Promoting people-centric physicians


by Randima Attygalle

The Father of Medicine, Hippocrates said ‘it is more important to know what sort of person has the disease than to know what sort of diseases a person has.’ The Community Attachment Programme (CAP) initiated by the Community Stream of the Faculty of Medicine, University of Colombo is a clear manifestation of the great philosopher’s timeless words.
The programme gives an opportunity for second year medical students to interact directly with the community as well as multiple partners of the health care delivery system and thereby enabling first-hand experience in identifying the health related issues of people living in rural areas. The CAP, which has been conducted for seven batches of medical undergraduates in the Embilipitiya MOH area of the Ratnapura District, aspires to extend itself to other MOH areas of the country.

The Community Attachment Programme (CAP) of the Colombo Medical Faculty is a personification of its mission to ‘develop a graduate who will contribute to fulfill the health requirements of the individual and community with competence compassion and care.’ It is also means of championing the modern expectations of a doctor which is not only to cure patients but also to be a change-maker in taking action to influence, adjust and improve the health of apparently healthy people and thereby contributing to the responsibility of preserving and promoting their health.

No medical textbook or curriculum can enable the insights CAP provide the budding physicians, says Professor in Community Medicine and Head of the Department of Community Medicine, Manuj C. Weerasinghe. "This experience which comes at a very early stage of our students’ academic career will help them to grasp the authentic primary health care concept when they go to other attachments. If they are not exposed to this primary health care set up, the whole health education system is a failure. This is one of the most decisive interventions to make sure that they have the insights to become a better manager and better communicator serving people."

The CAP which provides the medical students opportunities to apply the concepts and principles of demography, statistics, epidemiology, behavioural science and community medicine which is learnt in classroom to a real community set up, prepares them to cater to smaller health care delivery establishments, notes Prof. Weerasinghe. "When the new medical graduates who are trained in tertiary care institutes are posted to rural settings, most of them find it very challenging to integrate into the system. This is even more challenging for students who have grown up in the ‘digital world’ and brought up in an over-protective home environment in which human interaction is minimal. What the CAP envisages is to mould our products to understand the expectations and aspirations of a community which are very different to that of an urban landscape."

The CAP, as Prof. Upul Senarath, the Chairperson of the Community Stream further illustrates, is means of going beyond the ‘one-way process’ of the traditional curriculum where problems of a community are identified and solutions are proposed with very little community participation in the process.

"The overall aim of teaching public health is to promote good health practices so that people are healthier and happier and in this approach we need to engage with the community to have a clear understanding of the factors influencing the diseases and disease management." More than 200 students from each batch of the Faculty of Medicine had been exposed to this residential community attachment programme over the last five years, interacting closely with multiple partners of the health care delivery system from primary medical care units to base hospitals as Prof. Senarath explains. Students who are housed in the Leadership Training Centre, Embilipitiya, liaise with several stakeholders including the MOH office, local police and divisional secretariats in selecting their localities for health promotion activities and mobile health clinics which include dental care, diabetes and hypertension screening and Well Woman Clinics.

The residential programme which runs for 11 days each year opens new vistas for medical students which in turn they could translate to their future clinical settings, points out Prof. Senarath. "Embilipitiya MOH area was selected for the initial CAP programme as it is fairly a large area with a population of about 120,000. The programme was successful in unearthing health issues at the grass root level which are often not reported or presented to the existing health system. Among them were a lot of environmental issues which have a direct bearing on people’s health such as waste management, lack of healthy drinking water, stray dog problems and concerns over the use of agro chemicals."

The initial discussions with the community are followed by a household survey. The findings are presented by the students to their respective tutors and the priority issues are then collated to find solutions for in form of an action plan. "The ultimate message which the programme strives to convey is that health is beyond hospitals and the community can play a pivotal role in promoting it," observes Prof. Senarath who goes on to note that the villagers are empowered on sustainable health practices including healthy feeding practices, sanitation and occupational health as well. The programme is a mutually rewarding exercise where students can reap first-hand knowledge on region-centric socio-economic issues as well. "It will sensitize them to issues such as wild animal attacks which place these communities in many vulnerabilities," points out Prof. Senarath who notes that CAP also fosters communication and leadership skills required to make a fully-fledged physician with a thorough understanding of the dynamics of primary health care.

Promoting health literacy and health care utilization among the communities is also envisaged by CAP points out the Senior Lecturer from the Faculty of Medicine, Dr. Dulani Samaranayake. "Although many health screening facilities such as Well Woman Clinics are now available in the state sector, rural communities are hardly aware of them and CAP also encourages them to seek such facilities," says Dr. Samaranayake. The Suwa Arana Health Promotional Camp of CAP provides on-site screening for blood sugar, blood pressure, breast and pap smear examinations. In addition, a dog vaccination and sterilization programme is also carried out. All these, as Dr. Samaranayake explains, are organized by medical students themselves under the supervision of their tutors with the support of the regional health staff. A school-centric mobile dental clinic brings much needed dental care to the door step of many students. "It is similar to a health promotional day for the local community and the demand for these on-site facilities is very high," observes Dr. Samaranayake who goes on to note that while this exercise addresses specific health care needs of communities, at the same time it exposes students to event organizing and crowd-handling, an advantage which they will not gather within the walls of a medical school.

With the country having to carry the double burden of non-communicable diseases (NCDs) and the rising ageing population, interventions such as CAP should necessarily be long-term ventures opines Dr. Samaranayake. "Moreover, it helps students to understand the health services better as they will be interacting with large and small health care institutions and with preventive as well as curative sectors. This holistic picture will help produce fully-fledged physicians who would serve the health sector which is the ultimate goal of this labour."

For H.A. Sadini Upeka and Minura Manchanayake, both second year medical students who come from Colombo suburbs and have had their entire school education in Colombo, the CAP had enabled a window to the public health system at the grass root level. "The CAP is a golden opportunity to receive exposure to the rural public health setting, both by learning from the community as well as giving back to them. Moreover, it has been one of the most engaging, informative and exciting activities we took part in, as students of the Colombo Medical Faculty," says Sadini. The programme, as Sadini illustrates further, encouraged the students to build a good rapport with the members of the community in order to gain insights into their lifestyles, their perceptions of the health care system and health concerns distinct to them.

She also notes that the programme made it possible for students to objectively observe the public health system at the grass root level. "We gained a lot of knowledge on how principles of community medicine are applied in real-life, practical settings. In addition, we were able to develop communication, coordination and presentation skills as we had to gather information from multiple field visits and present them in front of our colleagues, lecturers and local health professionals such as Medical Officers of Health, Public Health Inspectors and the Public Health Midwives. We learned the importance of teamwork when we faced the challenging task of completing the work as accurately and efficiently as possible within a limited time frame." The progamme, as Sadini explains further,

Alluding to the CAP as a ‘pleasant surprise’, Minura notes that it is one of the few opportunities the students get to approach people outside the ward setting. "The focus is on the narrative of the people and the preventive aspect of common illnesses that affect the community as a whole, and this is in stark contrast to the process of history taking, examination, diagnosis and management of patients in the wards. The value of this exposure far exceeds academic merits as it drives us to become leaders because to become a good doctor, one must necessarily become a good leader." The visits to primary care centres, NCD screening clinics, etc provided further insights to the roles of Public health officers including the PHIs, Public Health Midwives and other officers in the field, says Minura further.

"The community diagnosis helped us to understand the health issues of our community. Here we identified that the prevalence of NCDs like diabetes, hypertension etc which are essentially urban concerns, permeating into a rural setting like Embilipitiya owing to urbanization and the associated tendency to consume unhealthy food and sedentary patterns of living. The programme also urged me to become a better leader which I believe is fundamental in functioning as a House Officer later on in a ward," remarks Minura adding that the CAP helped him to look at various illnesses from an Epidemiological point of view while appreciating the role of PH officers in their early prevention.

(Pic courtesy: Department of Community Medicine, University of Colombo)

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