When I’m not working for Nyaya, I spend my days working as a resident physician in Boston (United States). In the USA we attend medical school for 4 years, after a previous 4-year bachelor’s degree, and then complete our “residency training” in our specialty of choice – for example, general surgery, primary care, ophthalmology, etc. During our residency we are required to work under the supervision of an “attending physician,” or a more senior physician who has already completed his or her residency. Having just completed my first year of residency – the so-called “internship” – I can say that an attending physician is crucial to ensuring effective and appropriate care. We as interns are not yet qualified and even as we become more senior residents we still have much to learn; our “attending” accompany us to ensure that their experience informs both the care of our patients and our education.
In contrast to where I train in the USA, in many developing nations around the world, and especially in rural areas within
developing nations, young physicians such as myself often have no backup support. This week while working with our clinical team at Bayalpata Hospital, it was hard to not be cognizant of the fact that our physicians, and in some cases even our Medical Director, have more or less similar clinical training to what I have now, yet we normally have no attending-level physicians at Bayalpata. This is the case throughout most of rural Nepal, where physicians often work by themselves, without any senior-level oversight or support.
We’ve written elsewhere on this blog about the rural and impoverished area our team works in. Similar to the limited resources in the area, there is a dearth of senior physicians. Job postings in rural areas are extremely challenging due to limited resources and limited clinical capacity, and living in such environments is equally if not more challenging. As a result, the large majority of physicians working in rural areas are young and less-experienced physicians, as those with more experience typically choose to work in more urban and affluent areas. This is not only a challenge we face daily in Achham, but it is also a problem dealt with globally in both developed and developing countries.
This dynamic leads to many health facilities in rural and/or impoverished areas – whether they are smaller health posts or district-level hospitals such as Bayalpata – being overseen by junior-level clinicians early in their careers. This blog post by no means aims to criticize such physicians; indeed, they are the backbone of health systems the world around. Nonetheless, as managers of health facilities ourselves, a critical question for human resource development quickly becomes how best to help support junior-level staff.
First, I will say that from a personal perspective it is deeply impressive, while at the same time concerning and disappointing, that clinicians with only limited experience and training oversee so many health facilities world-wide. I, having just finished my internship and with the equivalent training of some of our doctors, do not feel appropriately qualified to oversee a district-level hospital, yet this is precisely how we operate Bayalpata, and how thousands of other facilities operate globally. In fact, for likely more than 5 or 6 billion of the world’s 7 billion people, seeing one of these junior doctors is the best they could reasonably hope for; in many cases, people around the world (and indeed, here in Achham) do not even have access to one of these physicians, much less a senior-level clinician with decades of experience or specialty training.
Secondly, from a managerial and systems-level perspective, my time here after finishing my first year of residency has underscored the critical importance of continuing medical education programs, or “CME.” CME programs exist globally to enhance the education of licensed clinicians. In many countries doctors, nurses, and allied health professionals are required to attend lectures, workshops, or courses to fulfill a certain amount of CME “credit” each year. This ensures that clinicians maintain knowledge gained in their training, while also continuing to gain new knowledge and current updates on what they have previously been taught.
In many health facilities globally, and in particular facilities in rural and impoverished regions, such CME programs are non-existent, given limited resources and small numbers of faculty, often including only junior-level clinicians. Unfortunately, it is precisely these facilities that stand to benefit the most from such programs – both for the clinicians, and for the patients they serve.
Currently at Bayalpata Hospital we employ two Bachelor of Medicine, Bachelor of Surgery (MBBS) physicians. One has ~1.5 years of experience following medical school, and as our Medical Director, oversees a clinical staff of 8 health assistants and 8 auxiliary nurse midwives. Our second physician started last week, immediately after graduating medical school.
To help support our clinicians as they care for upwards of 200 outpatients and 25 inpatients daily, we have developed several educational initiatives, including a morning teaching session, formal inpatient rounding twice daily, and additional weekly and biweekly lectures. Currently we are also privileged to have an attending-level doctor from the USA volunteering with us who helps to oversee these initiatives while also supporting clinical care on a daily basis. In the future we hope to maintain an attending-level physician as a volunteer to ensure continued CME and clinical quality oversight.
We are nonetheless not able to provide our clinical staff with the educational resources of a larger clinical facility, and are similarly unable to provide our patients with the experience and clinical acumen that comes only from clinicians who have worked for many years. It is humbling to imagine the challenges our clinical team faces, and a crisp reminder that we, as the next generation of global health implementers, must prioritize continued medical education for our clinical staff, to ensure both their own career development, and the best care possible for the patients we serve.
Ryan Schwarz, MD, MBA, is a former director of Nyaya Health and is currently on the Board of Directors. He is a resident physician in Harvard University’s Internal Medicine and Pediatrics Program and fellow in the Global Health Equity Residency Program at Brigham and Women’s Hospital and Children’s Hospital of Boston.