Year : 2017 | Volume
: 42 | Issue : 3 | Page : 131--133
Clinical practice in community medicine: Challenges and opportunities
Department of Community Medicine and School of Public Heath, Postgraduate Institute of Medical Education and Research, Chandigarh, India
Department of Community Medicine and School of Public Heath, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
Clinical practice with community health perspective makes community medicine a unique specialty. In their health centers, community physicians not only implement disease prevention programs, assess community health needs, manage healthcare teams and advocate for health promoting policies but also diagnose and treat diseases. However, participation of community medicine faculty in the delivery of clinical care varies from place to place due to administrative constraints. Health centers attached with medical college are not dependent on community medicine faculty for clinical service as these centers have their own medical and paramedical staff; whereas, other clinical departments in medical colleges depend on their faculty for delivery of clinical care in the hospital. Consequently, a perception is gaining ground that community medicine is a para-clinical specialty. Strategies for a fixed tenured rotation of faculty in the health centers should be evolved. All faculty members of community medicine must also provide clinical care in the health centers and the quantum of clinical services provided by each one of them should be reported widely to all stakeholders. Community medicine residency programs must ensure that trainee community physicians acquire competency to deliver comprehensive primary health care (promotive, preventive, curative, and rehabilitative) in a health center.
|How to cite this article:|
Kumar R. Clinical practice in community medicine: Challenges and opportunities.Indian J Community Med 2017;42:131-133
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Kumar R. Clinical practice in community medicine: Challenges and opportunities. Indian J Community Med [serial online] 2017 [cited 2020 Jan 28 ];42:131-133
Available from: http://www.ijcm.org.in/text.asp?2017/42/3/131/212059
Provisioning of comprehensive health care to all members of the community is one of the major responsibilities of Community Medicine Doctors; however, the extent of their involvement in clinical care varies between countries and within a country depending on the way health systems have evolved historically in a particular context. Practice of community-oriented primary care approach that promotes teamwork and linkages with the community can enhance the impact of community medicine programs.
Community-oriented doctors provide comprehensive primary health care to the entire community through the health center, clinic, or dispensary which includes the diagnosis and treatment of acute and chronic illnesses for children, adults and elderly, preventive checkups, routine maternity and newborn care, immunizations, certain minor surgeries, and mental health care in consultation with other specialists when needed. Their involvement in the follow-up care throughout life enhances the understanding of the medical history of the patients and their participation in home care establishes a knowledge base and relationship with the community they serve. In India, this approach was advocated long back in 1946 by the Bhore Committee and initiatives for reorientation of medical education had also gained momentum.
In line with the recommendations first Medical Education Conference held in 1955, Medical Council of India mandated the establishment of Department of Social and Preventive Medicine/Community Medicine in medical colleges with attachment of rural and urban health centers. Over the years, these departments have developed their undergraduate and postgraduate teaching and training programs in a variety of ways. Faculty Members of Community Medicine Departments utilize health centers, which serve a defined urban or rural community, for practical training of their undergraduates and postgraduate students; though in some medical colleges and medical institutes they themselves may not be directly involved in the delivery of clinical care in these health centers due to some structural constraints.
Unlike the Medical College Hospital, all urban and rural health centers attached with the medical college may not be fully staffed and managed by the medical college. In many instances, medical and paramedical staff appointed by the state health services may manage these health centers. The participation of community medicine faculty in the delivery of clinical care in these health centers also varies from place to place since health centers have their own medical and paramedical staff; hence, these centers may not be completely dependent on the community medicine faculty for delivery of clinical services. Whereas faculty members of other clinical departments in medical college have to provide clinical services in the Medical College Hospital which is dependent on them. Consequently, a perception is gaining ground that Community Medicine is not a Clinical but a Para-Clinical specialty. Recently, Medical Council of India has changed its classification and labeled community medicine as a “nonclinical” specialty despite the fact that clinical practice is a fundamental feature of community medicine.
Clinical practice with a community health perspective is what makes community medicine a unique specialty. Community Medicine Departments allot households in the community to undergraduates early-on in their training calendar when they start performing the role of a household doctor under the supervision of the faculty. Their skills as a community doctor are evaluated at the end of the training by allotting long clinical cases in the household and short clinical cases in the health center clinic. The focus of the viva voce examination, which is generally conducted in the household as well as in the clinic, is also to assess the ability of the candidate for delivery of comprehensive primary health care (promotive, preventive, curative, and rehabilitative). In other words, value addition of community medicine training is evaluated to certify whether the doctor is fit to practice community-oriented primary health care.
Most of the Community Medicine Departments in India provide clinical care in urban and rural health centers and some even have secondary level hospital, whereas others conduct immunization clinic, adolescent clinic, geriatric clinic, filaria clinic, rabies clinic, noncommunicable diseases clinic, general screening outpatient department (OPD), and few also have communicable disease ward in the medical college hospital. Millions of patients attend these clinics every year. Community medicine practitioners not only diagnose and treat diseases in their health center clinics but their practices also include prevention of diseases and disabilities and promotion of health in the community served by their health centers. Thus, they are “doctor +;” the plus sign denotes focus on disease prevention and health promotion in addition to the traditional role of curative care performed by other doctors.
In addition to their above-mentioned clinical duties, community medicine specialists also plan and organize healthcare in the community by assessment of community needs using epidemiological methods and manage the health-care teams comprising nurses, pharmacist, laboratory technicians, health assistants, health workers, and accredited social health activists. In their nonclinical administrative and statistical roles they also advocate for changes in the social policies to address social determinants of health.
In view of the shortage of doctors, the entire community medicine workforce (faculty and students) should shoulder the responsibility for providing comprehensive primary health care to people. If one community medicine department takes care of three urban and three rural health centers, all medical colleges of India can directly provide care to about ten crore population (each of the six health centers attached with each existing medical college can serve about 30,000 population). Using common data collection protocols and information technology tools, a large dataset can be built up for analysis of epidemiological trends in morbidity and mortality and for carrying out operational and implementation research. Therefore, all faculty members of Community Medicine Department must attend urban or rural health center clinic OPD at least 3 days in a week and on each day they should provide clinical care to at least 10 patients or persons (take history, conduct general physical checkup, and write prescriptions) in the clinic and or in home visit. They should conduct community-side grand round every week (like bedside rounds in a hospital ward) with a group of students. Learning from the cases in community should be used for classroom teaching also.
Let us not wait for the directions from Medical Council of India or ideal infrastructure but continue community medicine clinical practice wherever possible or whatever service can be provided, in the given circumstances prevailing in the medical college or medical institute. Clinical activities, i.e., a number of clinics conducted and number of patients attended by each faculty member and resident should be recorded in the Departmental Annual Report which can be put up on the World Wide Web for review by all stakeholders including the Medical Council of India. In due course, evidence-based standard guidelines for promoting clinical practice in the community should be developed by community medicine faculty themselves rather than looking up to regulatory authorities. Self-assessment checklists should also be developed and periodic review should be carried out and best practice should be published in the Journal. Peer review and peer recognition are a time-tested method for continuous quality improvement to overcome the gap between knowledge and practice. Evaluation should assess processes, outputs, and outcomes in view of the available inputs and structures.
Strategies need to be developed for overcoming the administrative, financial, and infrastructure constraints and for changing the beliefs and attitudes of faculty so as to increase the involvement of community medicine faculty in the delivery of clinical care in the community. Model Health Research Units set up by the Department of Health Research and State Health Departments can also provide an opportunity for involvement of community medicine departments of the medical colleges in the delivery of clinical care in the primary health centers. A memorandum of understanding can be signed with government or nongovernment health organizations to develop collaborative community medicine programs. A fixed tenured rotation of faculty and residents to rural and urban health centers as is the practice in some medical institutes could be evolved. Living away from the comforts of city life in the company of nature in the village for few years (say about 5 years out of the 35 years' service for a faculty member and 2 years out of the 3 years tenure for a resident), on the one hand could enrich experience of faculty and residents - some of whom are future health leaders of the country, and on the other hand, it will increase availability of community doctors in the health centers, which are not usually well staffed, making primary health care accessible to a large section of population living in the underserved areas of the country.
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Conflicts of interest
There are no conflicts of interest.
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