Investing in better trained doctors

Bangladesh has witnessed significant gains in the primary health care sector under the stewardship of the government and the non-government organisations since 1972. These achievements have been referred to as the 'Bangladesh miracle': strong health gains with relatively few funds. Our head of the government has received a number of prestigious awards on behalf of her government and the country over the last few years. 

While the primary health care sector has received extensive attention and significant funding, the secondary and tertiary health care sector has long been neglected resulting in stagnation and regression of the sector as a part of the global phenomenon. Bangladesh's entire health sector is experiencing a critical and chronic shortage of medical staff, an imbalanced skill mix and inequitable deployment of the health workforce in urban centres. This has resulted in a substantial loss of national income to neighbouring countries where many Bangladeshis go for treatment. In addition, according to a BRAC study, every year, up to eight million people become poorer because of the costs of health care.

Bangladesh, a country of 161 million people, only has 0.4 physicians per 1,000 people. By contrast, in India this figure is 0.7 for every 1,000, and in the UK, France and Italy 2.8, 3.4 and 4.1 per 1,000 respectively. So the first thing we need to do is double the number of doctors available in the country if we wish to have a ratio close to India and 10 times the figure to match the developed world. The number of doctors available no doubt raises concern but what is more disturbing is the pathway of producing good doctors in our country.

Patients need good doctors. Good doctors make the care of their patients their first priority: they are competent, armed with the required knowledge, skills and attributes, keep their knowledge and skills up to date, establish and maintain good relationships with patients and colleagues, are honest and trustworthy, and act with integrity and within the law. Good doctors work in partnership with patients and respect their rights to privacy and dignity.A good doctor must be competent in all aspects of his work, including management, research and teaching. They must take steps to monitor and improve the quality of their work in order to provide a good standard of practice and care, adequately assess the patient's conditions, taking account of their history (including the symptoms and psychological, social and cultural factors), their views and values. They must have the consent or other valid authority prior to and should perform where necessary, examination of the patient, promptly providing suitable advice, investigations or treatment and refer a patient to another practitioner when this serves the patient's best interest. In providing clinical care a good doctor must prescribe drugs or treatment only when they have adequate knowledge of the patient's health and are satisfied that the drugs or treatment serve the patient's needs based on the best available evidence. 

Ensuring provision of good doctors in a health care system requires a comprehensively structured training process. In any developed country no one is allowed to practice independently after simple graduation (MBBS) in medicine. Every medical graduate requires post-graduate training prior to shouldering any responsibility independently even of a single patient. By contrast in Bangladesh, any medical graduate is allowed to practice without supervision in a training post after MBBS and a year of internship.

Let's see how doctors are armed with required post-graduate education and training in the UK. It is a continuous process of acquiring competency that each and every medical graduate has to complete before he or she is allowed to see a patient without senior supervision. What we perceived in the past as FRCS, a Fellow of the Royal College of Surgeons in the UK for example, has been transformed to fit into this process of the post-graduate education and training for doctors wishing to practice as surgeons. The Fellowship award (FRCS) process, its interpretation, eligibility and assessment all have been redefined and has become an integral part of competency. Thus FRCS can no longer be awarded by individual Royal College of Surgeons in England, Scotland or Ireland. It is now an intercollegiate and specialty examination awarded by the Intercollegiate Specialty Board, a body representing all the Royal College of Surgeons of the UK.  The transformed FRCS (intercollegiate/general surgery) or FRCS (intercollegiate/ colorectal) or FRCS (intercollegiate/orthopaedics) and so on comprises of Foundation, Core and Specialist training stages with in-built curriculum as well as continuous, yearly examination based assessment and progression modules that take ten to twelve years to complete. Surgical trainee doctors may appear in the FRCS examination in the last two years of the 10 to 12 year programme and after completion of the training the Fellows are awarded the CCT, Certificate of Completion of Training allowing them registration with the General Medical Council as specialist in their field of expertise. This is representative of the requirement before medical graduates are allowed to practice as consultants in the hospitals. In general practice in the UK, medical graduates require Foundation and GP stages encompassing a minimum of five years of post-graduate training. Similar or different models of post-graduate education and training exist in the rest of Europe and the North Americas prior to being registered as GP or hospital specialist to practice without supervision.

In Bangladesh, on the contrary, there are post-graduate diplomas but no set structured curriculum based post-graduate education and training programme before medical graduates may be allowed to practice as specialists in the hospitals or as general practitioners in the community health setting. But sadly only about 10 percent of the total independently practicing medical graduates in Bangladesh possess some form of post-graduate diploma. In order to prevent human suffering Bangladesh needs urgent attention to and investment in its method of producing doctors capable of independently treating the patients either in the hospital or in a general practice setting. 

The writer is Consultant Colorectal Surgeon
Bart's and The Royal London Hospital
Whitechappel Road, London and President and CEO, RAHETID (RCS Assisted Hospital Education and Training Institute Dhaka).