PSM as a Career Option: #3 What Do We Learn in MD PSM and Does It Help Later in Life?

Each year, around the time of AIPG counseling, I get a fair number of emails asking about PSM as a career option. These question are mostly from students who have not really considered PSM as a career option, and hence, do not have the information or evidence needed to take an informed call. I usually try my best to provide what I think is my evidence based opinion (yeah, that is an oxymoron right there!). This year, I received an exceptionally well worded email, articulating the questions in a very cogent and coherent manner, and I thought that I could use my responses to frame a series of blog posts that could function as a repository for such future queries (till such time as the content becomes outdated). In the subsequent posts, I shall try to make the case for, and against, joining PSM as a career option, based on the questions posed to me this time around. Hopefully these shall help clarify your doubts, and if not, feel free to write in to me.

This is the third in a series of ten posts. Read the previous posts here:

PSM as a Career Option: #1 Why Choose PSM?

PSM as a Career Option: #2 Is Delhi the Best Place for Doing MD in PSM?

Disclaimer: Please note that I am not liable for the outcomes of any decisions (whether positive or negative) that you have taken based on the information I provide in this blog. This is my studied opinion and for all practical purposes, they may be off base and totally wrong. Please do not judge everything I say here to be the ultimate truth. 

What does the PG course entail for 3 years? What will a PG student learn and how will he/she be benefited? 

AND 

Does one need to be good in math? No, seriously!

I have covered a fair bit of this query in the first post of this series, but basically, you would be expected to learn a mixed bag of things. From what I have seen, Delhi University seems to have a pretty comprehensive set of guidelines as far as the learning issues in PSM are concerned. The broad objectives of the training in MD (they call it Community Medicine here) are:

1. Lead team of health professionals for planning and managing community health problems effectively and proactively.
2. Study critically and manage existing health programmes of all levels (local state, national) and suggest alternatives for achieving desired goals.
3. Be proficient in human resource management along with materials (resources) and finance management for health schemes and health service implementation.
4. Have global perspective of health scenario and be capable of understanding cultural and societal specific health needs, its implications and its interventions.
5. Plan budget, execute and evaluate health problems of routine and emerging in nature.
6. Have strong analytical abilities, comprehension skills, creativity, lateral thinking and resourcefulness.
7. Administer functions of big hospitals (Size > 500 beds).
8. Function effectively as Industrial Health Officer.
9. Conduct and guide research in various disciplines of health sciences, health management, health systems research, and operational research.
10. Impart undergraduate curriculum of university in the subject in terms of knowledge and skills to medical, nursing and paramedical students.
11. Work as consultants / full time officer of national and international agencies (Govt. as well as Non Govt.) working in the field of health.
12. Identify and understand the changing health needs of ever-changing community and organize relevant effective interventions for amelioration of health problem.
13. Design need based teaching and training programmes / teaching materials for various categories of health professionals including its implementation and evaluation for the desired change in knowledge and skills.
14. Design need based health – teaching and training programmes / teaching materials for community at large for desired change in health practice.
15. Develop as a “Health – Philosopher.”

Whilst a lot of this is aspirational, and some, frankly speaking, sound a bit wishy washy to me, in reality, there are no structured course curriculum which matches the objectives with teaching-learning activities. This is probably true for all subjects in all medical postgraduate courses in India, so I guess I am being a little too critical here.

The skill set that an MD in Community Medicine should acquire over the three year residency period is also highlighted by the Delhi University. However, they do not identify how these goals shall be reached and lack the structured approach that has become the hallmark of graduate and postgraduate training of medical doctors in USA and other developed countries. The aspirational list of skills that a postgraduate student is expected to acquire include:

1. General Skills: The post graduate student should be able to: Elicit the clinicopsychosocial history to describe the agent, host and environmental factors that determine and influence health; Recognize and assist in management of common health problems of the community; Apply principles of epidemiology in carrying out epidemiological studies in the community; Work as a team member in rendering health care; and Carry out health education effectively for the community.
2. Laboratory and diagnostic skills: Water testing, Stool testing, identification of vectors and microbiological tests for proper diagnosis.
3. Communication Skills: able to communicate with the family, community, and government and non-government organizations; able to organize health education program in the community, generate community participation, etc.
4. Problem Solving skills: Communicable and Non-Communicable diseases (including social problems) at the family and community level.
5. Health care delivery skills: Skills required to deliver Reproductive and Child Health at the community level; a minimum of 5-10 families to followed for a year to study various family dynamics aiming at educating and improving the health of family members;
6. Epidemiological, Statistical and Analytical skills: Conduction of survey or study; analysis and interpretation of results.
7. Organizing and management skills: developing program for community participation; demonstration of Inter-sectoral coordination; Health Management: demonstration of logistic and resource management skills in health centers; Health Center Drug Indent Preparation; Guide and train workers (TBA, AWW, ASHA, Health workers, Health assistants, PHN) and Supervision of workers and programs.
8. Skills to be acquired to manage at primary health center, community health centers, and district level hospital. For that exposure to these centers and hospital required.
9. Teaching Skills: Teaching of medical, nursing, dental, paramedics, etc.

The DU also provides a list of broad themes that we should be studied as a part of the curriculum, and it pretty much reads like a list with the chapter titles from Park’s Textbook of Preventive and Social Medicine.

The principle is that at the MD level, the students should be self-motivated and indulge in a sustainable, self-learning environment. As such, the DU has even gone to the extent of scrapping the “subject wise allocation of question papers” for the final MD exams. The logic is that by structuring the question paper, the thought processes of the students will be compartmentalized into an artificially created, logically unsustainable, water-tight silos. While I understand the logic, I still feel that the curriculum should be structured, and a credits system should be in place to estimate what skills a student is expected to achieve, how they go about achieving them, and how their skills are evaluated. The position that an MD curriculum should be treated the way a doctoral training program (PhD program) is structured has led to the DU allocating less and less rigidity to the curricular process. This does create a congenial environment for motivated students to work and acquire skills that they want to hone, it may not work out very well for all, especially since the quality control checks and balances kept in place are really meager.

As it turns out, in such an environment, there is a wide spectrum of learning that students leverage out of the system. Whilst this unstructured approach may work for some, and they may study a lot and learn a lot on their own, many others, without a structure to guide their approach to life and studies, tend to meander off. In the clinical side of things, though there is an equally unstructured approach to education, there is a regimentation of work schedule and a consolidated list of “expected outcomes”, which provides the much needed structure. However, without a credits system in place, and without educational activities designed to fulfill the objectives spoken of in the aspirational goals the program intends to achieve, there is little concrete headway one can make in the subject.

On a personal note, I learnt a lot from my teachers, and yet, I had to actively study (and study a LOT) once I landed my new job in order to be able to catch up. So there is no way to say whether the training is going to be helpful or not as a lot of it is left unsaid and depends on the individual. It also depends on what kind of job you eventually do. For example, my work, which is a lot of research work, including policy and systems study, required a lot of skills which were only rudimentary in course of my MD training, despite being a motivated student studying under some of the best teachers of the subject. A lot of people tend to go into implementation research, or even program implementation (think WHO jobs, especially those in the National Polio Surveillance Program), for which most programs do not equip us well enough. However, most of us tend to learn on the job and acquire the necessary skills. Most MD programs are geared towards the making of medical teachers, and have little lateral training.

Coming to the bit about Mathematics, I share the trepidation for the subject as do many other of my fellow mates! Although there is a strong component of biostatistics and you can never get anywhere in research without understanding the basics of statistics, it is more in the realm of understanding and applying tools rather than in the mode of doing calculations. I do a fair bit of statistics for my research, and though I needed to study basic statistics in order to get underway, I ended up never having to “do” maths. Let me give an example: suppose we are doing a study to investigate whether a drug successfully lowers blood pressure or not. We give it to a group of people and measure their blood pressures before and after the administration of the drug. We need to know what statistical measures to use in order to prove our hypothesis and how to go about it. Once we know that, we can ask a software (typically used software include SPSS, EpiInfo, Stata, R, etc.) to do the heavy lifting for us. So, your knowledge of Maths has to be more functional than anything.

If you have any queries regarding picking up Preventive Medicine/Social and Preventive Medicine/Preventive and Social Medicine/Community Medicine as a career option, please consider dropping me an email or leaving a comment in the box below!