Curriculum for Masters in General Practice – Bhutan

Edited by: Professor Lambert Schuwirth MD, PhD Professor of Medical Education. Director, Prideaux Centre for Research in Health Professions Education, Flinders University, Adelaide, South Australia. Foreword by: Professor Michael Kidd AM, FAHMS Executive Dean, and Matthew Flinders Distinguished Professor, Faculty of Medicine, Nursing and Health Sciences, Flinders University, Adelaide, South Australia. President World Organization of Family Doctors (WONCA) Table of ContentsTable: No title available.Foreword General practice, called family medicine in many countries, provides the opportunity to strengthen health systems, improve the quality and safety of primary health care, and support countries to move towards universal health coverage, ensuring that every person, every family, and every community, in every nation, has access to health care services delivered by well-trained primary health care providers. Many countries are rising to the challenge of developing strong systems of community-based medical care, and Bhutan is no exception. Bhutan, like many countries, faces the dual serious health challenges of both communicable and non-communicable diseases, along with the challenge of an increasing population of elderly people, often with multiple comorbidities and many needing home-based care. Bhutan also has the challenge of providing high quality accessible health services to those people based in rural areas. This curriculum will provide medical graduates with the knowledge, skills, and attitudes that they will need to be effective general practitioners. The curriculum includes not just the essential clinical and communication skills required to be a safe and competent general practitioner, but also sound understandings of community health, professional ethics, legal considerations, and the evolving use of new technologies in health care delivery. This curriculum is a major contribution to ensuring the future health and well-being of the people of Bhutan. I commend Dr Chhabi Lal Adhikari, on this achievement. This curriculum will assist future generations of medical graduates to train to become highly skilled general practitioners who are equipped to ensure excellent care provision to the individual patients and communities they will serve. Professor Michael Kidd AM FAHMS Executive Dean, and Matthew Flinders Distinguished Professor, Faculty of Medicine, Nursing and Health Sciences, Flinders University, Australia, and President World Organization of Family Doctors (WONCA) Background Bhutan is a small country in the Himalayas sandwiched between two giant nations, China in the north and India in the south, east and west. The country has a difficult and rugged terrain consisting mostly of steep and high mountains crisscrossed by a network of swift rivers, which form deep valleys before draining into the Indian plains.[1] The current population of Bhutan is 775,445 with general literacy rate of 63 percent (2012).[2] The provision of basic health services are state's affair as enshrined in the constitution, “The state shall provide free access to basic public health services in both modern and traditional medicines”.[3] The National Health Policy states that Royal Government of Bhutan shall continue to follow the Primary Health Care Approach with Primary Health Care Workers at the primary level, General Practitioners at the district level and specialized services at the regional and central level and it aspires to be congruent with the philosophy of Gross National Happiness and reflects various inputs ranging from social, cultural, spiritual and environmental aspects.[4] Rationale The country is heavily dependent on the regional countries for training of medical students due to unavailability of an undergraduate medical school in the country. The health service at medical officer's level in the district is mostly reliant on the junior MBBS doctors who are expected to deliver “too much too soon”. They become more competent as general practitioners in the districts as they receive short term in-service trainings and learn working with senior doctors. However, now due to a shift in policy and a change in working environment, medical officers can go for postgraduate trainings within two years. The service is continued by fresh junior doctors whose competencies are at a lower level. This has resulted in imbalance at the level and quality of service provided in different districts. The Royal Government, the Ministry of Health and the Medical University, have for long, known that the General Practice Training Programme at masters level would bring a difference in the way we deliver our health care services at the districts, and for that reason, the specialty has been recognized at the highest level, at par with any other masters in medical profession. The country already has a medical university with three academic programmes, the faculty of Nursing and Public Health, faculty of Traditional Medicine and faculty of Postgraduate Medicine. The medical university has been established with a vision to become a premier centre of excellence in medical education, research and quality health care. Its mission is to develop health human resources for the provision of sustained quality and patient centred care through innovative learner-centred, integrated and humanistic curricula and research activities.[5] Therefore, a well-designed curriculum based on the need of the country is crucial to start a Residency Programme in General Practice. Learners and learning environment The symbiotic relationship that exits in the context of Bhutan for training of General Practitioners is depicted in the following diagram (adopted from the work by[6] Worley et al. 2006). After completion of an internship, the undergraduate doctors are employed by the Government (Royal Civil Service Commission - RCSC) under the Ministry of health (MOH). When they qualify for the vocational training, this will be an “in-service training” funded by the government. The Medical University (KGUMSB) will run the training programme in association with the teaching hospital (Jigme Dorji Wangchuk National Referral Hospital – JDWNRH). The Ministry of Health, collaborating with RCSC, is responsible for deployment of doctors and other allied health professionals in the health centres throughout the country. The central referral hospital (JDWNRH) is a multispecialty hospital with General practice and emergency departments, where the training of GPs will take place. The postgraduate training in General Practice will be a time limited phase of training under supervision leading to recognized and competent General Practitioners.[7] The eligibility to sit the entrance examination requires candidates to have a recognized MBBS, to have completed the internship and to have at least one year of experience in working in a health centre. Once selected, they will undergo a supervised vocational training mainly in the Central Referral Hospital and other Referral and District hospitals. After 4 years of training, the successful resident will be awarded Masters in General Practice (MDGP) after completion of the University Examination.[8] The major residency training will take place at Jigme Dorji Wangchuk National Referral Hospital. This hospital has all the relevant departments including a department of General Practice. The residents will rotate through different departments during their four years training, but General Practice will be their home base for learning environment. This is important because of encoding specificity, which claims that practice in a certain context is better when the learning has taken place – at least partly – in a similar context. The well-known Godden and Baddeley[9] experiment in 1975 illustrated that the ability to activate knowledge from the long term memory and to make it available is influenced by contextual cues more strongly than originally assumed. So, availability of the same context at a future point in time facilitates retrieval of the information. The escalating costs of modern treatments in hospital, have led to a development in many countries where much of the care formerly provided in outpatient departments of hospital is now provided by primary care health professionals in the community.[10] So a rural-based curriculum provides opportunities to learn in these environments. 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