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 Table of Contents  
LETTER TO EDITOR
Year : 2018  |  Volume : 5  |  Issue : 4  |  Page : 310-314

What's in a name?


Centre for Community Medicine, AIIMS, New Delhi, India

Date of Web Publication14-Nov-2018

Correspondence Address:
Kiran Goswami
Room No. 30, Centre for Community Medicine, AIIMS, Ansari Nagar, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cjhr.cjhr_70_18

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How to cite this article:
Goswami K. What's in a name?. CHRISMED J Health Res 2018;5:310-4

How to cite this URL:
Goswami K. What's in a name?. CHRISMED J Health Res [serial online] 2018 [cited 2018 Dec 11];5:310-4. Available from: http://www.cjhr.org/text.asp?2018/5/4/310/245450



Sir,

“A rose by any other name is still a rose” my friends say in reaction to recent mushrooming of Schools of Public Health in Departments of Community Medicine in Medical Colleges. The chaos reminds me of my own journey that started almost four decades back in a Medical School. To tell you the truth, I was quite frustrated to find myself amidst dead bodies and frogs. There was a subject however where we went to college of nursing and learned to inject potatoes! It was for the first time that I felt I was indeed attending a course to “become a doctor.” The subject happened to be Preventive and Social Medicine. We went outside the four walls of College, away from the smell of formalin. We bonded with each other during the outings that seemed more like picnics. We learned so many things that were interesting and related to our own life, health and disease – visit to water and sewage treatment plant, textile unit, and mother dairy. There was an orientation to welfare organizations such as SOS village and Institutions of excellence such as National Institute for Communicable Diseases (now renamed NCDC-National Centre for Disease Control) and CHEB (Central Health Education Bureau). These excursions sensitized us to government health services, health-related schemes, and circumstances faced by our patients. First-hand experience of administering vaccines and interacting with people removed hesitations and boosted our confidence. This was the knowledge of practical life. No subject had so much variety and relevance! No wonder I chose it for postgraduation despite the opposition. No one could understand the logic of not choosing specialization and I myself was at loss of words to explain what kind of specialist I was going to become!

Did the things improve after postgraduation? Not at all! The subject name kept changing from “Social and Preventive Medicine” to “Preventive and Social Medicine” to “Community Medicine” to “Community Health” to “Family Medicine” to “Public Health” and the ride still continues. I discovered the confusion to be deeper than superficial name for there has never been a consensus about focus area, who all qualify as faculty and what should be the way forward.[1],[2] The whole issue of identity crises without any logical conclusion! This makes one thing clear however, that for students, there is no generation gap in being confused by this subject! This inspires me to reflect my thoughts for this special issue on Medical Education [Figure 1].
Figure 1: Community medicine and related disciplines

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  Evolution of Discipline Top


The subject has accepted whatever came in the way, with open arms! It started with a focus on control of infectious diseases in times of industrial revolution.[3],[4] It was realized that mere treatment of patients who seek treatment will not make a community free of disease and that the prevention was actually not only better than cure but also cost-effective. Over the time, as chronic diseases increased, prevention became even more cost-effective than treatment or supporting burden of disability. Since the control of epidemics formed the foundation of the subject, it was but natural for disaster management to be included in this study. The preventive measures focused on living environment as well as workplace environment and all this was related to economics too. It was observed that the disease occurrence and its course were a result of factors beyond biological agents emphasized in clinical medicine and thus parts of sociobehavioral, bio medical, and ecological approach to address health determinants evolved.[5] The subject took pride in being holistic and comprehensive.

As medical Institutions and medical education evolved, it was observed that despite the fact that most of the students had to work outside the walls of proverbial ivory towers, training did not prepare them well to face the outside world and failed to produce recommended ‘social physician”.[6] Blind imitation of Western model and standards of education made a medical graduate feel more at home abroad than rural areas of country for which the investment was made.[2] India became the largest provider of emigrant Physicians.[7] Reorientation of Medial Education was the felt need to empower young product with knowledge and skills needed to address most of the needs of common men.[8] It was thought that whole Medical college faculty and students will be reoriented by teaching in subdistrict and community level setting. Department was given responsibility to impart community-based learning experience in real world to “would be doctor.” Basically, the four core pillars of subject are summarized in [Figure 2].
Figure 2: Subject area of community medicine

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With globalization and shared susceptibility to health risks from any part of world, there has been a resurgence of interest in public health. Moreover, increase in private players, management of big private health service facilities in business mode, sensitization to quality care, economic compulsions, digitalization etc. have brought the need for training in “management practices.” Imbalance in demand and supply in Public Health and Health Management (including Health Information System) have provided another opportunity to community medicine department to rise to occasion.[5],[9] This has created greatest confusion on role of community medicine department in medical institutions with some faculty favoring public health, family medicine and research with immediate flow of budget and posts while others feel a loss to original mandate by fishing in newer ocean.[5],[10],[11],[12],[13] Another school of thought by some experts is that community medicine is best practiced as purely preventive science without clinical inputs.[14]

With tremendous progress in Medicine in last half-century, there has been specialization and super specialization, leading to a huge knowledge and skill gap between the medical graduate treating majority and the super specialists essential for smaller population.[15] People have become more health aware and prefer specialist consultation, who could probably be devoid of vision of holistic care! Copying the concept of meeting “quality care needs, and public health services” at the time of the Second World War by training generalists to become specialists, experimentation with “Family Medicine” has started with department undertaking clinical training in surgery, obstetrics, medicine, and disease surveillance/public health, without any substantial change in contents or approach.[16] Community medicine departments have been appended with family medicine to be known as Departments of Community and Family Medicine.


  Role of Discipline in Medical Education Top


Medical education system in India is one of the largest in world.[17] As part of medical institutions, the community medicine department faces a challenge to address training in multiple domains discussed above, involving multiple skills, not all of which have been accepted by choice![18] From pre independence time, the inadequate emphasis on preventive medicine in medical education has been well discussed.[19] It was realized that it is being taught in a way that students consider it to be of little importance. Shrivastav Committee visualized teaching of community medicine as a joint endeavor of whole faculty of medical institution for reorientation of medical education. However, it is the department of community medicine that solely runs the show!

WHO interregional conference on Medical Education (1970) emphasized necessity of setting appropriate goals on medical education that was reiterated again by Srivastav Committee.[8] According to General Medical Education Regulations of Medical Council of India (amended till July 2017), the approach to MBBS training is to make a physician of first contact who should be aware of community aspects of healthcare and rural healthcare services.[20] MCI regulations clearly state that the educational experience should emphasize health and community orientation instead of disease and hospital orientation [Figure 3]. With goal of medical education ensuring acquisition of public health competencies to address upcoming healthcare needs of population, it is clear that the teaching of Community Medicine and Public Health cannot be divorced.[21],[22]
Figure 3: Role of community medicine

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Community-based training, though variable, is a part of most of the medical schools in world.[23] Research observes that students value community-based education and are positive about educational experience thus provided.[23],[24] Students gain insight with patient-centered healthcare as well as understand the concept of continuity of care.[23],[24],[25],[26] Their confidence and understanding of primary care is improved.[27],[28] Community medicine departments in the country continue to provide community-based learning experience in their field practice areas where contact with patients as well as community in which they live occurs. Despite bearing the responsibilities, the subject does not enjoy good repute. Students do not prefer to opt for it as a career.[29],[30] They are afraid of subject due to distorted perceptions.[31] Moreover, the skills we aim to impart them are still not acquired by current teaching learning exercises.[12]

To me, it reflects our own failure to define clearly what the subject is and what it is not beside a disconnect between policy statement and training program. We still lack the clarity on role of the subject in medical institutions and its contents. An important reason is an overlap in areas covered by different nomenclature used to describe the subject.[1] Thus, we have a range of terms, public health as a comprehensive term addressing all the determinants of health at mega level while preventive medicine focuses on specific action customized to the concerned patient. A medical practitioner in a clinic has to address the felt need of patient like a family doctor or a physician. However, he has to advice preventive measures to family to avoid recurrence and transmission to other members of family, practicing preventive medicine. Further, for control of disease in community, he is expected to lead the community to health and act as Community Medicine expert. These are the roles majority of the physicians need to play in the community. When we talk of many communities, at a senior level, the medical practitioner has to provide Public Health Leadership. It is apparent that public health does need advocacy and leadership by medical practitioner but is actually outside the forte of Medical College! It needs a multidisciplinary team of nonclinical experts and training in public health does not need contact with patients in hospital. It is more concerned with epidemiological research and equity of health care services.


  Possible Solution to the Puzzle Top


With an ambition to encompass the whole health, that too at a national or international level and directing departmental human resources to research projects at the cost of ignoring primary job responsibility of developing personnel to meet health demands of nation, we are losing justification for our existence as a Department in a Medical College. Our expectations from students become vague and irrelevant to the basic training needs. Unless we are clear and develop a consensus on the role of subject in training a Medical Graduate, we shall continue to see the deteriorating quality of Medical graduates. The department has to take up the challenge of Medical education as a whole entity, with clearly defined goals and objectives to make dream of universal health coverage a reality. A start has been made by Indian Association of Preventive and Social Medicine declaration 2018 to define community medicine, its role and scope not only for undergraduates but also for postgraduate students as well as Faculty.[32] However, it still needs discussion on subtle distinction between the sister sciences, with due acknowledgement to shared tools in their arsenal. Perhaps the related disciplines have evolved to a level sufficient enough to branch into separate independent specialties with adoption of appropriate tools from each other. Unless this clarity is brought, each branch will be dragged behind in this three legged race. Community medicine has to detach and give space to an independent Public health, family medicine, and health promotion. It has to win the race on its own without the caliper support of related sciences. It has to borrow from strengths of related sciences, but to a specified depth and translate it to a single holistic comprehensive specialty. The students who feel interested in related branches can develop their skills by moving to institutions providing such specialization outside the medical institutes to become master of one instead of remaining jack of all. For community medicine, as part of a medical institute, the focus has to be in line with World Health Day theme (1990) “Think Globally Act Locally”.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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[PUBMED]  [Full text]  


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