My Dominant Hemisphere

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Posts Tagged ‘Healthcare Policy

Calling For A Common Worldwide Medical Licensure Pathway

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Obstacles

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Medicine – Realm Of The Unknown

For ages, the medical sphere has been shrouded in mystery – for people outside of medicine that is. And this hasn’t been too good for the medical profession because many policy makers on matters of healthcare/medicine aren’t sufficiently acquainted with its many nuances to yield considered judgements. Sometimes you just can’t help get the feeling that doctors have a language of their own, with a community so tightly knit that it borders some sort of illuminati like cult.

Earlier, most of this mystery was limited to the knowledge base of medicine. Doctors were treated like gods walking on earth and people had no qualms whatsoever in having blind faith in them. With the rapid rise of web technologies however, doctors find themselves facing tough and pointed questions by their patients and policy makers about the decisions they make.

Some aspects, for the large part, still remain hidden away however. Stuff that affects policy decisions and how medical communities across the world interact with each other. Issues concerning licensure and taxonomy immediately come to mind.

An aspect of medicine that to this day, remains an enigma for many ‘outsiders’ is the entire academic hierarchy that applies to medical systems across the globe. Many ‘insiders’ end up at their wits ends too. The taxonomy is definitely confusing. What the heck is a Senior Registrar? Or for that matter, what in god’s name is the difference between house surgeons/officers, resident medical officers, civil surgeons, residents, interns, attendings, senior house officers and all that jargon? The world could definitely use a universal taxonomic architecture for medical systems akin to the WHO’s International Classification of Diseases (ICD) to streamline stuff and make interactions between communities easier.

Licensure – One Too Many Exams For A Globalised Age

When medical students step into the medical world, being relatively new ‘insiders’ at this stage, very few are cognizant of the fact that their careers depend on having to satisfy licensure requirements before even thinking about pursuing higher education. Getting through medical school is one step. After that, students are required to go through long winded licensure pathways before even beginning to gain higher training. Licensure serves as a quality control measure to ensure the safety of patients and is arguably, a necessary evil.

Modern society depends on the exchange of ideas and talent between countries. The same applies to medicine as well. Unfortunately, due to the myriads of medical licensure exams across different countries, this kind of exchange and collaboration can become extremely tedious and at times impractical. Getting into higher training for the international trainee becomes a daunting task. Take the following hypothetical scenario:-

Dr. Underdog went to medical school in a country bordering Angola and got his local medical license after graduating and passing local licensure exams. He now intends to gain higher training in colorectal surgery (… of all things :-) ) in the US. Before getting into a higher training program he needs an American license. He proceeds to sit for the United States Medical Licensure Exam (USMLE) and passes all 4 component exams in this process with flying colors. Good for him, Dr. Underdog’s thirst for knowledge is relentless. After gaining qualifications as a colorectal surgeon, he is now interested in learning a highly advanced and experimental procedure involving cosmic radiation and bizarre tumor polyps :-P , only available in Australia. He is now required to pass the Australian Medical Council licensure exams before he begins. He goes ahead with that and gains the skills he’s always dreamed about :-) . By now, Dr. Underdog has been through at least a dozen different licensure exams. The exams he gave in the US and Australia weren’t directly related to the subjects he studied at those places. Seeing great potential in this emerging pioneer, a group of people from a country near Chile invite Dr. Underdog over. They’d like him to impart some of the training he received to a couple of their fortunate students. Unfortunately, he needs to clear their local licensure exams before he can begin. He candidly goes through that as well. In this new land, Dr. Underdog meets a fellow international doc who’s been through twice the number of licensure exams as he has, to get to a position as senior faculty member while also dealing with some mind blowing research – literally involving blowing stuff :-P , partly as an outlet for his bottled up frustrations over licensure systems. … See how tedious it can get?

If I’m interested in gaining specialized skills and/or knowledge available in only certain parts of the world, I need to get straight down to business without having to worry about sitting for multiple licensure exams. Sitting for multiple licensure exams is not only wasteful of time and money, it is also redundant. Most of these exams test the same content anyway. Most importantly, as an aspiring international trainee, my focus has to be on the exams directly related to the training I intend to pursue rather than random licensure tests.

Solution? A universal licensure pathway ratified by an international body such as the WHO that should be acceptable to all countries.

At the moment, a few agencies such the Medical Council of Canada and the Australian Medical Council are conducting joint licensure tests. Their efforts in this direction are laudable and should be wholeheartedly welcomed. Hopefully other countries will follow suit and some day a universal licensure pathway will become a reality. Until then, international trainees can only follow in Dr. Underdog’s tortuous footsteps!

Readability grades for this post:

Kincaid: 10.0
ARI: 11.2
Coleman-Liau: 14.4
Flesch Index: 53.2/100
Fog Index: 13.1
Lix: 48.9 = school year 9
SMOG-Grading: 12.0

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Copyright © 2006 – 2008 Firas MR. All rights reserved.

Our Backyard

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Over 80% of healthcare privately owned. Roughly 13% of the populace insured. That’s incredible, India!
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Copyright © 2006 – 2008 Firas MR. All rights reserved.

Written by Firas MR

April 27, 2008 at 12:28 pm

Evidence Based Medicine in Developing Countries

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UPDATE 1: Check out multimedia from recent international meetings of the Cochrane Collaboration that have touched on this topic: here, here and here.

Have developing countries actually been active in EBM (Evidence Based Medicine)? This was a question that kept ringing in my head during a discussion I had with some of my buds recently. Speak to a Joe medic in any of the medical establishments in a country like India, and you can’t help feeling that developing countries for the most part have become consumers of research that cannot be applied to them. These medics are not only being taught but are also being tested on guidelines developed by a plethora of alien organizations such as NICE (National Institute of Clinical Excellence-UK), SIGNS (Scottish Intercollegiate Guidelines Network-UK), Cochrane (UK), ACP (American College of Physicians-US), CDC (Centers for Disease Control-US), NIH (National Institutes of Health-US) and many others in their curricula. Most of these guidelines have been produced for patient populations that are entirely foreign to them.

The only international body with a modicum of relevance to their lives and that of their patients and one which cuts across all geographical and cultural lines is the WHO (World Health Organization). Some might argue that such an enormous and overarching agency as the WHO is intrinsically incapable of producing practice guidelines that might be sufficiently context-centric to be of any use. The WHO sure has a lot of responsibility on its hands and it really is difficult to produce guidelines that apply to all geo-cultural contexts. Indeed, the WHO has produced only a handful of guidelines to date.

India and developing countries like it, desperately need indigenous agencies to construct and regulate guidelines that are appropriate to their peoples’ resources and needs. It is extremely common, for example, to see how guidelines by some agency are taken lightly solely because of resource constraints (transportation problems, lack of appropriate instruments, etc.). Actions that a clinician needs to make given these constraints, need to be backed by evidence. The whole idea of EBM is that actions need to be based on the ‘best available’ collective body of scientific evidence pertaining to a problem – pathological, economic, whatever. Doesn’t it make sense then, to look for ‘evidence’ backing a given course of action to our problems?

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We do have bodies like the ICMR (Indian Council of Medical Research) making progress, but honestly we aren’t doing enough. Over the course of my undergrad career, perhaps the only ICMR guidelines we came across were a handful of appendices at the back of a pediatrics textbook. I mean, come on! We can do better than that, right? The arguments linking this appalling void to decreased government funding are no doubt valid. Budgets allocated to healthcare are grossly below the minimum ‘5% of Gross Domestic Product’ standard set by the WHO and quite surprisingly have kept declining. Amidst this budget-strapping,  public healthcare establishments are overwhelmed by the demand for clinicians whose focus is on the manual delivery of healthcare services rather than research. In the ‘medical automobile’, these clinicians are just too busy being passengers in their back seats to care about driving. This unbalanced emphasis has had a profound impact on the very nature of our medical society. Its effects are visible right from the very beginning, as medical students enroll into institutes. Students are not even remotely exposed to the tenets underlying academic medicine and there is absolutely no mentorship mechanism in place at any level, all the way up to post-graduation and beyond. Departmental research is obscenely underfunded and students lack motivation to get involved in the absence of a nurturing environment. To make matters worse, owing to the abject lack of any academic medical component whatsoever in their curricula, students find it near impossible to take time out to engage in any form of academic activity at all. Even if they do manage it, their efforts often receive no curricular credit. Post-graduate students take the thesis requirement casually and often resort to a trial-and-error hodgepodge approach in the absence of necessary guidance. The situation finally spirals down to a vicious cycle where the blind lead the blind. End result: Institutes in chaos whose sole purpose is to produce en masse, semi-literate manual clinicians of low-innovative-potential who can’t even search or appraise medical literature, let alone use it properly.

Let’s just try to understand why this is the need of the hour. It not only paralyzes our education system but also our fragile economy. How does it degrade our economy? Well, without national guidelines there can’t be a just audit system in healthcare establishments. Without audits, resources are squandered and quality of care declines. When quality declines, the disease burden in a population rises and that in turn leads to an economic vicious cycle as national productivity declines.

How do we solve this?

  1. Government funding on healthcare ought to increase. Clearly, providing concessions and subsidies to private establishments hasn’t and most definitely isn’t going to produce results. Private establishments only care about making money – from the public or the government, and that’s all. Unless incentives are provided to them to engage in academic medicine or research, they aren’t going to bear the torch. In a developing country like India, the sheer demand for manual services forms a competing interest for these entities.
  2. Even if public funding is lacking, it might be possible to develop meaningful research. Some of the most groundbreaking research comes out of very small undertakings. It didn’t take a million dollars for us to realize the benefits of surgical asepsis.
  3. Hierarchical translational research bodies ought to be created – private or public or a possible mix of the two. Guidelines need to be produced and taught at medical schools. Students should no longer need to put up with the arbitrary whims of their superiors in the face of inapplicable guidelines in their textbooks.
  4. Audit systems should be enforced at all healthcare establishments. Students and practitioners should be taught how to audit their departments or practices.
  5. An academic component should be incorporated into the medical curriculum at all career grades – whether optional or otherwise. Mentorship mechanisms should be brought into place and could be incentive driven. Sources of funding and grants should be made more accessible and greater in number.

I hope readers have found this post interesting :-) . Do care to leave behind your comments.

Readability grades for this post:

Kincaid: 11.0
ARI: 12.2
Coleman-Liau: 14.7
Flesch Index: 49.1/100
Fog Index: 14.7
Lix: 50.3 = school year 9
SMOG-Grading: 13.0

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Copyright © 2006 – 2008 Firas MR. All rights reserved.

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