A Six-Star Community Medicine Specialist

In recent times, community medicine has probably been the most discussed ever in India, courtesy of the COVID-19 pandemic, which was formerly the least known subject among nonmedicos and possibly the most detested by many medicos. The subject started as Preventive and Social Medicine (PSM), which was recommended by the Health Survey and Development Committee, chaired by Sir Joseph Bhore in 1946.[1] They emphasized the training of undergraduate students in PSM alongside curative medicine. They also recommended an MD in PSM. Over the decades, the subject has undergone several name changes, for which it has faced much criticism. However, the name should only matter to a certain extent, so long as the essence of the subject is maintained. “What’s in a name? That which we call a rose By any other name would smell as sweet.” -William Shakespeare in Romeo and Juliet[2] Yet, it also confuses potential postgraduate students about what exactly community medicine entails, possibly because they have been taught the subject differently in their colleges. Moreover, when we introspect, most of us will agree that this is probably the only specialty with wide variations in how and what is imparted in the training of the MD students of community medicine all over the country. MD/MS students in other clinical subjects know exactly what they will do after their training. However, community medicine is so diverse that it changes according to region, state, type of institution, and even the personal inclination of those in command. Some uniformity can be found in the MD curricula of the National Medical Council (NMC) and the All India Institute of Medical Sciences, Delhi.[3,4] However, the entire curriculum is rarely adopted in its full form in any college. Universities and colleges often modify their curriculum based on their interpretation, priorities, feasibility, and local leadership. Despite these variations, postgraduate students in community medicine must receive training to become competent community physicians. Hence, what makes a competent community physician? The ideal candidate should be capable of delivering essential comprehensive primary health care to those in need, applying the principles of epidemiology and biostatistics for community diagnosis, making meaningful contributions to national health programs, conducting research with sound methodology and ethical integrity, and serving as a teacher for both students and health workers. All domains of learning must be given due importance and coverage. The cognitive domain should be sound enough to provide a strong foundation on which the skills will be based, whether it is diagnosing and treating a disease, critiquing research, evaluating a health program, or contributing to policy formulation. The affective domain should cover communication skills with patients, the community, and the health team and ethical conduct in all aspects, including service, education, and research. The psychomotor domain should include clinical skills and public health skills. Aspiring postgraduates in community medicine should have a clear understanding of the field, regardless of its variations. Efforts should be made to standardize teaching across the country, though the process is slow and challenging. Nonetheless, an MD in community medicine should be trained to be a six-star specialist. The six stars represent the roles they will assume based on their chosen path upon completing their training. Among all the stars, the one which is most contended, within the fraternity and beyond, is the role of a clinician. 1. Clinician at the primary care level: Even within the fraternity, the role of the community medicine specialist as a clinician is contested by some groups. However, one of the roles of the community physician is to be a physician to the sick and the needy. As a community physician, one cannot advocate health promotion and prevention when there is an immediate need for curative healthcare, and it was well elucidated in the Health Survey and Development Committee report.[1] NMC also lays out in the “Guidelines for Competency-based postgraduate training program for MD Community Medicine.”[3] The same is also found in the syllabus for MD community medicine of AIIMS Delhi[4] “Demonstrate clinical skills of preparing case history, examination, provisional diagnosis, treatment and clinical case management, and interpretation of laboratory findings.” “Conduct common procedures such as incision, drainage, dressings, and injections.” - MD Community Medicine, NMC “Able to apply the clinical skills to recognize and manage common health problems including their physical, emotional, social, and economic aspects at the individual and family levels.” “Able to manage and deal with medical emergencies at the community level” - MD Community Medicine, AIIMS Delhi 2. Public Health Expert: In most parts of the world, public health is separate from community medicine, which has a clinical component. However, in India, community medicine is an amalgamation of clinical medicine and public health. Therefore, a community medicine specialist should possess public health knowledge and skills to assess and solve population needs, including addressing the determinants of health, be it environmental, biological, nutritional, occupational, commercial, etc., They should have the management and administration skills to implement various national health programs, conduct surveillance activities, and evaluate the programs. They should be able to cater to the needs of different population groups such as maternal and child health, occupational groups, the differently abled, or the terminally ill. Whether it is as an in-charge of a primary or community health center, district or state official, program in-charge at the central level, or heading an international agency working in health, a community medicine specialist should be able to fulfill the role of a public health expert “To create a skilled cadre of medical professionals having expertise in application of principles of Public Health,…” - MD Community Medicine, NMC 3. Researcher: A community medicine specialist should use the knowledge of epidemiology and biostatistics to diagnose and solve health problems, from conducting an outbreak investigation to conducting clinical trials or implementation research to carrying out secondary data analysis. They should be able to judge the quality of evidence and generate high-quality evidence. All research should be conducted with the utmost ethical standards. Whether they work in a teaching institute, research institute, private sector, or developmental sector, research is a vital component of community medicine 4. Academician: Teaching and training are integral parts of every specialist subject, and if one chooses to be a Community Medicine faculty, most of the teaching will be done in a medical college or institute and its peripheral centers. This requires that they gain expertise to become effective teachers. Innovation is encouraged in teaching–learning methodologies as well as assessment. However, teaching and training skills are part of all aspects of healthcare education and management. It will entail teaching, training, supervision, and assessment of different categories of health workers, too. Health education, which is a crucial function, also utilizes principles of andragogy “Able to act as a good teacher/facilitator” - Syllabus for MD Community Medicine, AIIMS Delhi 5. Contribute to Health Policy: While no postgraduate will instantly become a policymaker, they should acquire the knowledge and skills necessary to understand policy formulation, navigate the process, and effectively influence policies. Many will enter the government and developmental agencies, such as the Bill and Milinda Gates Foundation, Welcome Trust, WHO, UNICEF, DST, DBT, and ICMR, gaining early opportunities to contribute to policy formulation or influence its direction. They should be equipped with the essentials of policy determinants, including health economics. The policy component is not dealt with much in the curricula now, and in some places, it is included under public health. However, policy is too important to be mentioned fleetingly. Whether it is health policy, population, nutrition, or any other policy, the MD community medicine students should be equipped to contribute significantly 6. Be the Team Leader: Doctors are leaders of the health team, which is taught even to the undergraduate medical students, so they have the correct perspective and can ably lead the team. A community medicine specialist has a much greater need for leadership skills than other specialists. They interact with a wider repertoire of healthcare professionals, from the grassroot-level workers to national or international professionals. They should be able to lead, inspire, and motivate the team members. They need to exhibit qualities that make good leaders, such as possessing ethical standards, integrity, empathy, compassion, being up-to-date with the latest developments like artificial intelligence, and effective health advocacy skills. They should take responsibility for their actions and be visionary for the team. The skills of health advocacy will be essential at all levels. Collaboration with different stakeholders would be needed to bring about the desired changes in population health. “Be an effective team leader.” - Syllabus for MD Community Medicine, AIIMS Delhi. In community medicine, to fulfill these six key roles – we refer to as the “6-stars” – will require comprehensive training and competency development across all areas. The extent to which each role is applied and enhanced will depend on their chosen career path, shaping the progression and refinement of their expertise. As the world rapidly changes and witnesses the epidemiological transition, their role becomes all the more important as the COVID-19 pandemic has shown. The risk of emerging and reemerging diseases, climatic changes affecting health, international travel, and the burgeoning mental health burden should make the community medicine specialist more alert and innovative in their approaches. Strengthening public health systems is an essential role they will play in achieving universal health coverage and ensuring equitable, sustainable health outcomes for all. Efforts should be made to standardize the teaching of community medicine nationwide, ensuring alignment with the six-star roles students will undertake. There are some institutions such as the Mahatma Gandhi Institute of Medical Sciences, Wardha, and the Christian Medical College, Vellore, that have a unique structure in their curricula.[5] It would be good to take from them and incorporate what is feasible. Training should extend beyond departmental instruction, with a strong emphasis on field-based learning in both rural and urban settings. The curriculum should incorporate daily clinical practice, active participation in national programs, placements in key public health initiatives such as the National Health Mission, and community-based research. Our goal should be to nurture postgraduate students who, after three years in the department, are not confused and equipped with the confidence and competence to fulfill all these roles successfully.