Residential Field Site Training: Bangladesh Approach to Community- Based Education to Develop Generic skills in Tomorrows' Doctors

	Abdus Salam MBBS; MPH; Dip Med Ed; M Med Ed (UK) Senior Lecturer Department of Medical Education Faculty of Medicine Universiti Kebangsaan Malaysia Medical Centre Rabeya Yousuf MBBS; DBS&T Medical Officer Blood Transfusion Unit Department of Pathology Universiti Kebangsaan Malaysia Medical Centre
	Dr Abdus Salam Department of Medical Education Faculty of Medicine, UKM Medical Centre Jalan Yaacob Latif, Bandar Tun Razak Cheras, 56000 Kula Lumpur, Malaysia Phone:6 03 91457973; Fax: H/P: 6 0199061724 E-mail: salabdus@gmail.com; salam@ppukm.ukm.my

ABSTRACT Background and Objectives: Residential field site training (RFST) is an approach to community based education (CBE) in undergraduate medical curriculum in Bangladesh. Hospital-based education is no longer the only place to train doctors for the 21st century as it fails to develop generic skills of doctors. Society expects tomorrows' doctors should be a good care provider, decision maker, communicator, leader and manager, which are the generic skills and have been advocated by WHO, as five star doctors. The objective of this paper is to identify the students and teachers' perceptions of RFST. Methods: It was a questionnaire survey carried out among 4th year undergraduate medical students and teachers of Comilla Medical College, Bangladesh, during the RFST programme in 2001. Data was collected using a common questionnaire from a sample of 40 students and 24 teachers who participated in RFST. Results: Most of the students (78-98%) and teachers (88-96%) felt that RFST provides students an opportunity to aware of common rural health problems, develop a caring attitudes and assists to develop their generic skills. Conclusion: As an approach to CBE, RFST provides a real life exposure and helps to develop generic skills in future doctors. CBE requires a close collaboration between health and educational administration and should not be seen as a separate entity. Resources and their proper utilization are important for an effective CBE. Key words: residential field site training, generic skills development, tomorrows' doctors.

INTRODUCTION

Medical education is in a process of constant change^(1,2) and internationally it is recognized that undergraduate medical education must adapt to changing needs.⁽³⁾ Many factors may influence the outcome of education such as educator, educational material, educational foyer such as lecture rooms,⁽⁴⁾ educational settings like hospital based, community based etc. Community-based education (CBE) is an important strategy of WHO in the education of health personnel for achieving the aims of primary health care⁽⁵⁾ and thereby health for all. Traditional hospitals, which are gradually turning into a huge intensive care unit are no longer treated as the only or best places to train doctors for the 21st century^(2,6) as they fail to meet the needs of the society. There is a growing recognition that in addition to strong scientific knowledge and excellent clinical skills, the doctors should possess generic skills and be able to communicate effectively with patients, patients' families and colleagues; act in a professional manner; be aware of socio-cultural diversities, values, prejudices etc. and provide care with understanding of those values and dimensions of patient's lives.⁽⁷⁾ Society expects tomorrow's doctor should be a good care provider, decision maker, communicator, leader and manager, the characteristics which have been advocated by World Health Organization (WHO) as five star doctors.⁽⁸⁾

Residential field site training (RFST) is an approach to community-based education in undergraduate medical education in Bangladesh, one of the most densely populated developing countries in the world located in the South Asia region. Bangladesh gives special priority to economic, social and health service development like other developing countries. The undergraduate medical curriculum of Bangladesh has been changed to community based by the Center for Medical Education Dhaka in 1988, and it has been implemented since 1990 under the guidance of Further Improvement of Medical Colleges Project. The ultimate aim of RFST is to teach tomorrow's doctors in the context of their everyday life where they have to practice in future after graduation. The country produces medical graduates for its health service delivery through seventeen public medical colleges including nine new ones. Some private medical colleges are also functioning to produce medical graduates. The undergraduate medical curriculum in Bangladesh consists of three phases over a duration of five years leading to a MBBS degree. Phase-I comprises year 1 and 2, phase-II comprises year 3 and 4 and phase-III comprises year 5. Recently the curriculum was reviewed again and phase-I consolidated to one and a half years, phase-II remains as it is, i.e. two years and phase-III expanded to one and a half years. In phase I, basic science subjects are taught mainly. Para-clinical and clinical subjects are taught from phase II onwards. Students have to appear at three professional examinations at the end of each phase. In between, there are formative assessments as well. The 6th year is the internship year in which the interns attend ward rounds, take part in management of patient care and do the roster duty under the supervision of a consultant.

During their study in phase II, year 4, every medical student has to reside two weeks in a Thana Health Complex (THC) for RFST under the guidance of the Community Medicine Department. THCs are the basic units of primary health care service centers. Students are placed in an affiliated THC of the respective medical colleges under the Thana Health and Family Planning Officer (TH&FPO), who is the head of THC. They are placed usually in a group of around 20-24 students, which are further subdivided into two sub groups. The two week period is divided into one clinical medicine week and the other community medicine week. Students of one sub group join the clinical medicine week and the other subgroup join the community medicine week and at the end of the week they rotate. One teacher from the community medicine department usually stays at the THC by rotation along with the students to guide them. During clinical medicine week, students visit different sections of THC and observe the functions of each section. Case discussions are held in the morning with in-patients as well as outpatients. According to a pre-prepared schedule, senior teachers from the respective disciplines of respective Medical Colleges and personnel of THC facilitate students during clinical medicine week. In the evening group discussions are held among the students and faculty focusing on the student's experiences, and what they already observed and discussed with academics in the morning. During Community medicine week, students do a survey on the socio-demographic structure of rural families. During their survey they are divided into further smaller groups. Each student has to fill out five pre-prepared questionnaires by visiting five rural families. Before home visits of rural families, students are aware of social and religious sensitive issues of families. Teachers of Community Medicine and field level staff of THC guided the students during their survey. They also visit different rural health sub centers (grass root levels health posts), talk to different domiciliary health and family planning workers, traditional birth attendants (TBA) and other personnel engaged in community development activities. In the evening / night students unite together in a community hall and share their experiences. Each of the students compiled and analyzed their data first individually, then by subgroups and finally by the whole group. Students present their survey findings by organizing a seminar at the closing day of RFST program where institutional heads of both the campus (Medical College) and Community (THC), with other facilitators, are present.

For better group functioning, students usually form three committees, namely general committee responsible for overall supervision of the students, scientific and cultural committee responsible for organization of seminars and other related matters and a committee responsible for food management for the students. Each committee usually comprises one convener and two members, one from the males and the other from the females. This study was designed to investigate the perceptions of students and teachers about RFST as an approach to CBE.

METHODS

It was a cross sectional questionnaire survey carried out among all the 4th year undergraduate medical students and all the teachers who participated in RFST. The study was conducted in 2001 at Laksham THC, which is an affiliated primary health care center of Comilla Medical College, under the University of Chittagong in Bangladesh. Though recently four more new public medical colleges were established in Bangladesh, during this study period, Comilla Medical College was one of the then new five established govt. medical colleges where every year new student intake was 50. However, this intake has now increased to 100 students every year. This study was done on the 6th batch / intake of Comilla Medical College, and comprises 40 students while they were in year-4 and 24 teachers who facilitated the students during RFST. Working as a head of the department of Community Medicine at Comilla Medical College, Bangladesh in 2001 the 1st author had to plan, implement and evaluate the whole RFST program and as such this study was carried out. Data was collected from both students and teachers utilizing a common questionnaire that contained different attributes of RFST. A rating scale in the questionnaire was used ranging from 1-5, where 1 rated as strongly disagrees and 5 rates as strongly agree. The data was then compiled and analyzed.

RESULTS

Table 1 shows the students' perception of RFST where 90% of the students opined that RFST helps them to develop awareness on common health problems of rural community and 97.5% felt that they learn group management and team building skills. As a result of participation in RFST, 77.5% students felt that it helps in the development of their positive caring attitude towards the rural community, while 95% of students thought that RFST helps them to develop their communication skills and reduce the gap between teacher and students. According to 87.5% students RFST gave them a real life exposure and 77.5% opined that RFST gave them the flavors of education in a different setting.

Table 2 represented the teachers' perspective, where 91.7% facilitators stated that RFST helps the students to be aware of common health problems of the rural community and to learn group management and team building skills. In the development of positive caring attitude, 87.5% of tutors opined that RFST provides an opportunity to students to develop a positive caring attitude towards the rural community. Ninety six percent of teachers felt that RFST assists the students to develop communication skills, 98.5% believed that it provides an opportunity to reduce the gap between teacher and students while 87.5% opined that it gave the students a real life exposure and tested the flavors of education in a different setting.

DISCUSSION

Most of the students (90%, Table 1) and teachers (91.7%, Table 2) in the present study agreed that RFST offers the students an opportunity to develop awareness on the common health problems of diverse rural people. Once students have better awareness and understanding of the diverse community problems, they will be in a better position to make decisions in handling those problems later in their professional life.⁽⁹⁾ RFST exposed the students to a real life situation through an opportunity to come into close contact with rural people, which helped them to be aware of their norms, beliefs, prejudices, financial problems, housing problems, illiteracy, violence, ignorance etc. and also be aware of the role of these factors in the causation and management of illness.

During RFST, students had to work in a different committee like general committee, food committee, scientific committee etc. with different students and having different responsibilities and also had to work with multi-professionals, which helped them to develop group management, team building and leadership skills, which are generic skills and should be possessed by every future doctor. According to 97.5% of students (Table 1) and 91.7% of teachers (Table 2) RFST offered the students the ability to gain the skills of working in groups and team management. Jira⁽⁵⁾ pointed out that to address the community health problems, future doctors should be able to work as a member of the team with their responsibilities and be able to share knowledge and skills with other members of the team. This finding of RFST has a positive aspect to meet the community health problems.

To meet the expectation of society, development of mindset and attitudes of "tomorrow's doctors" are essential. Attitudinal development can be best taught in the community educational setting, exposing students to real life situations. Most of the respondents (77.5% students, Table 1) (87.5% teachers, Table 2) of this study were of the opinion that RFST offered the students an opportunity to develop a positive caring attitude towards the rural community.

Communication skills are an essential component of medical competency and good communication improves care and enhances patient satisfaction, compliance and health outcomes.^(10-16) Many studies⁽¹⁷⁾ have reported the importance of effective communication in improving patient health outcomes,⁽¹³⁾ in fostering patient compliance to treatment,⁽¹⁸⁾ and in improving patient satisfaction with the medical encounter.^(19,20) Through RFST, students are encouraged to develop a sensitive and empathic response to the needs and circumstances of people in the community. To complement this awareness, students are expected to develop generic skills of observation, reflection and communication. Most of the students (95%) and teachers (95.8%) in this study opined that RFST offered the students an opportunity to improve their communication skills. Communication skills with different sources and the different communities and with people of varying cultures are important factors in determining the success of communication in any situation. The ability to communicate effectively is an essential element of a physician's clinical expertise.⁽²¹⁾

An important consideration in a teaching learning session is arousal or excitement that implies a state of readiness of the learner to accept new information.(22,23) This study revealed that 80% (Table 1) of the students and 95.8% (Table 2) of the teachers felt that RFST aroused students' interest and they took the flavors of education in a different setting. Motivation is a key factor for learning that implies a willingness to direct its activity to a specific task.⁽²²⁾ The present study revealed that 95% (Table 1) of the students and 95.8% (Table 2) of the teachers believed that students were motivated as the gap between students and teachers was reduced through RFST.

RFST did not waste time, was reported by 60% students (Table 1) and 58% (Table 2) teachers. Although 8% of teachers opined that RFST wasted their time, 17% of teachers were undecided and the other 17% did not respond to this attribute of study (Table 2). On the other hand, 27.5% of students opined that RFST causes wastage of their time while 12.5% were not sure and undecided (Table 1). Actually while conducting this programme, the comments by some sections of the teacher population as "RFST is wastage of time", aroused the interest of 1st author to include this statement in the instrument as a study element. RFST or any other programme, whether wasting time or not, depends on how and what strategies are adapted to implement the programme and also the mindset of institutional head to value the programme and mobilization of the resources for the programme.

A similar study conducted in 2003 at Universiti Sains Malaysia, named as Community and Family Case Study (CFCS) as an approach to CBE revealed similar findings to the present study. The essential characteristic of a community based curriculum is the distribution of community-based learning activities throughout the duration of entire curriculum.⁽²⁴⁾ There is no universal solution on how to approach CBE. It is the situation, program, strategies and resources of a particular country, which dictate how the objectives are incorporated. However, allocation of resources in terms of man, money, materials and their proper utilization are important factors for an effective programme. Since CBE is based on the practice of health care, it requires the close collaboration of health and educational administrations and integrated policies need to be outlined through inter-institutional consultation and coordination.⁽²⁴⁾

CONCLUSSION

RFST as an approach to CBE arouses students' interest and provides an opportunity to the students to have close contact with rural people and be aware of their norms, beliefs, prejudices, financial problems, housing problems, illiteracy, violence, ignorance etc. and also aware of the role of these factors in the causation and management of illness. Exposure to the real life situations of rural people through RFST, students have to work and behave in a certain way which helped them to develop their generic skills. Implementing an effective community based educational programme is not an easy task. It requires close collaboration between health and educational administrations and proper integration of inter-institutional consultation and coordination. A community based component in curriculum should not be seen as a separate entity by the policy makers. To get real benefit from CBE, it is important that the entire learning process and the institutional involvement should be programmed as one entity. The way in which objectives are incorporated into the curriculum will depend on the situation, program, strategies and resources of a particular country

Acknowledgement: The authors would like to thank Director Medical Education and Line Director Pre-service Education, Directorate General of Health Services, Dhaka, Government of Bangladesh, for funding the program.

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