Are recent graduates enough prepared to perform obstetric skills in their rural and compulsory year? A study from Ecuador

Job Performance of Medical Graduates With Compulsory Services in Underserved Rural Areas in China: A Cohort Study

BACKGROUND

China started a national program in 2010 to train qualified general practitioners with compulsory services program (CSP) in rural and remote areas. While the program has shown positive effects on staffing primary healthcare (PHC) in rural areas, very little is known about how well they perform. This study aims to evaluate the job performance of medical graduates from this program and the influence of program design on job performance.

METHODS

A cohort study was conducted with graduates from CSP and non-CSP (NCSP) from four medical universities in central and western China. Baseline and three waves of follow-up surveys were conducted from 2015-2020. The pass rate of China National Medical Licensing Examinations (NMLE) and self-reported job performance were used as measurements. Multivariable regressions were used to identify factors affecting job performance.

RESULTS

2154 medical graduates were included, with 1586 CSP and 568 NCSP graduates. CSP (90.6%) and NCSP (87.5%) graduates showed no difference in passing the NMLE (P=.153). CSP graduates reported similar job performance with NCSP graduates (CSP, 63.7; NCSP, 64.2); in the multivariable regression, CSP graduates scored 0.32 and 1.36 points lower in the total sample and graduates of 2015-2017, respectively, but not significantly. Having formally funded positions improved the job performance of CSP (β coefficient=4.87, P<.05). After controlling for Qinghai which adopted a different contracting strategy, "working in hometown" showed significant influence on job performance (β coefficient = 1.48, P<.05).

CONCLUSION

CSP graduates have demonstrated as good job performance as NCSP, proving the competency to provide high-quality care for remote and rural areas. The contracted township health centers (THCs) should provide guidance for CSP graduates, especially in the first few years after graduation. The local government should provide formally funded positions on time and prioritize signing contracts with hometowns or places nearby.

Training and expertise in undertaking assisted vaginal delivery (AVD): a mixed methods systematic review of practitioners views and experiences

BACKGROUND

During childbirth, complications may arise which necessitate an expedited delivery of the fetus. One option is instrumental assistance (forceps or a vacuum-cup), which, if used with skill and sensitivity, can improve maternal/neonatal outcomes. This review aimed to understand the core competencies and expertise required for skilled use in AVD in conjunction with reviewing potential barriers and facilitators to gaining competency and expertise, from the point of view of maternity care practitioners, funders and policy makers.

METHODS

A mixed methods systematic review was undertaken in five databases. Inclusion criteria were primary studies reporting views, opinions, perspectives and experiences of the target group in relation to the expertise, training, behaviours and competencies required for optimal AVD, barriers and facilitators to achieving practitioner competencies, and to the implementation of appropriate training. Quality appraisal was carried out on included studies. A mixed-methods convergent synthesis was carried out, and the findings were subjected to GRADE-CERQual assessment of confidence.

RESULTS

31 papers, reporting on 27 studies and published 1985-2020 were included. Studies included qualitative designs (3), mixed methods (3), and quantitative surveys (21). The majority (23) were from high-income countries, two from upper-middle income countries, one from a lower-income country: one survey included 111 low-middle countries. Confidence in the 10 statements of findings was mostly low, with one exception (moderate confidence). The review found that AVD competency comprises of inter-related skill sets including non-technical skills (e.g. behaviours), general clinical skills; and specific technical skills associated with particular instrument use. We found that practitioners needed and welcomed additional specific training, where a combination of teaching methods were used, to gain skills and confidence in this field. Clinical mentorship, and observing others confidently using the full range of instruments, was also required, and valued, to develop competency and expertise in AVD. However, concerns regarding poor outcomes and litigation were also raised.

CONCLUSION

Access to specific AVD training, using a combination of teaching methods. Complements, but does not replace, close clinical mentorship from experts who are positive about AVD, and opportunities to practice emerging AVD skills with supportive supervision. Further research is required to ascertain effective modalities for wider training, education, and supportive supervision for optimal AVD use.

A Checklist for Implementing Rural Pathways to Train, Develop and Support Health Workers in Low and Middle-Income Countries

Background: There is an urgent need to scale up global action on rural workforce development. This World Health Organization-sponsored research aimed to develop a Rural Pathways Checklist. Its purpose was to guide the practical implementation of rural workforce training, development, and support strategies in low and middle-income countries (LMICs). It was intended for any LMICs, stakeholder, health worker, context, or health problem. Method: Multi-methods involved: (1) focus group concept testing; (2) a policy analysis; (3) a scoping review of LMIC literature; (4) consultation with a global Expert Reference Group and; (5) field-testing over an 18-month period. Results: The Checklist included eight actions for implementing rural pathways in LMICs: establishing community needs; policies and partners; exploring existing workers and scope; selecting health workers; education and training; working conditions for recruitment and retention; accreditation and recognition of workers; professional support/up-skilling and; monitoring and evaluation. For each action, a summary of LMICs-specific evidence and prompts was developed to stimulate reflection and learning. To support implementation, rural pathways exemplars from different WHO regions were also compiled. Field-testing showed the Checklist is fit for purpose to guide holistic planning and benchmarking of rural pathways, irrespective of LMICs, stakeholder, or health worker type. Conclusion: The Rural Pathways Checklist provides an agreed global conceptual framework for the practical implementation of "grow your own" strategies in LMICs. It can be applied to scale-up activity for rural workforce training and development in LMICs, where health workers are most limited and health needs are greatest.

A systematic review and meta-analysis of valued obstetric and gynecologic (OB/GYN) procedures in resource-poor areas

Background

Obstetric and gynecologic procedures are valuable in rural settings. Data identifying common procedures may better prepare surgeons to meet patient needs in remote settings.

Materials and methods

A literature review using key MeSH terms was performed according to methods described by the Cochrane Collaboration and PRISMA on studies that described obstetric and gynecologic surgery in rural high-income countries or any setting in middle- to low-income countries. Meta-analysis was performed using random effects modeling for odds ratios of cesarean delivery and hysterectomy as proportions of total surgical volume.

Results

A total of 195 studies were included for qualitative synthesis and 22 for quantitative analysis. Obstetric and gynecologic procedures made up a 19% of all surgical cases. As compared to other obstetric and gynecologic surgical procedures, cesarean delivery was the most common procedure with odds ratio of 2.39 (95% confidence interval 1.48–3.86), and hysterectomy was the second most common procedure with odds ratio of 1.60 (1.57–1.64). However, heterogeneity between the studies was extremely high and risk of bias was high, limiting quality of findings.

Conclusion

Greater provision of surgical care can be enhanced by defining which procedures are most needed, which include many obstetric and gynecologic procedures, most commonly cesarean delivery and hysterectomy.

Women's, partners' and healthcare providers' views and experiences of assisted vaginal birth: a systematic mixed methods review

BACKGROUND

When certain complications arise during the second stage of labour, assisted vaginal delivery (AVD), a vaginal birth with forceps or vacuum extractor, can effectively improve outcomes by ending prolonged labour or by ensuring rapid birth in response to maternal or fetal compromise. In recent decades, the use of AVD has decreased in many settings in favour of caesarean section (CS). This review aimed to improve understanding of experiences, barriers and facilitators for AVD use.

METHODS

Systematic searches of eight databases using predefined search terms to identify studies reporting views and experiences of maternity service users, their partners, health care providers, policymakers, and funders in relation to AVD. Relevant studies were assessed for methodological quality. Qualitative findings were synthesised using a meta-ethnographic approach. Confidence in review findings was assessed using GRADE CERQual. Findings from quantitative studies were synthesised narratively and assessed using an adaptation of CERQual. Qualitative and quantitative review findings were triangulated using a convergence coding matrix.

RESULTS

Forty-two studies (published 1985-2019) were included: six qualitative, one mixed-method and 35 quantitative. Thirty-five were from high-income countries, and seven from LMIC settings. Confidence in the findings was moderate or low. Spontaneous vaginal birth was most likely to be associated with positive short and long-term outcomes, and emergency CS least likely. Views and experiences of AVD tended to fall somewhere between these two extremes. Where indicated, AVD can be an effective, acceptable alternative to caesarean section. There was agreement or partial agreement across qualitative studies and surveys that the experience of AVD is impacted by the unexpected nature of events and, particularly in high-income settings, unmet expectations. Positive relationships, good communication, involvement in decision-making, and (believing in) the reason for intervention were important mediators of birth experience. Professional attitudes and skills (development) were simultaneously barriers and facilitators of AVD in quantitative studies.

CONCLUSIONS

Information, positive interaction and communication with providers and respectful care are facilitators for acceptance of AVD. Barriers include lack of training and skills for decision-making and use of instruments.

Umbilical catheterization training: Tissue hybrid versus synthetic trainer

BACKGROUND

This study of umbilical catheterization deliberate practice training compared skill and knowledge outcomes of umbilical catheterization using a tissue-hybrid simulator (REAL) versus a synthetic simulated umbilical cord task trainer (ART).

METHODS

This was a prospective randomized control study. Pediatric residents were randomized to REAL or ART umbilical catheterization deliberate practice training. Pre-post-training changes in skill performance and knowledge scores for REAL and ART groups were compared. Fidelity of REAL and ART were compared by neonatologists.

RESULTS

Twenty-seven pediatric residents completed training. Post-training mean skill scores were improved compared to pre-test scores (REAL, P < 0.001; ART, P < 0.0001). Post-training skill, knowledge, and self-efficacy scores were not different between the REAL and ART groups. Fidelity of REAL was higher than ART for neonatologists (P < 0.01).

CONCLUSIONS

The face validity of REAL was superior to ART, but resident umbilical cord deliberate practice training demonstrated no difference in skill, knowledge, and self-efficacy improvements between REAL and ART. Further studies on real patients are needed to evaluate the impact of using real or simulated umbilical cords for umbilical venous catheter/umbilical arterial catheter training.

Addressing the physicians' shortage in developing countries by accelerating and reforming the medical education: Is it possible?

INTRODUCTION

Doctors' shortage has remained a concern worldwide. The developed countries started aids to recruit international medical graduates (IMG) to cope with the defects that the health care system suffers from; however, this solution may not work in developing countries that have a limited resource and poor budget to spend on the health care system. This study aims to present an alternative way to approach the physicians' shortage by accelerating undergraduate medical education and reform some post-graduate courses in order to cope with this problem.

METHODS

The literature in PubMed/Medline and Google scholar were searched using such keywords as undergraduate medical education, physician shortage, health care reform, physicians' performance, medical curriculum.

RESULTS

The finding revealed that performance during undergraduate medical school does not have a relationship with the physician's performance post-graduation. Moreover, the overloaded curriculum and the years spent in undergraduate education have a negative impact on the students in terms of burn out, and lack of competency, and loss of motivation in medicine. The method of education was found to have a positive effect on preparing good students and ultimately good physicians.

CONCLUSION

Since performance in undergraduate years does not have an impact on the practice post-graduation, the developing countries may consider the option of changing the context, and abbreviating undergraduate medical education as a solution for physicians' shortage dilemma. Moreover, modifying some post-graduate majors such as family physician, and general practitioner to allow the physicians enter the practice in areas of need is recommended.

Programas de formacion en medicina familiar en iberoamerica

En el siglo XXI los sistemas de salud buscan fortalecer su estructura y funcionamiento enfocándose en la estrategia de Atención Primaria de Salud, para lo cual se necesitan recursos humanos de alta calidad. Para alinear los sistemas de salud sobre la base de los valores que guían esta estrategia hacen falta políticas ambiciosas en la formación de recursos humanos competentes y suficientes. La medicina familiar, como disciplina orientada hacia la atención curativa, integral y continua, hacia la promoción de la salud y prevención de enfermedades, así como hacia la prestación de servicios en los diferentes niveles de atención, es el eje que permite cumplir dicho fortalecimiento. El médico familiar, previo a su papel como especialista, pasa por un proceso de formación en la residencia. En Iberoamérica existen pocas residencias de Medicina Familiar, y muchos programas no acreditan la calidad necesaria para formar un recurso humano médico competitivo. La respuesta académica de las  instituciones en la mayoría de los países latinoamericanos ha sido muy diversa; y en algunos casos ha servido para cubrir la brecha entre la necesidad de personal y la oferta formativa, debido a la urgencia político-gubernamental. Esta revisión desea mostrar la actualidad de los programas de formación en Iberoamérica. Metodología: Se realizó una búsqueda bibliográfica en varias bibliotecas virtuales, así zomo literatura gris en páginas de sociedades científicas. Se recopilaron datos de líderes de opinión en la “V Cumbre Iberoamericana de Medicina Familiar” celebrada en Quito, Ecuador, en Abril de 2014. Resultados: Se obtuvieron los siguientes datos: Los tiempos en formación en Medicina Familiar en países Iberoamericanos varían entre 2 y 4 años; el 61% de los países (11 de 18) ofertan 3 años de formación, el 22,2% 4 años, y 11% 2 años (Cuba y Venezuela); en el 63,6% (7 de 11 países), el título de Medicina Familiar es obligatorio para la práctica. Conclusiones: En Iberoamérica, los programas de residencia en medicina familiar están dirigidos a corregir las deficiencias en la formación de los médicos generales y cerrar la brecha para satisfacer las necesidades de salud pública. Sin embargo, estos programas todavía carecen de muchos elementos de la formación en medicina familiar para alcanzar las competencias estandarizadas en todo el mundo. Por otra parte, si existen deficiencias en los programas de formación con las competencias y si sus necesidades no están basadas en normas internacionales, la formación resultante no produce los espe cos de alta calidad capaces de resolver el 80% de los problemas de salud que presentan los pacientes.