A qualitative study on working experience of rural doctors in malappuram district of kerala, India.

BACKGROUND: Improving the working conditions of rural doctors is an important issue to increase the quality of health services to target groups.
OBJECTIVES: To assess the working experience of rural doctors at primary health care level.
MATERIALS AND METHODS: This qualitative study was conducted among 30 medical officers from 21 primary health centers in Malappuram district of Kerala, India. In-depth interview was conducted, and content analysis was performed with the identification of themes based on the responses obtained.
RESULTS: There were 19 males and 11 females belonged to 25 to 55 years age group. About 70% (21) of them were graduates with MBBS qualification, and the rest were postgraduates. About 2/3(rd) of them (20) had experience of less than 5 years. They expressed difficulty in managing the work in stipulated time period. However, this had never affected their OP management in anyway. They told that higher authorities were supportive, but they faced some opposition from the public in implementation of national program. Few opined that the training received was grossly insufficient in running the administrative affairs of the health center. Most of them satisfied with physical infrastructure, but manpower including medical officers and supporting staff were not sufficient. Some opined that the age of retirement is too early and should be increased. They participated in Continuing Medical Education, but expressed that it's content should suit to primary health care level.
CONCLUSION: This study highlighted their concern to patient care and time, field work, administrative work, infrastructure, professional development, and future prospects. Further large scale evaluation studies will explore the situational analysis of it.

Introduction

Working conditions among primary health care doctors in rural India is an important issue to be considered for efficient and effective functioning of health care delivery system. Excessive workload, inadequate infrastructure, proper supervision and support, and professional development opportunities were considered as important factors in this regard. A recent study in Australia showed that significantly increased hours work, more diverse activities, and significant after-hours demands experienced by current rural general practitioners.[1] Another study in Germany found that primary care physicians in single-handed practices in rural areas worked on average 4 hours more per week than their urban counterparts. Poor working conditions, low salaries, and high stress levels were contributed to poor patient-doctor relationship.[2] But, in India, studies on this regard are limited.[3]

Primary care is undergoing significant structural change after launching of National Rural Health Mission (NRHM) in the year 2005, which sought to improve the rural health care delivery system through various innovative measures.[4] Although the situation has improved, still at primary health care level, shortages of doctors result in increased workload on the existing medical workforce, poor work environments, and low productivity.[5] NRHM recommended a set of standards, which redefined the roles and duties of healthcare providers, especially medical officers.[6] Also, it is important to identify factors that satisfy or dissatisfy doctors working in rural areas, as these factors determine the retention of doctors in rural hospitals. With this background, the present study was conducted to assess the experience of rural doctors on their working conditions in a rural district of Kerala, India.

Materials and Methods

This qualitative study was conducted from September 2010 to February 2011 among the medical officers in Malapuram district of Kerala, a state in coastal south India. Out of 697 Primary Health Centers (PHCs) present in Kerala, 62 are in Malappuram district. We selected all the 30 medical officers under 3 health blocks of Vettom, Neduva, and Valavannurin 21 PHCs who has working experience of more than 1 year in regular government service. We excluded the doctors working in contractual basis under NRHM, doctors on compulsory rural service, and Ayurveda, Yunani, Siddha, Homeopathy (AYUSH) doctors as their working pattern will be different and to maintain the uniform work-related characteristics in the group.

Ethical issues

The study was approved by the scientific and ethical committee of the institution. Prior written permission to conduct the study was obtained from district medical officer of health, Malappuram district, Kerala. Written informed consent was obtained from the participants of the study.

Method of data collection

The in-depth interviews were held at medical officer's respective PHCsusing semi-structured questionnaire in English language. Principle investigator used an interview guide to elicit the data on the issues of their working experience. The main question asked by the interviewer was: “What is your experience on working conditions as a medical officer of the primary health center?” The questions on patient care, field work, administrative work, professional development, physical infrastructure, and salary issues were asked and recorded. The interviews were audio-taped and transcribed. Content analysis of the data was performed with the identification of themes based on the responses obtained. With the help of quotes from the interviews, categories were formed and described.

Results

A total of 30 medical officers were participated with 19 males and 11 females. They were belonged to age group of 25 to 55 years, and majority of them were married (96.7%, 29). About 73.3% (22) of them had got administrative responsibility. About 70% (21) of them were graduates with MBBS qualification, and the rest were postgraduates. The distribution of postgraduates in relation to their specialty is: D.N.B in ENT – 1, M.D in Dermatology – 1, DPMR (Diploma Physical Medicine and Rehabilitation) – 1, Diploma in Anesthesia – 1, Diploma Child Health ( DCH ) – 3, and M.D. in Pediatrics – 2.

About 2/3rd of them (20) had experience of less than 5 years. The average years of experience of the MBBS and postgraduate doctors were 5.4 and 2.4 years, respectively. This shows that the years of experience were significantly higher (P < 0.05) in MBBS doctors when compared to the postgraduate doctors.

The theme related to working experience was categorized into patient care and time management, field level activities, infrastructure, administrative responsibilities, age at retirement, and professional development.

Patient care and time constraint

The interview highlighted that the medical officers had difficulty in managing the work in stipulated time period. They were competent enough to manage the clinical workload, but due to time pressure, they cannot work satisfactorily. Majority (27, 90%) of doctors were not getting sufficient time for properly examining, diagnosing, and treating the patients in OP due to time pressure. Eighty percent of them reported insufficient time for rest and refreshments, even during the break time in the hospital, and 60% of them faced problems with patients. However, a majority (83.3%) of those who reportedly faced problems with patients stated that these patient-doctor problems had never affected their OP management in anyway.

“Most of the days, I will be seeing around 150 to 200 patients. That itself is a work overload. And at 11 am, when around 100 patients are in the queue, an injury which requires suturing or a suspected M.I (Myocardial Infarction) comes to the Out Patient (OP) department. Then, the whole situation is thrown out of gear.” One doctor remarked about his O.P atmosphere.

Field work

The problems related to time availability and field problems were highlighted by the subjects.

“Opposition to immunization is a real problem in some pockets. Even though young mothers want their children to be immunized, the old people in their houses (Grandparents) will not allow. ‘Give the drops, (OPV), but no injections.’ This is their usual reply” One PHC doctor from Vettom Health block.

“Actually, we should be giving more importance to field work. But where is the time?” Another doctor asked. “Some are efficient, but some are lazy. I have a tough time managing them.” A doctor working in a block PHC commented about his field staff.

Eighty percent of the doctors reported that higher authorities were supportive, whereas 13% felt them to be indifferent, and only 7% reported that they do not get any support from their superiors. Majority (93%) of the doctors reported that the general public in their service area are co-operative with the health professionals during their field work. However, regarding the implementation of some of the National Health Programs, especially recently introduced Mass Drug Administration (MDA) program, 43% of the medical officers reported that they faced some opposition from the public in its implementation. A majority of (96.7%) doctors indicated that people's representatives from local self-government and other elected bodies were co-operative with them in running the PHC smoothly.

Administrative work

About 60% of them not received any formal training in administration. Even among those who received training, 50% felt that the training they received was grossly insufficient in running the administrative affairs of the health center.

“I have attended some administrative training in the past. Still in case of confusion, I call my seniors and discuss with them, as I am not confident of dealing it on my own.” Another young specialist. “Financial matters give me nightmares. After NRHM came in to existence, so much money is flowing to us, and I am really frightened about dealing it.” Admitted a young doctor who joined service recently.

“I have additional administrative charge of a PHC, which is around 10 kilometers away from my PHC. OP will be looked after by an NRHM doctor, still I have to go over there frequently to sign administration-related documents.” A lady doctor reported.

Infrastructure

Majority (63%) stated that they were satisfied with the physical infrastructures provided in PHC. A majority (76.7%) of the doctors also reported that they were satisfied with the availability of medicines and medical equipments. However, 57% of them felt that manpower including medical officers and supporting staff were not sufficient in their PHC in view of the large number of patients attending OPD.

“My consultation room is spacious and well-ventilated, so I don't feel suffocated sitting there.” A doctor commented about the infrastructure in his PHC. “We have enough and more medicines. The problem is staff shortage. Whenever I ask for additional staff, they (Higher Administrative Authorities) say no post is lying vacant there. But the number of patients coming to the hospital has more than doubled, and we need more posts. Why don't they understand that?” Another doctor working as a single medical officer in a PHC said.

Age at retirement

When enquired about their views on retirement age (55 years), 46.7% of the doctors opined that the age of retirement is too early and should be increased, whereas 40% were against such an increase and 4 persons did not offer any response.

“If professors and judges can work up to 60-65 years, why not a doctor? After all it is not a heavy physical work.” Comment from a doctor who is around 45 years of age.

Professional Development

Majority of the doctors (86.7%) reported that they were able to attend professional development training offered by health services department during the past 1 year, and among this, 73% felt that it was useful and sufficient in running the health center and implementing the interventional and health promotional programs. The continuing medical education (CME) programs conducted by other agencies like Indian Medical Association (IMA), Medical colleges were attended by 27 (90%) participating doctors.

“These CMEs are useful only for the specialists working in specialty hospitals. They discuss only latest technology and medicines. Even though we gain some knowledge, it is not useful for a PHC doctor. We need CMEs specifically suited for us.” Another doctor suggested.

“The Salary is not sufficient to run a family in these times. So we have to earn through private practice, and I think Internal Medicine is the best specialty available to make a good private practice.” A doctor regarding the choice of specialty.

In Kerala, because of information technology development and high level awareness regarding health among population, majority of people want to visit only specialists, even for minor ailments. So, MBBS doctors feel inferior to specialists. Among the 21 medical graduate doctors, 10 (48%) were preferring postgraduate training in general medicine, followed by 5 medical officers in dermatology. The pediatrics, general surgery, and radio-diagnosis were preferred by 1 medical officer in each. Two medical officers were not interested in PG training, and the remaining 1 was not decided. Thus, except 3 doctors, all other 19 MBBS doctors wanted to go for specialization, because majority thought they can have a good private practice in future life. In Kerala, health service doctors have a reservation quota for postgraduate courses in government medical colleges.

Majority (96.7%) of the participating doctors reported that they have an excellent rapport with the other doctors working in the same PHC or other PHCs. About 66% of the doctors indicated that their interaction with specialists in the secondary and tertiary care hospitals help them improve their medical knowledge and skills.

Discussion

To understand the issues and identify the gaps in the working conditions of rural doctors in Indian context, there is a need for collecting the information with regard to it. There are many studies reported in other countries. A study found that majority of doctors had perception of work overload, due to large number of patients attending OPD. Another study stated that majority of rural doctors reported workloads heavier than they would like.[7] Similarly, Saudi Arabia study found that about two-thirds of physicians felt it difficult to implement promotive and preventive activities due to patient load.[8] Other studies also had reported that majority of participating general physicians had a perception of work overload.[9101112] Australian study found that if the doctors are able to take time off work, they feel more satisfied.[13] With the improvement in work control and avoiding increases in workloads, Professional Quality of Life (PQL) perception can be maintained despite deep organizational changes at the macro-management level.[14]

It was found that a majority of doctors were facing interruptions in their out-patient work most of the time. Another study found that majority of participants faced OP work interruption due to emergency cases during consultations.[15] The percentage of doctors feeling work interruption is very high here, may be because of attending emergency cases, issuing medical certificates, and administrative duties. Time required for patient management widely varies from patient to patient. Doctors reporting insufficient time to do justice to patients during consultations.[15] Another study found that majority of participants reported time pressure while doing physical examinations during office time.[16]

The working conditions of rural doctors with respect to wages, various types of resources, security conditions, and connectivity in Kerala differ to some aspects from other states in India. With regard to wages, majority of the doctors indicated that their salary was insufficient. The studies done in other states in India also found that salaries had not been increased to match the rising prices of commodities and service.[317] Similarly, shortage of doctors being reported from rural areas every state in India.[1819] In Chhattisgarh state, in case of shortage of doctors, a doctor from another PHC is given additional administrative charge of the PHC.[3] According to Rural Health Statistics report (2009), no vacancy or shortfall of doctors working in PHCs is reported in Kerala, mainly due to appointment of doctors on contract basis under NRHM.[20] This shows that the number of regular government doctors working in PHCs is inadequate. A study conducted in Chhattisgarh state found that doctors were not satisfied with the physical infrastructure and material availability in contrast to our study.[3] This may be due to the fact that there is better transportation and communication facilities available in Kerala compared to Chhattisgarh state, which improves accessibility. It may also be due to the comparatively peaceful atmosphere prevailing in Kerala, which might have helped development activities to go on uninterruptedly.

A study reported that a majority of the participants had not received any sort of training as health co-coordinators, even though most of them were involved in administrative work similar to our study where 60% of the doctors were not received training on health administration.[21] Our study showed that the team climate exists among doctors and health functionaries. A study among doctors and nurses indicated that majority of participants in both states were having a good relationship with their colleagues.[17] Other studies also reported that their relationship with colleagues and fellow workers was satisfactory.[311152223] While studying work stress in primary health care and hospital physicians in Finland, minority of general physicians reportedly suffered from poor team climate in hospital.[10]

In a study conducted among women doctors working in rural primary health care institutions in South Africa, majority of doctors stated that doctors working in the referral hospitals are ignorant of their problems and did not take rural doctors seriously.[23] This is in contrast to our study because of geographical proximity of rural and urban areas in Kerala, which make doctors meet regularly and move in same circle. In our study, majority of the graduate doctors wanted to go for specialization in clinical subjects. Similar feelings were expressed by majority of physicians who participated in another study.[8] There was a perception of decreased social status among rural physicians in Lithuania.[11] Most of participants in our study reportedly preferred internal medicine as their specialty of choice. This finding is in contrast to another study, where majority of graduate doctors were willing to join primary care specialty.[8]

In contrast to our study, other studies reported lack of opportunity for training and skill development among doctors.[3121517] A study found that total job satisfaction of doctors working at primary health care establishments was relatively low, and one of the reasons cited was low compensation.[11] Similar results were also reported from different studies.[8915]

There is also shortage and mal-distribution of doctors being reported from rural areas in India and other countries.[1824252627] If this cause of dissatisfaction is properly addressed by taking measures to increase the compensation and enhance the allowance for rural doctors, it will help in reducing the shortage of doctors in those areas.

The study was qualitative study, and findings may not be generalizable to other parts of the country because of difference in socio-cultural factors and health care delivery system. In spite of these limitations, study gives valuable information on the status of perception of rural doctors about working conditions, which can be utilized for improving the efficiency and effectiveness of health services by the concerned authorities.

Conclusion

This study highlighted the concern of medical officers for time management, field works, administrative works, professional development, and future prospects. Further large scale evaluation studies will explore further the situational analysis of it.