Family Adoption Program, A Way Forward to Community Based Medical Education.... Challenges Ahead

Medical education in India is based predominantly on hospital environments and specialist services covering a narrow spectrum of health problems, with especially dependent on technology. A significant reorientation is needed in medical education, to allow students to understand people in their social contexts in a more holistic way, rather than seeing them merely as parts of a biological machine.1

National Medical Commission (NMC) in their recent notification included Family Adoption Program (FAP) in the undergraduate curriculum to provide a learning opportunity towards community-based health care to Indian Medical Graduates.2 The NMC documented its vision as “to provide for medical education system that improves access to quality and affordable medical education, ensures availability of adequate and high-quality medical professionals in all parts of the country; that promotes equitable and universal health care that encourages community health perspective and makes services of medical professionals accessible to all citizens; that promotes national health goals...”3

Vanikar et al had depicted the road map of this FAP, where one village outside the RHTC will be allotted to every new batch of a medical college assigning 5-7 households to each student. The orientation to the rural health problems with rural health infrastructure will start from the very beginning of the foundation course in the first professional year. Assistant professors and senior residents of Dept of Community Medicine will act as the mentors and will coordinate with Gram Sabha and local villagers with local ASHA workers and medical social workers. The students will collect data from the households by visiting them physically along with availing telemedicine facilities, besides they will also take part in the outreach health and awareness camps. As a step towards environmental consciousness, the students will be encouraged for tree/ medicinal tree plantation.4 Several studies envisaged the advantages of learning in ‘the community as a classroom’ as achieving communication skills; understanding the customs and cultural beliefs of the rural population, learning to be humane and develop empathy; inculcate leadership skill; working as primary consultants for the households; and learning basic skills of diagnosing and managing health problems, ultimately having training in family medicine.4-6

Examples of participation of medical students in community health activity are not scarce. The Social Service Camp with village adoption program was running in Mahatma Gandhi Institute of Medical Sciences (MGIMS) Sewagram, Wardha successfully for few decades to expose the students to a value based and cost-effective medical education in resource constrained rural areas. They have developed an interface between community, health system & the institute to discharge its role in social responsibility in short term & social accountability as a long-term goal. 7,8 The term Community Based Medical Education (CBME) is also vogue, which refers to learner's clinical training at the community setting and utilized by health science faculties worldwide to provide a relevant primary care experience for students and a service to underserved communities. Diab et al in a qualitative study in South Africa had cited the short term benefits the community achieved from community based education (CBE) as improved service delivery, reduction of hospital referrals, community oriented primary health care, improved communication with patients and long-term benefits included improved teaching through a relationship with an academic institution, students’ participation in community upliftment projects thereby acting as agents of change in these communities.4

Experience from Australia and Canada showed through Longitudinal integrated Clerkships (LICs), year-long community-based placements, students gain strong communication skills and excellent clinical reasoning and management skills, which they described as ‘Meaningful personal learning experiences’. 9 But implementation of this FAP poses a challenge in India. This needs good infrastructure of each medical college at the RHTC like human resources, vehicular support, funds as well as good accommodation facilities. The renowned well established private medical colleges had built their rural infrastructure on their own or in collaboration with Govt settings with an objective of conducting the students/ internship training program, as well as attracting the patient pool for curative services in the hospitals. But most of the Govt medical colleges are in backfoot, not having adequate human resources to run the FAP at rural areas, will have to depend solely on the district health infrastructure. What a herculean task it is when one medical college with 250 students will have to select at least 750 households per year. ASHA workers working at grassroot level are already overburdened with their routine activities and motivation without incentives will create a problem to engage them in FAP activities. In most of the medical colleges we don't have Medical Social Worker posted in the department who can be the main pivot for making all collaboration with Gram Panchayat and Village Health Sanitation & Nutrition Committees.

Dept of Community Medicine is having faculties as per the NMC norms, but they are engaged in teaching and training activities throughout the year from 1st to 3rd Professional MBBS with multiple batches, along with implementation of national programs and participation in administrative activities at college level.

Moreover, as per NMC, the villages to be adopted will be outside the field practice area of RHTC and repetition of villages should be avoided. In spite of having NMC norms for non-medical/ paramedical manpower in urban and rural field, most of the medical colleges have not employed these designated personnel. In this context, the sole responsibility will lie on the Assistant Professor at RHTC without support of adequate manpower (Post graduate trainees are not present in many medical colleges) to build liason with the villagers, Gram Panchayat or local NGOs.

College to college variations exist in respect to number of students, strength of faculty and support staff, distance of RHTC from Medical Colleges etc, therefore FAP application cannot be uniform everywhere, so this needs flexibility in its implementation.

In the competency based medical education, NMC has provided the curriculum planning how these competencies to be achieved in 1st to 3rd professional MBBS. Within the 1-year span of 1st Professional, the students have to pay 9 visits (27 hours duration) to complete the competencies, for which they have to know the survey methodology, PRA techniques, communication skill, history taking, clinical examination, management of illnesses which seemed to be impossible without any clinical exposure and in an overburdened situation to grasp the 1st Professional subjects. Moreover, clarification is lacking about incorporation of the allotted hours of family visits throughout the year in the routine of the whole curriculum.

NMC should get thanks for taking an initiative to make the curriculum of community medicine more community oriented. In Indian context, if this FAP can be implemented successfully, this will be a great achievement for the country. The IMGs engaged in both community and hospital setting will understand the health problems in real context, will develop the essential attitude and communication skill needed for a family practitioner, might choose the career options in rural setting. Success of FAP will depend on intersectoral collaboration, logistics, support system & motivation of faculties & students. The colleges or state will have to provide necessary support, otherwise sustainability will be a great question.