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 Table of Contents  
BRIEF COMMUNICATION
Year : 2017  |  Volume : 30  |  Issue : 3  |  Page : 240-243

Evaluation of a distance learning academic support program for medical graduates during rural hospital service in India


1 Foundation for Advancement of International Medical Education and Research, Philadelphia, PA, USA
2 Department of Medicine, Christian Medical College, Vellore, Tamil Nadu, India
3 Department of Medicine, Ida Scudder School, Vellore, Tamil Nadu, India
4 Department of Medicine, Madras School of Social Work, Chennai, Tamil Nadu, India
5 Department of Medical Education, University of Illinois at Chicago College of Medicine, Chicago, IL, USA

Date of Web Publication18-Apr-2018

Correspondence Address:
Rashmi Vyas
Foundation for Advancement of International Medical Education and Research, 3624 Market Street, Philadelphia, PA 19104
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/efh.EfH_194_15

  Abstract 

Background: Christian Medical College (CMC), Vellore, India, a tertiary care hospital, designed a year-long Fellowship in Secondary Hospital Medicine (FSHM) for CMC graduates, with the aim to support them during rural service and be motivated to consider practicing in these hospitals. The FSHM was a blend of 15 paper-based distance learning modules, 3 contact sessions, community project work, and networking. This paper reports on the evaluation of the FSHM program. Methods: The curriculum development process for the FSHM reflected the six-step approach including problem identification, needs assessment, formulating objectives, selecting educational strategies, implementation, and evaluation. Telephone interviews with students were conducted to determine if the program motivated them to consider working in smaller hospitals. Results: Qualitative data analysis showed that the program motivated the FSHM students to consider practicing in secondary hospitals by creating awareness of challenging opportunities and instilling confidence to provide good quality clinical care with limited resources. Discussion: We propose rural service for MBBS graduates, supported by a blend of on-site and distance education as a model for medical education.

Keywords: Distance learning, medical graduates, program evaluation, qualitative research, rural service, secondary hospitals


How to cite this article:
Vyas R, Zachariah A, Swamidasan I, Doris P, Harris I. Evaluation of a distance learning academic support program for medical graduates during rural hospital service in India. Educ Health 2017;30:240-3

How to cite this URL:
Vyas R, Zachariah A, Swamidasan I, Doris P, Harris I. Evaluation of a distance learning academic support program for medical graduates during rural hospital service in India. Educ Health [serial online] 2017 [cited 2019 May 20];30:240-3. Available from: http://www.educationforhealth.net/text.asp?2017/30/3/240/229505


  Background Top


Medical graduates in India obtain the MBBS degree (equivalent to US MD degree) after 5 and ½ years of medical training. They can then practice as a general practitioner after registration with the Medical Council of India.[1] Graduates from some medical colleges have a service obligation in secondary hospitals, which are small hospitals, mainly in rural areas.[2] Graduates are not well equipped to practice in smaller hospitals and face challenges such as cases which are different from those at a tertiary care center,[3],[4] limited access to academic resources, and academic isolation. The secondary hospitals are unable to retain the medical graduates once they finish their service obligation,[3],[5],[6] primarily due to their remote locations, lack of updated facilities, and academic isolation. Thus, secondary hospitals are facing a crisis; many are closing because of lack of staff.[5],[6]

The shortage of health-care professionals in smaller hospitals is a global problem.[4] Providing support to practitioners in smaller rural hospitals is suggested as a measure to achieve retention of a rural medical workforce.[3],[4] Christian Medical College (CMC) Vellore, India, is a tertiary care hospital. CMC graduates, following graduation with the MBBS degree, have a service obligation for 2 years at secondary hospitals. Faculty at CMC designed a year-long Fellowship in Secondary Hospital Medicine (FSHM) for CMC graduates, which included a blend of distance learning modules, contact sessions, community project work, and networking. CMC aspired, through the FSHM, to provide support to graduates during rural service.

This paper describes the design and implementation of the FSHM program. It reports the evaluation of the FSHM program, with a focus on whether the program motivated the medical graduates to consider practicing in small hospitals.

Fellowship in Secondary Hospital Medicine program: Design and implementation

The curriculum development process for the FSHM reflected the six-step approach.[7] Needs assessment was done using focus groups, written surveys, and interviews of CMC faculty and graduates who had worked in secondary hospitals, undergraduate students participating in their internship, and faculty working at secondary hospitals. Graduates faced difficulties in transition to secondary hospital care due to lack of the knowledge and skills required to practice at secondary hospitals. Challenges included the management of the type of cases seen, which related to the prevalence of disease patterns in their areas, such as falciparum malaria in the east and northeast regions.[8] Graduates also faced difficulties in following standard guidelines for treatment because of limited patient economic resources and laboratory referral support.

Program purposes were discussed through faculty deliberations, using the needs assessment data. The purposes agreed upon were to provide support to medical graduates during rural service, help them to practice effectively in smaller hospitals, and be motivated to consider practicing in these hospitals.

The instructional strategies designed to achieve the purposes were a combination of the following: 15 paper-based distance learning modules, 3 contact sessions at CMC, a community project, mentoring, and networking. Formative assessment included faculty feedback for distance learning activities and project proposals. Summative assessment included tutor-graded assignments after each module, a final examination consisting of multiple-choice questions and an objective structured clinical examination, and tutor assessment of a community project. Faculty development was integral to implementation of the program. The FSHM curriculum was implemented in 2007.


  Methods Top


The evaluation was done after 3 years of program implementation. Telephonic interviews were conducted with FSHM students (n = 22): 16 from the years 2007 to 2008 and 6 from 2008 to 2009. There were also interviews with eight medical superintendents at secondary hospitals where FSHM students were working. The purpose of the interviews was to explore, through open-ended questions, the effectiveness of the program and to analyze whether the program motivated the FSHM students to consider practicing in secondary hospitals.

Qualitative data were analyzed using the constant comparative analysis method associated with grounded theory, a process of reading and rereading the narrative data, developing themes in the process, and then reviewing previously read data to check the appropriateness of themes developed.[9] Two of the authors independently analyzed the data. Inter-rater reliability of identified themes, and comments assigned to themes, was calculated using Miles and Huberman's formula.[10]

Institutional approval was obtained from the CMC-Vellore, consistent with CMC policies. Institutional Review Board approval was obtained from the review board at the University of Illinois, Chicago, where the first author completed this project, in partial completion of her Masters of Health Professions Education degree.


  Results Top


All the FSHM students (100%) said that the program had motivated them to consider practicing in secondary hospitals. On further exploration of how and why, the following themes were identified.

Creating awareness of challenging opportunities

Twelve out of the 22 students interviewed felt that through the program they became aware of challenging opportunities at small hospitals. One student commented: “It made me look at secondary hospital work as quite challenging.”

Increasing confidence to provide good quality clinical care with limited resources

Ten out of the 22 students interviewed thought that the program changed their perspective about the type of work they were doing. It gave them confidence that even with limited resources they were providing good quality clinical care. One student commented: “The major impact of the FSHM was the confidence imparted to me that we could manage cases with limited resources. Earlier I used to think that I should refer most cases, but now I am confident about what I do. I used to think I was doing harm and giving inferior quality treatment. Now my perspective has changed. I know we are giving what we can with limited resources which may be comparable to the best treatment.”

Strengthening motivation to work in a secondary hospital

Eight out of the 22 students interviewed said that the program strengthened their motivation to work in secondary hospitals as a long-term career choice. One student commented: “I always wanted to do my post-graduation and come back. After FSHM I am sure I would want to work in a small hospital.”

Providing exposure to work in secondary hospitals

Eight out of the 22 students interviewed felt that the program showed them a different perspective of working in a secondary hospital. It exposed them to the type of work being done in these hospitals. One student commented: “I would say in a way it showed me what life would be working in a secondary hospital. FSHM opened a window into working in secondary hospital for me.” “I find it exciting, as I see a wide variety of cases. Very exciting, so wouldn't mind coming back. My whole idea has changed.”

Revealing a need

Eight out of the 22 students interviewed felt that the program showed them that there is a need for doctors in small hospitals which motivates them to make working in these hospitals a long-term career choice. One student commented: “Knowing that there is a need in the community, I will go back to work in secondary hospital.”


  Discussion Top


This study shows that a blend of distance learning modules, contact sessions, project work, and networking can be implemented to support medical graduates working in small hospitals. A highly desirable outcome was that the program led to changes in students' attitudes toward practicing medicine in secondary hospitals and improvement in hospital practices. All course participants expressed a willingness to consider working in secondary hospitals and making it a career choice. The program strengthened the positive attitudes of some about working in secondary hospitals and appeared to change the minds of many regarding secondary hospital practice and working in secondary hospitals as a career choice. Providing postgraduate rural practice training has been shown to influence physician retention in smaller rural areas.[3]

Since this study, the FSHM program has expanded to an 18-month Post Graduate Diploma Course in Family Medicine and topics not originally addressed have been included. The 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.

A limitation of this study is that evaluation is based on self-reports by students. Further research is required to evaluate the long-term outcomes of the course, including how many are actually practicing in the secondary hospitals.

Recruiting rural students to medical schools has been used as a strategy for them to practice in the same rural area.[11] A recent systematic review in 2016 of strategies to recruit and retain primary care doctors found six studies and only one with a comparative group that evaluated recruiting rural students to medical school, with the expectation that they would return to their home town for practice.[11] The comparative study found that 68% of students were still practicing family medicine in the same rural area up to 16 years after graduating compared to 46% in the comparison group (P = 0.03). While the remaining five studies found that a large proportion of individuals recruited from rural areas subsequently work in rural areas (one study reported up to 90%), the lack of a comparison group makes it difficult to determine what would have happened if recruitment from rural areas had not taken place. India started the Bachelor of Rural Medicine and Surgery (BRMS) degree for high school graduates from rural areas to go back and work in rural areas from where they were recruited, or a similar community of practice, after graduation from the BRMS program.[12] However, this has not been as effective a strategy in India as it was envisioned.

A strategy which has been effective to some extent is providing rural practice training during undergraduate medical education as well as postgraduate education as a potential factor in recruitment and retention of rural physicians.[3] The FSHM program has incorporated the above principle and its evaluation has demonstrated a change in the attitudes of graduates about practicing in secondary hospitals. We would, therefore, propose a model of medical education for India of 5 and ½ years for the MBBS, plus 2 years of rural service supported by a blend of on-site and distance education. Other medical schools, globally, could adapt this model with suitable modifications tailored to the learning needs of students and to the health-care needs of communities.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Biswas R, Sarkar N, Umakanth S, Singsit J, Hande M. Medical education and the physician workforce of India. J Contin Educ Health Prof 2007;27:103-4.  Back to cited text no. 1
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2.
Vyas R, Zacharah A, Swamidasan I, Doris P, Harris I. Blended distance education program for junior doctors working in rural hospitals in India. Rural Remote Health 2014;14:2420.  Back to cited text no. 2
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Curran V, Rourke J. The role of medical education in the recruitment and retention of rural physicians. Med Teach 2004;26:265-272.  Back to cited text no. 3
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Wilson NW, Couper ID, De Vries E, Reid S, Fish T, Marais BJ, et al. A critical review of interventions to redress the inequitable distribution of healthcare professionals to rural and remote areas. Rural Remote Health 2009;9:1060.  Back to cited text no. 4
    
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Zachariah A. Secondary Hospital FAIMER Project; 2001.  Back to cited text no. 5
    
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Mullan F. Doctors for the world: Indian physician emigration. Health Aff (Millwood) 2006;25:380-93.  Back to cited text no. 6
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Kern DE, Thomas PA, Howard DM, Bass EB. Curriculum Development for Medical Education. A Six-Step Approach. Baltimore and London: John Hopkins University Press; 1998.  Back to cited text no. 7
    
8.
Malaria Country Profile India (1995-2007). Available from: http://www.malariajournal.com/content/11/1/233/figure/F1. [Last accessed on 2016 Aug 08].  Back to cited text no. 8
    
9.
Harris I. What does “The discovery of grounded theory” have to say to medical education? Adv Health Sci Educ Theory Pract 2003;8:49-61.  Back to cited text no. 9
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10.
Miles M, Hubermann M. Analyzing Qualitative Data. Thousand Oaks CA: Sage; 1994.  Back to cited text no. 10
    
11.
Verma P, Ford JA, Stuart A, Howe A, Everington S, Steel N, et al. A systematic review of strategies to recruit and retain primary care doctors. BMC Health Serv Res 2016;16:126.  Back to cited text no. 11
    
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Jayaraman K. India moves toward creating a new cadre of rural doctors. Nat Med 2010;16:350.  Back to cited text no. 12
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