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Provide primary care medical officers the assistance of senior doctors, consultants: Study

17 May 2021

By Ruwan Laknath Jayakody   Among healthcare service professionals, primary care medical officers (MOs) should be provided with the assistance of senior doctors and consultants, so that they may discuss the management and treatment choices of difficult clinical cases and also because this step will help prevent large numbers of cases being referred to tertiary and urban hospitals. Furthermore, it is essential that there be at least a small library which contains the latest editions of textbooks, handbooks, atlases, drug guidelines, and encyclopaedias, in each hospital and health facility, as such will help MOs learn new techniques and methods. These proposals were made by University of Colombo Postgraduate Institute of Medicine Senior Assistant Librarian M.P.P. Dilhani, former Open University of Sri Lanka Librarian W. Senevirathne, and University of Kelaniya Faculty of Medicine Public Health Department Head and Cadre Chair Senior Prof. C. Abeysena in an article titled “Accessibility of medical information by MOs attached to divisional hospitals in rural Sri Lanka” and published recently in the Journal of the University Librarians Association of Sri Lanka. Medical information concerns diagnosis, prognosis, treatment, and the prevention of diseases. MOs information needs are, as emphasised by Dilhani et al., higher in the context of clinical and educational work, within which they are supposed to achieve particular tasks such as decision-making and managing patients’ different health problems (they need to, among others, update their knowledge on the diagnosis of diseases for current treatment modalities and on the guidelines of management), teaching, or studying. “Some of the health problems are clear and easily managed; however, others are less clear. This lack of clarity is, for example, if they were not satisfied with their understanding of the problem or about what was involved in resolving the problem, or being unsure of the final result they were seeking. This situation would in turn lead to anxiety in MOs. They might think that they are aware of what to do and what results they are seeking, but might not be sure of the impact of their intervention/s. Such a psychological state has implications on their state of knowledge,” Dilhani et al., further elaborated. As noted by D.W. Bates, M. Cohen, L.L. Leape, J.M. Overhage, M.M. Shabot, and T. Sheridan in “Reducing the Frequency of Errors in Medicine Using Information Technology” (2001) and C. Friedman, G. Gatti, A. Elstein, T. Franz, G. Murphy, and F. Wolf in “Are clinicians correct when they believe they are correct? Implications for medical decision support” (2001), accessing new information in an up-to-date manner is essential for evidence-based clinical decision-making. And if information needs remain unanswered at the time of making medical decisions, the practitioner may not be able to perform the task in an authentic manner and consequently, there may be medical errors such as incorrect diagnosis, errors in administering treatment, or the failure to provide prophylactic treatment as noted by L.T. Kohn, J.M. Corrigan, and S. Molla in “Rapporteur's Report Session I: Origin of the problem: Malcolm Ross. Regulatory Toxicology and Pharmacology” (2008), which in turn as pointed out by R.B. Haynes, K.A. McKibbon, C.J. Walker, N. Ryan, D. Fitzgerald, and M.F. Ramsden in “Online Access to MEDLINE in Clinical Settings: A Study of Use and Usefulness” (1990), impacts the quality of treatment and outcomes in medical care. MOs who serve in the rural hospital settings are, as found by J.L. Amararachchi, C. Perera, and K. Pulasinghe in “Towards Knowledge Management for Health Care: Effects of the Latest Medical Information for the Quality of Health Care in Developing Countries” (2014), in a disadvantageous position when it comes to obtaining medical information required for their continued professional education. It was observed by Dilhani et al. that there is no proper information system or channel for MOs who work in rural areas to access formal medical information services to fulfil their information requirements. As explained by Dilhani et al., MOs who provide health services, especially patient care, to rural communities, require and need to acquire a range of high-quality and relevant medical health information to both serve and for their own professional and educational development, and therefore the providers of such information services should design services targeted for the medical profession. However, it is evident according to C. Dolea's “Increasing access to health workers in remote and rural areas through improved retention” (2009) that poor accessibility to medical information has a direct impact on the MOs who provide treatment in rural hospitals. According to the findings of “Achieving Quality Health Care through Knowledge Management Initiatives in Health Institutions in Rural and Remote Areas in Sri Lanka” (2012) by Amararachchi et al., due to geographic and infrastructure-related barriers and other barriers, rural MOs are at more of a disadvantage when compared to urban MOs, and as a result, they do not have access to information and therefore have unmet needs on clinical problems and the day-to-day medical practice. The study sample (chosen through randomly selected clusters – from Type C rural divisional hospitals and MOs attached to each such hospital representing regional directors of health services [RDHS] areas – generally, two MOs are attached to each such hospital) was 400 MOs attached to 289 Type-C rural divisional hospitals. A self-administered questionnaire was used. Of the 400 respondents, in terms of gender/sex, the majority were male (61.8%) and 38.3% were female, while age-wise, the majority (251 – 62.8%) were between the age group of 26 to 40 years, while 100 (25%) were between 41-50 years, 47 (11.8%) were between 51-60 years, and two (0.5%) were 61 and above. With regard to the courses they had followed, the vast majority (89.3%) had followed no courses while 5% had followed a postgraduate diploma, 4.5% had followed certificate courses, 1% had followed a master of science degree, and 1% had followed other courses. In relation to their work load, the majority (247 – 61.8%) had managed to see more than 75 patients per day while 98 (24.5%) managed between 50 and 75 patients per day, and 55 (13.8%) managed less than 50 daily consultations a day. Concerning their work experience, the majority had six to 10 years of work in rural Type C divisional hospitals. As noted by Dilhani et al., those who had more work experience were more likely to need information because of their involvement in the work of colleagues or with junior MOs. The types of medical information that were needed included patient records (the most important information that was needed), information on diseases, drugs, diagnosis, diet and nutrition, medical statistics, and medico legal, new findings related to medical research, on new medical equipment, and new medical guidelines. According to the study, the most common kinds of information that the majority of the MOs needed in patient care were general information about diagnosis (96.3%  – likely according to Dilhani et al., for education purposes), patient data (used to answer questions from the patients and their families), drugs, diet and nutrition, new medical guidelines, new medical equipment, medico legal information, and medical statistics. The purposes of using information was to be updated and to confirm opinions, for continuous medical education, to answer the questions of patients and families, for patient care, to write research papers and journal articles, and to respond to queries by colleagues. According to the opinion of Dilhani et al., the main purposes of using different kinds of information is to provide patient care and to be up to date; information needs which were therefore perceived as problem oriented. However, the study found that MOs hardly used medical information to write journal articles (0.8%), which Dilhani et al. opined, might be due to the lack of time. The sources used to seek medical information from included books (94.3%), professional newsletters and government publications (85%), journals (39.1%), and conference lectures and research papers (18.8%). Other sources of information used were technical reports (14.3%) and drug company presentations and representatives (13.3%). Books were used to keep up to date and to confirm opinions (32%), for patient care (42.8%), for education purposes (15.8%), to answer questions posed by patients and their families (6%), to answer the queries of colleagues (22.3%), and to write journal articles (3.5%). Government publications and professional newsletters were used to keep up to date (41.8%), to confirm the opinions (19.3%), for patient care (16.8%), for education purposes (37.5%), to answer questions put by patients and their families (4.5%), to answer the questions put forward by colleagues (41.3%), and to write journal articles (1.8%). Dilhani et al. noted that MOs tend to rely heavily on books compared to electronic sources. The channels used for medical information included hospital libraries and other medical libraries (medical faculties libraries used by 15 – 3.8%, and medical organisations libraries), the internet (312 – 78.1%), personal contacts with colleagues, specialists, and consultants in hospitals (199 – 49.8%), and visiting doctors and external experts, professional meetings including of local medical associations and congresses (79 – 19.8%), and the information systems of hospitals, mobile devices, and medical blogs (198 – 49.5%). The determining factors included availability, instant access, credibility, the ease of use, and the ability to search. A total of 45.5% of MOs indicated that they are satisfied with the information obtained from professional meetings while 34.8% were satisfied with the information services of medical blogs. The majority (345 – 86.3%) believed that it was easy to find out what they needed from colleagues, specialists, and consultants in the hospitals. As explained by Dilhani et al., MOs need to continually update their skills and knowledge, through processes of continuous learning and improvement subsequent to university education, and therefore, have to attend local and international meetings which serve as a source of general medical information to exchange ideas with colleagues, and take educational including postgraduate courses to stay updated on current medical practices. The significant problems and barriers encountered when searching for medical information included the lack of access to medical faculty libraries or academic health sciences library services (86.5%), the lack of time for reading, the lack of local information (79% – common problem – due to the unavailability of peer-reviewed medical journals for rural communities which address specific issues in rural areas such as snake bites, cases of self-poisoning, chronic kidney disease, waterborne diseases, and rabies), the lack of awareness about the available information (63.8% – common problem), geographic isolation (86.3%), the distance from specialist colleagues (92.3%), inadequate road and telecommunication infrastructure (55.8%), the lack of computer literacy (technological illiteracy), the lack of technological equipment, the cost to be incurred for the subscription to databases and articles, less opportunities being available for clinical practice (59%), the unreliability of information on the Internet (61.8%), software-related problems, the lack of a health information system (all respondent MOs agreed that it directly impacts the clinical decision-making process and administrative aspects), the lack of medical consultants in the hospital (all respondent MOs agreed that it directly impacts the clinical decision-making process and administrative aspects), and the irregular work hours of the hospital (86.5% – due in part to the heavy workload and the demands of a strenuous practice and the unavailability of medical information). The unavailability of a proper system for continuous professional development programmes for rural MOs is another issue. Dilhani et al. explained that the non-availability of library facilities in these hospitals can be considered as another barrier and that due to the scarcity of medical libraries in the hospitals, accessibility to books and journals is poor. “Also, due to the professional and geographical isolation, MOs are not certain as to where to go for the medical information they need,” Dilhani et al. noted. Therefore, as per the study, in building and improving the system for providing health information in rural hospitals, a health information management service supported by high-quality resources and advanced technologies, should be established. Towards achieving such, Dilhani et al. proposed certain strategies and solutions. These included establishing and implementing a clear strategy and plan showing the flow of the provision of information in rural and other related healthcare delivery systems including the information system infrastructure; implementing an information management system with orientation and training programmes; improving the information communication process and providing information and communications technology resources such as paging systems, mobile phones, high-quality and speedy telephone services, faxing, and electronic mail services along with fast access to the internet; improving the awareness of the availability of information services in the hospitals by putting up posters, organising orientation seminars and tour programmes; improving accessibility to online resources in all units and sub-units in the hospitals; and providing extensive, structured, and formally scheduled training by medical librarians in using and interacting with different systems of information provision, including on search strategy techniques, searching for information in online and electronic resources, and improving communication skills and time management.


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