Update May 27th, 2015 – in Today’s news, an article about the Ministry of health and the difficulty faced in assigning young MBBS doctors to the quake zone. click here. I invite the government to learn more about my small project and what I have learned, that will help this problem. We have been working on a solution to this exact issue, since 2011.
Part two. There will be two more parts after this.
note: I am an outsider to the system, and I know that there will be people to say this is not accurate etc. Any reader who wishes to complain is welcome to submit a comment. If you can help me make this better, I appreciate. I would love to “cloud source” this to make it the best possible. If you are not comfortable with commenting due to sharing your name, send an email to firstname.lastname@example.org and I can incorporate your feedback anonymously.
This is the second part of wrapping up activities for CCNEPal in 2014-2015.
I am writing for an international audience, and I feel the need to take a detour in the report of activities. The medical education system in Nepal is not a one-to-one equivalent to USA. When I work with MBBS docs here, there are different needs than USA med students would have.
About the Medical Education system of Nepal
Here is the career path.
1) Go to school and pass SLC at the age of sixteen, then take two more years of science courses.
2) Enroll in Medical School as an undergraduate in Nepal. The degree is named “Medical Bachelor’s, Bachelors of Surgery ” – MBBS
MBBS is four years of school and one year of internship. during the school period, there are electives for various rotations. There is no specific critical care rotation, it is included in the rotation for anesthesia. Note: most other rotations are two months but anesthesia is usually about two weeks – about long enough to develop some practice managing an airway and performing endotracheal intubation. MBBS docs do not learn ecg in the format of an organized course- they are told to study that on their own. They typical MBBS graduate can not read an ecg rhythm strip.
3) On graduation from internship, the person is called a “Medical Officer.” If they do not have government loans, they are free to go anywhere. If they do have loans, they owe two years of service in a rural area to pay them back.
At some point after the two years, they can take a “Lok Sewa” exam ( civil service) and become a permanent government employee.
4) After a period of time, they can return to school for a “Master’s” – the post-graduate course- and become a Medical Doctor. Also known as a post-graduate doctor.
That’s the bare bones.
Government Policy Background
The government of Nepal has expanded the number of medical schools in the country over the past ten years or so, and now there are twenty. Click here for a nifty infographic. Prior to the earthquake there was a big scandal in the country because the government was planning to award permission to open four more schools, and there were nationwide protests led by Dr Govinda GK. At that time, the news coverage focused on government corruption in the health sector. (that’s why the Kathmandu Post generated the infographic above.) The pool of senior doctors in Nepal to run all these schools is stretched thin due to rapid expansion.
Because of the lead-in time, only recently have larger numbers of MBBS grads come out of the pipeline. In some cases, the schools are specifically saying they wish to produce people who are prepared to serve in the rural areas. The schools market the idea that they will help address the shortage of medical care in rural areas by setting up better-supervised placements in support of the recent MBBS grads doing this role. Read here for a description by a supporter of PAHS, one of the medical schools that markets this idea.
There are key points I have learned from interview with students about their perception of the education at this point in their development.
The undergraduate degree is science-based, focused on book learning and reading, and does not presently use simulation learning or case-based learning.
The MBBS undergrads are allowed to tag along on clinical rounds but are “junior” to everyone and in many cases, are not allowed to speak.
Senior vs. Junior is an issue
MBBS interns in many cases, have never written “doctor’s order” or collaborated with a nurse. They are not allowed to participate in emergency response. They generally have not taken a BLS course. They can not reliably interpret an ECG.They have never given a “verbal order.”
The MBBS grad has read about psychiatric counseling, but the curriculum does not include opportunities to personally apply the skills. Mental health is a very new field in Nepal, land of Saddhus.
Specific education for rural practice is not included.
In this article, the author makes a point to describe the educational needs of students before they go to the rural area.
There is no support from post-graduate doctors to the Medical Officers in the rural postings in most cases. There is no structured program of professional development.
The threat of physical violence from family members of patients is real. This last statement may be a shock to people who wish to believe that Nepalis are a kind, hospitable, loving family-oriented people. To say otherwise would hurt Nepal’s marketing as a tourist destination. And so – nobody talks about it. It is hidden from the tourists. The threats of violence, and the actual violence, is not something the average 22 year old geeky med student kid from Nepal is prepared to deal with.
There is presently a pent -up demand among MBBS Medical Officers to take USMLE and continue their studies in USA. The young docs have heard that the USA system is different and they want to see for themselves. Maybe they will return to Nepal; they all have an attachment to the culture here. But, Nepal is not immune from the “Brain Drain.” Click here for an article that describes a study about Nepali MBBS practicing abroad. The link is to a newspaper article describing a study published in the British Medical Journal. In that study, it gives the statistic that one-third of graduates in the sample from one medical school, are practicing abroad.