility, the responsibility which is answerable to the individual as well as the community. When we the doctors talk about the community - the reality dawns on us and one is forced to think about the perceptions of community and physicians and whose perceptions count more. The knowledge, the need, the criteria, priority and appraisal of the community or the physician both have important bearing on the planning of the policies. Therefore the need of the hour is to reflect whether the medical colleges are designed to meet the needs of people or are they primarily made to meet the convenience of doctors. The question arises that are the doctors community friendly or more specifi cally are they aware what the community wants or needs? Of course there are no doubts that doctors serve the people but here I would like to quote a very common scene seen in common households. One of the members in the family is sick but the health facilities are not availed though they are at minimum costs, because the earning member may loose a day’s wages to avail these free services and hence no wonder that while the infrastructure in public sector is huge, it is the private sector which is providing most of the OPD services.

So the situation now is that we cannot carry on in the autocratic manner according to our own convenience, not only for the benefi t of the consumer but also for the survival of the public health system in the current competitive world we have to make the services more community friendly. I thus put it this way – The medical colleges have a corporate social responsibility and it is time we face it.

In this attempt to make the medical schools more community friendly, where do we start from? No doubts the first level of intervention has to be done at the formative stage i.e. ‘the doctors in making’. The mindset has to be changed; the priorities have to be decided. The priorities may be different at different levels. For, the community the priorities are the common illness, their diagnosis, treatment and outbreak response. For the faculty the priorities may be different they are more interested in the unknown, the rare diseases, investigations, publicist and advanced technologies while the priority of the nation as a whole may be to meet all the needs of the community. So let us summarize how the priorities of the community and the medical schools and their faculty differ in current scenario. On one hand where common man is more concerned about common problems and is seldom concerned about the rare diseases, the medical fraternity is lost in the quest to know the answer to rare diseases whose treatment are yet unknown and to bring in the latest technology for better diagnosis and treatment of the same.

When I say medical fraternity is lost in the race for technology several other things cloud my mind. To speak about same, I ask myself what has happened to the old tools, can good history taking and record keeping be replaced; the stethoscope, the torch, the hammer, the BP instrument and the thermometer all seem to have lost their signifi cance. ‘Teaching minus all these essentials of medicine’ – Is the product going to be a doctor?

Are not we tempted to ask what actually went wrong? Did we lack the vision, the expertise or the will? We are certainly not short of any of these dimensions then what next? I believe that our vision, expertise and the will are seduced by ‘technology’ and compassion is replaced by ‘false competence’.

The diversities among our rural and urban areas are many but the striking feature is that our population is divided in 3:1 ratio in urban and rural areas respectively but despite that the ratio reverse when it comes to the background of doctors in making.

Diversities:

  Rural Urban
Population
(Census 2001)
72.2% 27.8%
Medical Students
(2003 batch)
32% 68%
Medical Students
(2004 batch)
27% 73%
Medical Students
(2005 batch)
36% 64%

(Data source S.N. Medical College, admissions to UG seats)

The result of all this discussion which has been done uptil now can be summed up as- that the health services should priorities should be decided and thus addressed. It should also be ensured that the health system optimally responds to the needs of the community. The need of the hour is to produce not merely doctors but such physicians who are not only treating the disease but providing care, catering to needs of community and thus striking at the root of the community problems. The concept of five star physicians is now the need of the society and is the approach which will finally make a difference. The five star physician is a competent care provider, community health team manager, community catalyst, communicator and compassionate decision maker.

A doctor with all these skills is certainly going to make a difference in the present status of the community problems.

Another important point which needs elaboration in my view point is the determination of social responsibility of the health care systems in the hospitals and community.

There may be various dimensions to this social responsibility but I consider four of these to be very important. These are the

  • Relevance of the health system – Quality
  • Cost effectiveness
  • Equity in health care

The ‘Relevance’ of any health service is decided by the degree to which most important problems are tackled fi rst. We have already talked about the priority health needs of the community in addition to this the relevance of health system also lies in constantly updating our organized efforts. Care should be taken to increase the comprehensiveness of the service and thus to produce quality of students not only technically capable and competent but at the same time culturally adapted to the community.

The next dimension which is important to me is the ‘Quality’ of health services. Contrary to the common notion, quality does not increase with cost but right perception of the problem and right approach should be applied. Appropriate high quality care includes a broad range of services from primary to tertiary care.

The emphasis, till date, has been more on acute interventional care, the realization, that the disease prevention is an equally important aspect has to be made. Health promotion and health education are the powerful tools in improving the quality of health services but in the current scenario both of these are neglected in most of the health set up. The over crowded OPDs, the decreasing doctor population ratio in the public sector leave very little roam for health education and promotion.

Next comes the Cost-effectiveness of the services provided. As I have previously mentioned that increasing the expenditure might be helpful in accessing advanced technology but quality of care does not improve by merely increasing expenditure. The services being provided by the health system should prove the cost-effectiveness implying that such a health system should heave greatest impact an the health of the society while making the best use of its resources. There can be no doubt about it that if efforts are appropriately oriented, cost effective care can be provided even with meager resources.

Finally coming to Equity in health services, without which all the services provided may be meaningless. Does this huge infrastructure and whole army of health staff have any meaning if it is not able to provide services to one and all, irrespective of gender, economic status, social status, education and other marginalized conditions. The consumer being the determinant of the need-if he is being served without achieving satisfaction than all the efforts are a waste because they will not reach all the section of society. Hence my stress lies most importantly an equity of health services in all respects.

This discussion would be incomplete without mentioning the role of community medicine in the present health system. Public health has been neglected since long as a discipline but with emergence of new concepts of prevention of disease rather than cure and priority being set in accordance to the need of the community, the role of community physician has amply increased in health system. Community medicine deals effectively with the common ailments by resorting to prevention rather than cure, thus saving the great economic loss caused by morbidity due to common ailments. In contrast to a clinician, a community oriented provider thinks and acts in terms of whole community.

As an expert from fi eld of community medicine my belief says that revolutionary change can occur in the society if the tools of public health like Behavior change communication, Counseling and Health Education are brought in practice. Beside this there is ample room for improvement or rather almost everything has to done in fi eld of biomedical waste management and infection prevention. Birth and death registration also need a special mention where things have to be improved. People from this fi eld are also proving very efficient in hospital management and information system, research and epidemiological work and many more arenas.

So now what is to be done?

We all know that we have to respond to the call of the community, but how?

The situation could be more grave if interventions are not affected immediately: We already have an elaborate health care system then what else can be done? The time has come for the medical colleges and schools to assume their social responsibility and accountability. The teaching hospitals should no longer confi ne themselves to the boundaries of that building but to expand the area of work, to penetrate the population around them and to know about their surroundings, helping to raise the level of health awareness. The experts in these colleges are assets who can act as catalysts for the desired changes. The need to establish medical colleges as role models for other health institutions increases all the more when the level of health status has to be raised in totality.

Reiterating what I said before the experts from community medicine are the key persons who should take the lead in reorganizing and reorienting the system, this would further require a drastic change in the mindset of all those involved. Another role which could be assigned to the teaching hospitals is that they can be made responsible for implementation, evaluation and monitoring of national health programmes. These special tasks are in accordance with the capabilities of the resource persons available in the medical colleges and will utilize the great mind power of these esteemed institutions.

It is definitely heartening to think of the time when such a vision is materialized. I can visualize all undergraduates and postgraduates passing out from teaching hospitals having good exposure to the health problems of the community. This exposure will be suffi cient to instill the real and required skills to manage the problems within the scarce resources. Not only this, as I previously said somewhere in the quest for knowledge we have lost the humane touch, the exposure to fi eld conditions and the way of life of our people will sensitize the medical students to social needs. They will learn to view the patients as humans and not mere experimental subjects.

This vision which includes action oriented research, family study material and building up of morbidity profi le will add to the approach of the medical education. These outreach activities are defi nitely the refl ection of our social responsibility, the responsibilities which S.N. Medical College is dually trying to fulfi ll. Various health related activities in our college have involved the staff right from sweepers to nursing, pharmacy and teaching staff. Research methodology orientation of postgraduate students is being carried out so as to bring out quality research work and the process continues as the learning process goes on.

And in the end, as T S Elliot said:

Where is the life we have lost in living?
Where is the wisdom we have lost in knowledge?
Where is the knowledge we have lost in information?

So lets not get lost, lets not get carried away by the shine and shimmer, let us retain the humane touch, let us maintain the dignity of our noble profession and fi nally let us live up to the noble cause of community.

References

  1. World Federation for Medical Education, Continuing Professional Development (CPD) of Medical Doctors, WFME Global Standards for Quality Improvement, WFME Offi ce : University of Copenhagen, Denmark, 2003.
  2. Towards the Assessment of Quality in Medical Education, World Health Organisation, Division of Development of Human Resources for Health, WHO, Geneva, Switzerland, 1992.
  3. Defining and measuring the social accountability of medical schools, Division of Development of Human Resources for Health, WHO, Geneva, Switzerland, 1995.

Dhanwantri Oration, Indian Association of Preventive & Social Medicine (IAPSM)
delivered at Joint National Conference of IAPSM & IPHA at Tirupati on 21st Jan. 2006
Principal / Dean & Chief of Hospital, S. N. Medical College & Hospital, Agra.
E-mail: [email protected] Received: 29.4.06

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