Revisiting the Relevance of Community Medicine in Undergraduate Medical Curriculum.

There have been attempts recently to bring clarity as to the role/functions of the discipline of community medicine. Debates on whether community medicine is a discipline in itself and if so is it a clinical discipline has been there for decades across the world. As the departments of community medicine do not exclusively teach any clinical skill to undergraduate or postgraduates, it is difficult to argue that our discipline is a clinical discipline. Our stalwarts are also known for their work at community and government level and not as clinicians. Our current undergraduate course does not prepare the students adequately for their role in society, profession and health system. Our mandate is to prepare the would-be-doctors as a "finished product" to the country. Our training should address the current crisis that afflicts our profession. A list of learning objectives to be achieved in the three domains of profession, health system, and society and suggestions to improve the teaching of this discipline are provided in this paper.

INTRODUCTION

As per the Medical Council of India, the goal of medical graduates training is that at the end of undergraduate program, the medical student should contribute to “Health for All” by learning aspects of the National Policies on health, achieving competence in practice of holistic medicine, develop scientific temper, acquire proficiency in profession, and promote healthy living and become exemplary citizen by the observation of medical ethics and fulfilling social and professional obligations.[1] The objectives of teaching community medicine to MBBS students in India have been largely defined as preparing them to function as community and first level physicians.[2]

In the recent times, there have been attempts to bring clarity as to the role/functions of the discipline.[3] Community medicine bridges the fields of clinical medicine and public health and elaborations have been provided on the differences between public health and clinical approaches in medicine.[45] Debates on whether community medicine is a discipline in itself and if so, is it a clinical discipline have been there for decades across the world.[67] One can safely say that in India, the notion that our subject is a clinical subject is well entrenched in our current way of thinking. However, it needs to be revisited.

Do we exclusively teach any clinical skill to the undergraduate which is not taught by any other department or do we teach any new clinical skill to postgraduates that is not supposed to be taught during their undergraduate studies? For this purpose, the clinical skill is defined as any activity/procedure done to diagnose or manage a clinical condition. The general opinion is that both the questions are answered as “NO.” There is no denying that we teach some clinical skills, though not exclusively. For example, the teaching related to the Integrated Management of Neonatal and Childhood Illnesses or many aspects in maternal and child health. Next, if we ask our fraternity to name stalwarts or leaders in our discipline and their contributions, it will invariably be about their work at community, state, national, or international level, and not their clinical work. If we insist that ours is a clinical discipline, then this paradox needs to be explained.

Community medicine departments to provide a platform where clinical skills are practiced and honed. While Each department focuses on providing knowledge and skills to identify and treat certain diseases in their area of specialty, our focus is on applying these composite knowledge and skills to individuals in a “real world” context. What students learn in clinical department s of medical colleges are different from what they would face after graduation in their professional practice in a typical primary care setting in terms of patient profile or level of support available. Profile or level of support Community medicine teaching/postings address these shortcomings in clinical teaching. Does this make us a clinical department? This undue focus on clinical aspects detracts from the strength of our discipline. If we consider clinical subjects as the inner ring or core of the medical course, community medicine should be the outer ring of the course, linking the core to the external world.

We all know that at the end of the MBBS course, the graduates are not employable, a problem that is shared across almost all graduate education in India. In that context, our job is to chisel these square pegs into round holes needed for the health system. In other words, our job is to deliver the “finished product” to the country. There is no doubt in my mind that community medicine teaching to medical undergraduates has a key role to play in achieving the main goal of graduate medical education in India as described above. The basic rule should be that our teaching should be relevant to a doctor working at a Primary Health Centre or working as a family physician. Our mandate is to prepare the “would-be-doctors” to perform their role in society, profession, and health system. Keeping in mind these considerations, revised learning objectives for our subject in MBBS course has been provided [Box 1]. They may deviate from our original vision but are probably better nuanced to the current situation and better organized for clarity. The framework also allows us to add more objectives to it, as our fraternity would surely like to do.

Box 1

Learning objectives of community medicine teaching in undergraduate medical curriculum

At the end of community medicine teaching, an undergraduate medical student should

Professional level

Know the legal framework within which the profession works

Understand and practice professional ethics

Be able to evaluate evidence and keep oneself updated about the professional advances

Have effective communication skills and empathy for patients

Be able to practice clinical skills (preventive, curative, and promotive) in typical primary and secondary care settings

Be able to participate and perform professional clinical audits

Health system/services level

Understand the organization of the health system in the country, both private and public

Understand primary health care approach and translate it for local major health problems

Know the different national initiatives/schemes/programs/policies related to health and their role within them

Be able to organize health services for a community after assessment of health needs

Be a manager/team leader of a primary care facility/team

Be able to contribute requisite information needed for surveillance, reporting, notification, and international health regulations purposes

Be able to identify, investigate, and manage disease outbreaks

Society/community level

Be a role model and a change agent in addressing the social ills of the society

Understand the social model of health and linkage of health to other sectors

Be able to make a community diagnosis

Understand and practice public health ethics

Be able to work with/involve communities/panchayats/local-self-governments in the delivery of health care

Promote equity in access to health and social services

The first domain on professional aspects is new and addresses the current crisis in the profession. Real-life case studies can be used to discuss and highlight the challenges being faced by the profession with the help of colleagues from other departments. This component is essential for shaping the doctors as “not merely a shopkeeper who sells what is needed (wanted?) by patients but a professional with a specific skill set.”[8] Knowledge of regulatory framework is essential in today's context. For us to be called professionals, it is important to conduct clinical audit and ensure that the results contribute to clinical excellence. The self-regulation is one of the defining elements of a profession. Only this can ensure that the public has confidence that the members of that profession are competent, trustworthy, and fit for work. The component of the health system is perhaps the focus of our current teaching. Again, this requires that we must move decisively from our traditional role as “passively responding to sick individual, to become active guardians of the health of our populations.”[8] The third component is what converts medicine from “science” to a “social” discipline. We know that social and cultural factors influence the causation of disease, health seeking as well as outcomes of treatment. The medical professionals should, therefore, acquire competency to address them. To do so, we need to supplement the scientific content with social content in the curriculum and increase their synergy. Doctors must become an active change agent in the society in which they work and live.

This also requires changes in our approach to teaching the discipline. These are summarized as below:

Locating the community medicine teaching within the MBBS course

We should move from teaching community/social issues at the beginning of the course to health system issues and then to professional issues as students make progress. Community medicine requires a certain level of maturity for students to appreciate and understand the importance of social determinants and health system response to diseases. Providing a platform to practice clinical work at primary and secondary levels, giving hands-on experience in implementing national health programs and initiatives during internship is critical to our aim of shaping these students into an employable professional at community level or a practicing family physician.

Change in course content

This calls for strengthening the coverage of topics such as consumer protection act, clinical establishment acts, and professional ethics which are currently not adequately covered. Many of our lectures on diseases are repetitive (we repeat, microbiology/pathology/medicine/pediatrics) with very little value addition from our discipline. This must change, and the use of integrated lectures should be welcome. For example, while gynecology would teach about contraceptive methods, we should focus on ways and means to deliver these methods to the users and not repeat what has already been taught to them on these issues. The textbooks should also reflect this change.

Mode of teaching

This is our Achilles heel, and one of the major grouse of students is that we teach lot of theory and very little application. It is clear from the above list that most of our content is applied and not factual. Therefore, lectures are not the best way to teach them. We need to move toward problem-based learning, exercises, case studies, field visits (with clearly defined objectives) as our primary mode of teaching. Our “Bible” textbook of preventive and social medicine is overloaded with facts with relatively little focus on concepts or critical thinking or applied aspects. Family presentations need to be better structured and promote a multifactorial view of health.[9] These should be addressed in the textbooks that are likely to come out in the near future.

Mode of assessment

Our assessments include asking students about facts (definitions and guidelines) in multiple choice questions or viva voice or vague questions with long drawn answers in theory papers. Our assessments must be more objective and focused on community-based skills and test of critical thinking. A recent evaluation showed very poor performance of students in skills assessment (score from 3% to 13%).[10] The learning objectives listed above should form the core of the assessment. Methods of assessment systems can be improved by implementing techniques to assess psychomotor skills, presentation and communication skills, organizational skills, and the student's ability to work in a team.[11]

A revision of the content and modes of teaching of community medicine in the country is proposed. This needs more discussion and debate before we move toward a consensus. The time has come for us to do a collective review as our country is undergoing a major sociocultural-demographic transition. A, long overdue, revision in the medical curriculum, is just around the corner and time is ripe to put our best foot forward.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.