|Year : 2012 | Volume
| Issue : 1 | Page : 70-74
A Networking Approach to Reduce Academic and Social Isolation for Junior Doctors Working in Rural Hospitals in India
R Vyas1, A Zachariah2, I Swamidasan3, P Doris4, I Harris5
1 Medical Education Unit and Department of Physiology, Christian Medical College, Vellore, India
2 Department of Medicine, Christian Medical College, Vellore, India
3 Medical Education Unit, Christian Medical College, Vellore, India
4 Department of Distance Education, Christian Medical College, Vellore, India
5 Department of Medical Education, University of Illinois, Chicago, USA
|Date of Submission||06-Jul-2010|
|Date of Revision||29-Jun-2012|
|Date of Acceptance||03-Jul-2012|
|Date of Web Publication||30-Jul-2012|
Medical Education Unit, Christian Medical College, Vellore-632002, Tamil Nadu
Source of Support: Christian Medical College, Vellore, Conflict of Interest: None
Introduction: Graduates from Christian Medical College (CMC) Vellore face many challenges while doing their service obligation in smaller hospitals, including academic and social isolation. To overcome these challenges, CMC aspired through its Fellowship in Secondary Hospital Medicine (FSHM), a 1-year blended on-site and distance-learning program, to provide academic and social support through networking for junior doctors working in rural areas. The purpose of this paper is to report the evaluation of the networking components of the FSHM program, with a focus on whether it succeeded in providing academic and social support for these junior doctors. Methods: A mixed method evaluation was done using written surveys for students and faculty and telephone interviews for students. Evidence for validity was gathered for the written survey. Criteria for validity were also applied for the qualitative data analysis. Results: The major strengths of networking with faculty and peers identified were that it provided social support,, academic support through discussion about patient management problems and a variety of cases seen in the hospital, guidance on projects and reminders about deadlines. Recommendations for improvement included use of videoconferencing and Yahoo Groups. Conclusion: It is useful to incorporate networking into distance-learning educational programs for providing support to junior doctors working in rural hospitals.
Keywords: Academic isolation, academic support, distance learning, junior doctors, networking, rural hospitals, social isolation, social support
|How to cite this article:|
Vyas R, Zachariah A, Swamidasan I, Doris P, Harris I. A Networking Approach to Reduce Academic and Social Isolation for Junior Doctors Working in Rural Hospitals in India. Educ Health 2012;25:70-4
|How to cite this URL:|
Vyas R, Zachariah A, Swamidasan I, Doris P, Harris I. A Networking Approach to Reduce Academic and Social Isolation for Junior Doctors Working in Rural Hospitals in India. Educ Health [serial online] 2012 [cited 2019 Oct 16];25:70-4. Available from: http://www.educationforhealth.net/text.asp?2012/25/1/70/99212
| Introduction|| |
Christian Medical College (CMC) Vellore, India is a teaching hospital providing tertiary level care. Following graduation, CMC graduates have a 2-year service obligation at smaller, secondary hospitals , mainly located in remote rural areas. Secondary hospitals have between 20 and 200 beds, with a generalist practice, limited laboratory support (basic laboratory investigations such as complete blood counts, routine urine and stool tests, clinical biochemistry, and X-rays) and community-based programs such as antenatal care and malaria and tuberculosis programs. The junior doctors may work under a senior physician or sometimes alone. Most choose to pursue specialty training after the service obligation.
Graduates are not well equipped to practice in smaller hospitals and face many challenges during their period of service. Cases seen at these hospitals differ from those of a tertiary care center. , They also experience academic and social isolation, which prompts many not to choose to continue to practice in these hospitals after their service obligation. ,,, Thus, secondary hospitals are facing a crisis and many close for lack of staff. , To address this challenge, CMC designed a 1-year Fellowship in Secondary Hospital Medicine (FSHM) program for the graduates at secondary hospitals, which provided a blend of distance-learning modules, three contact sessions at CMC, community project work, and networking. 
There are published reports about networking among rural health professionals  and among faculty in academic centers.  However, there is only one report to our knowledge about networking among junior doctors and their peers and faculty in a postgraduate program.  Networking with CMC faculty and peers was developed through: interactions during three contact sessions; promoting contact through email, Google Groups, and telephone; feedback on assignments and project guidance; and periodic visits to the secondary hospitals by CMC faculty. Each FSHM student or junior doctor had an individual project mentor. All junior doctors were in contact with their project guides and other faculty through telephone, email, and during contact sessions. Project guides were matched with FSHM students or junior doctors based on topic and students' preference.  To ease communications, students were provided with contact information, including personal mobile numbers of faculty and course organizers. Some secondary hospital faculties were local mentors for the FSHM students and junior doctors, depending on feasibility and geographical location.
An orientation program for FSHM students and junior doctors and another orientation for faculty were conducted before the start of the FSHM program. Also, a faculty development program for project guides was conducted. The purpose of this paper is to report on the evaluation of the networking components of the FSHM program, with a focus on whether it provided academic and social support for these junior doctors working in rural areas in India.
| Methods|| |
FSHM students of the class of 2007-2008 and 2008-2009 and faculty were included in this evaluation of the networking component of the program. Institutional approval was obtained from the CMC Vellore for design and evaluation of a curriculum, consistent with the CMC policies. Approval was also obtained from the institutional review board at the University of Illinois, Chicago, where one of the authors (RV) was conducting this project as part of her Masters of Health Professions Education (MHPE)leadership degree.
Written surveys: Two written surveys were administered in person, one to faculty from CMC and secondary hospitals (n=20) and one to all FSHM students (n=16) from 2008-2009, when they came to CMC Vellore for graduation. It was not feasible to administer the survey to the 2007-2008 class as they had already graduated from the program and were scattered throughout India.
The surveys included structured and open-ended questions. The structured questions focused on rating the perceived effectiveness of the networking component of the program in achieving objectives. The open-ended questions were used to obtain views of students and faculty regarding strengths and their recommendations for improvement. Some questions were similar and some different in the student and faculty surveys.
Interviews: After the survey was administered, telephone interviews were conducted with FSHM students (n=22) for the class of 2007-2008 (n=16) and 2008-2009 (n=6) with students who agreed to be interviewed. In some smaller hospitals, telephone interview could not be conducted because of limited or no connectivity. The purpose of interviews was to further explore, through open-ended questions, the effectiveness of networking and to collect qualitative data to provide a richer characterization of its level of effectiveness. The guiding question was: "In what ways, if any, has networking with peers and faculty in the FSHM course been helpful to you? Please explain/give examples." Participation in the interview was voluntary, the process was explained, informed consent was obtained, and confidentiality assured. This provided an environment for participants to be open and honest.
Quantitative data analysis was conducted using SPSS statistical software (Version 11) and is reported as frequency distributions. Qualitative data analysis was done using the constant comparative method associated with a grounded theory approach.  Two authors independently analyzed the data using inductive content analysis as described in a previous paper.  Inter-rater reliability was 100% for qualitative data analysis after discussion among reviewers. Evidence for validity of surveys was gathered, as described in an earlier paper.  To help ensure validity of the qualitative data analysis, triangulation, member checking, thick description, and audit trail, recommended by Barzansky et al.,  were used as previously described. 
| Results|| |
All 16 students of the 2008-2009 class completed the survey (response rate 100%). Of 20 faculty involved with the program, a total of 12 responded to the survey (response rate 60%), but a maximum of 10 responded to any one question. Most students (62%) and faculty (71%) rated networking with peers and faculty as Very Good or Excellent in providing support to students. Most faculty (90%) said they were in contact with students, half (50%) less than once a month and half (50%) at least once per month. The majority of students responded that they were in contact with faculty less than once a month (75%) and with their peers from at least once per week to at least once per month (87%). Most (88%) used mobile phones to contact peers, while the majority (63%) used E-mail to contact faculty. Most (81%) said that they discussed the FSHM program with each other. [Table 1] shows student and faculty ratings of the effectiveness and use of networking.
|Table 1: Student and Faculty Responses to Questions Regarding Effectiveness of Networking with Peers and Faculty: Fellowship in Secondary Hospital Medicine (FSHM)|
Click here to view
Themes regarding the value of networking, recommendations for its improvement and issues discussed by students with faculty (collated from the student survey and interviews and the faculty survey) are outlined below in descending order of frequency, and presented in greater detail in a table available from the first author.
The main themes regarding issues discussed by students with faculty were: project work (Student survey: 6/8; Faculty survey: 4/5; Student comment: "I discussed any doubts regarding the project." ) and patient management (Student survey 1/8; Faculty survey: 4/5; and faculty comment: "The student discussed about patient care with me." ). Main themes identified regarding the value of networking with peers and faculty were: provided social support (Student survey: 7/10; Faculty survey: 7/7; Student interview: 12/22; Comment: "It provided emotional support. It was like going back to parents when we go back to Vellore."); provided academic support (Student survey: 7/10; Faculty survey: 7/7; Student interview: 22/22); discussion about patient management problems (Student interview: 18/22; Comment: "I had a patient with gas gangrene. I contacted the faculty in CMC and took advice on patient management. The patient got well and went home."); discussion and guidance on projects (Student interview: 14/22; Comment: "My project guide had come and visited my hospital and talked to the medical superintendent and convinced him of the importance of my project."); and discussion of varied cases seen in the hospital (Student interview: 8/22; Comment: "Some classmates would call up and we would discuss the cases which we saw which was very useful.").
Other themes were: getting to know about other secondary hospitals (Student interview: 7/22; Comment: "Definitely helpful. Secondary hospital scenario in the country is eye opening experience to know how other hospitals are and how they function.") and reminders about deadlines (Student survey: 3/10; Student interview: 6/22; Comment: Organizers kept reminding us for timely submission. Friends kept reminding each other for module submission."). Recommendations for improvement were to use videoconferencing and Yahoo groups. When students were asked in the interview if they would consider going back to work in secondary hospitals, all answered in the affirmative.
| Discussion|| |
This study provides evidence that networking with peers and faculty has provided academic and social support to FSHM students, based on the perspectives of both students and faculty. This networking process helps address some of the academic and social challenges faced by graduates working in rural hospitals. On the other hand, three students and two faculty rated effectiveness of networking as just fair or poor. This could have been because of limited connectivity to email and/or telephone.
Based on suggestions, and keeping in mind the limited connectivity of some hospitals, as well as the healthcare needs in India, the following has been done to strengthen the networking component of the program:
A limitation of this study is that evaluation of outcomes is based on self-reports by students and faculty. Another limitation was the low participation rate of faculty. Conducting interviews with faculty would have elicited their in-depth responses and thus improved on study information. Nevertheless, this study reflects the perspectives of two groups using multiple methods of data collection, with consistent results among the groups and data collection methods. Further research is required to evaluate whether changes in the networking component of the program has strengthened it and whether the desired outcome, of students actually selecting work in secondary hospitals, was achieved.
- The FSHM program has been created on E-Learning, CMC's learning management system. Students and faculty interact with each other through the discussion board of E-Learning. Application of E-learning on mobile phones is being pilot tested by students to enable them to have information just in time and enhance networking with each other and faculty. 
- Faculty from secondary hospitals visit CMC and participate in faculty development programs. CMC faculty visit the secondary hospitals to support students, lend their expertise in clinical work, and learn from secondary hospital faculty.
Providing academic and social support to rural practitioners contributes to their retention in rural hospitals. , Networking among rural practitioners and academics has been shown to contribute toward retention of rural practitioners.  This study shows that networking, by the methods described, provides academic and social support to junior doctors working in rural hospitals. This support may reduce isolation and thereby may change students' conceptions of a rural hospital and of work and a career in such settings. This may lead to more practitioners practicing in rural areas. Medical colleges may want to consider networking as an integral component of supporting students and junior doctors in rural practice.
| Acknowledgements|| |
The authors thank the FSHM students, faculty, and medical superintendents for their participation in the study. The authors acknowledge the contributions of Janet Grant, Open University UK in setting up the distance-learning program. The authors also thank CMC Vellore for supporting the program. The authors also thank Foundation for Advancement of International Medical Education and Research (FAIMER) for awarding the International Fellowship in Medical Education (IFME) Fellowship to one of the authors, which enabled the author to undertake this study as part of the thesis work for the Masters in Health Professions Education (MHPE) program at the University of Illinois, Chicago.
| References|| |
|1.||Christian Medical Association of India. Retrieved July 14, 2012, from: http://www.cmai.org. |
|2.||Christian Medical College Vellore, Bulletin summer admissions. Retrieved July 14, 2012, from: http://www.home.cmcvellore.ac.in/admissions/SumAdd/pdf/UG%20BULLETIN%202012.pdf. |
|3.||Wilson NW, Couper ID, De Vries E, Reid S, Fish T, Marais BJ. A critical review of interventions to redress the inequitable distribution of healthcare professionals to rural and remote areas. Rural and Remote Health. 2009; 9(2):1060. |
|4.||Curran V, Rourke J. The role of medical education in the recruitment and retention of rural physicians. Medical Teacher. 2004; 26(3):265-272. |
|5.||Zachariah A. Secondary Hospital, FAIMER Project, 2000. |
|6.||Mullan F. Doctors for the world: Indian physician emigration. Health Affairs. 2006; 25(2):380-393. |
|7.||Vyas R, Zachariah A, Swamidasan I, Doris P, Harris I. Integration of academic learning and service development through guided projects for rural practitioners in India. Medical Teacher. 2011; 33:e401-e407. |
|8.||Aaraas IJ, Swensen E. National Centre of Rural Medicine in Norway: A bridge from rural practice to the academy. Rural and Remote Health. 2008; 8(2):948. |
|9.||Norwood AD, Hicks EK, Thrish CR, Woods MB, Clardy JA. A graduate medical education initiative to promote professional excellence among residency program coordinators. Medical Education Online. 2006; 11:34. |
|10.||Straume K, Søndenå MS, Prydz P. Postgraduate training at the ends of the earth - A way to retain physicians? Rural and Remote Health. 2010; 10(2):1356. |
|11.||Harris I. Qualitative Methods. In: International handbook of research in medical education, Part 2. In: Geoff RN, Vander Vleuten CP, Newbie DI, editors. New York: Kluwer Academic; 2002. p. 45-97. |
|12.||Vyas R, Tharion E, Sathishkumar S. Improving the effectiveness of physiology record books as a learning tool for first-year medical students in India. Advanced Physiology Education. 2009; 33(4):329-334. |
|13.||Barzansky B, Berner E, Beckman CR. Evaluation of a clinical program. Applying the concept of trustworthiness. Evaluation & the Health Professions. 1985; 8(2):193-208. |
|14.||Vyas R, Albright S, Walker D, Zachariah A, Lee M. Clinical training at remote sites using mobile technology: An India-USA partnership. Distance Education. 2010; 31(2):211-226. |