District Residency Program: Exploration of the Perceptions of Postgraduates -A Way Ahead

Introduction

National Medical Council (NMC) announced the District Residency Program in 2020, which has been incorporated into Post Graduate Medical Education Regulations 2000 (PGMER-2000).¹ Students from the 2021 batch onwards are required to undergo this posting for three months before qualifying for the postgraduate examinations.² This program is mandatory for all students studying in government, private medical colleges, and deemed universities.¹ The students are posted to the District health system or Community outreach healthcare system, and this posting is usually scheduled in the 3rd/4th/5th semester of the postgraduate course.¹ The posted residents are called “District Residents”.²

The objectives of introducing DRP were as follows:

1. To facilitate learning closer to the community-based settings and focusing learning specific to the needs of the community.

2. To acquaint residents with the planning, implementation, monitoring, and assessment of outcomes of the National Health Program at the district level.

3. To orient them toward curative, preventive, promotive, and rehabilitative services provided by various healthcare professionals within the public healthcare delivery system.³

These postings will address the shortage of human resources, both at primary and secondary levels. District healthcare system delivery in India comprises district and taluk hospitals, providing healthcare services to the rural population. They provide secondary care services in our three-tier healthcare delivery system. These centres also act as referral units for specialized services not available in primary health centres and sub-centres. NMC directed the state governments to implement these postings.¹

It has been two years since the DRP posting was implemented for students. It is essential to evaluate this program now, as it will serve as a guideline for policymakers to make necessary changes. The main objectives of the present study were to assess perceived benefits, barriers, hardships, and challenges faced by the residents during DRP, to understand the limitations and take necessary measures for sustainable recommendations, and to assess whether the DRP will bring the required changes in healthcare services and health disparities. Additionally, this study also assessed the satisfaction with training and challenges faced by postgraduate residents during DRP.

Materials and Methods

The present study was conducted among the second- and third-year postgraduate students who completed their DRP postings at MVJ Medical and Research Centre, Hoskote, Bengaluru, Karnataka. It was a cross-sectional, questionnaire-based study. Before the commencement of the study, approval was taken from the institution’s ethical committee. An informed consent was obtained from each of the individual participants. Using purposive sampling, 57 postgraduate students were included as the study population. The data were collected through personal interviews using a pre-tested, semi-structured, paper-based questionnaire in the English language. This questionnaire was formed using the DRP guidelines by NMC and the guidelines given by the state health authorities, and also the available reports introduced by National Medical Council, India, and Post Graduate Medical Education and Regulations 2000, India, and validated by the experts in the institution.

The questionnaire comprised of following sections: - Section 1 involved details of the students, their specialization, and the details of their three three-month postings, while Section 2 included questions related to events during district residency postings, such as the satisfaction with training received, satisfaction with online academic learning during the three months, satisfaction with the basic amenities in the primary and secondary centres, specialty-focused skill training during DRP, and safety and security at DRP site, so as to assess the effectiveness and limitations. The total number of questions was 31, including 14 “YES” or “NO” type questions, five Likert scale questions ranging from “Strongly agree” to “Strongly disagree,” and 12 open-ended questions. The collected data were entered in Microsoft Excel and analyzed using SPSS for Windows to fulfill the objectives of the study.

Results

The study population included 57 postgraduate students, out of which 45 (78.9%) were from the 2021 batch and the remaining 12 were from the batch of 2022. Female postgraduate students were 32 (56%), and the remaining were males (44%). Table 1 shows the distribution of the study population as per specialization.

The District Health and Family Services, Bangalore Rural, is authorized to issue posting orders for postgraduates under the DRP. Out of the three-month duration, postgraduates are assigned for one month in Namma Clinic/Ayushmathi Clinic, which provides curative services to the rural poor based on the concept of Health and Wellness Centers. For the remaining two months, students are posted at a Primary Health Center (PHC)/ Community Health Center (CHC) or Taluka hospital in Bangalore rural district, based on their specialization and the requirements of the state health system.

In the study, 58.9% of postgraduates were posted in the District Government Hospital/Taluka Hospital. The remaining students were posted in CHC and PHC situated in Bangalore Rural district. Almost all the residents were aware of the objectives of the DRP framed by NMC (98%). Among the study population, 59.6% of residents opined that the objectives were partially achieved. Within three months duration, 41.1% of residents posted in the CHC/PHC expressed that they were working as medical officers and were attending general cases other than their specialty. Out of 57 residents, only 6 (10.5%) residents attended more than 80 patients per day.

All the residents were allowed to participate in the implementation of various National health programs in their area; however, only 63.2% of residents opined that the national programs they participated in were relevant to their subject of specialization.

Only 38% of residents remained motivated throughout the DRP postings, as most felt they were losing a significant amount of their second-year learning time to attend cases outside their specialty. About 48% of the residents also expressed dissatisfaction with the training and supervision received at the peripheral centers. There was inadequate support and supervision from government doctors for delivering clinical services. The residents also expressed that healthcare delivery and training during these three-month postings often went unsupervised. Their supervisors (Medical Officers) were frequently absent, occupied with meetings, or were present only for a short duration (6.1%). One resident also mentioned the difficult and authoritative attitude of the authorities, which created a barrier to approaching them. About 86% of residents expressed that their specialty-focused skill training was hampered during this posting. Only 51% were assigned to district hospitals in their respective specialties and were able to acquire the necessary skills.

About 72% of residents applied the skills they acquired during their postgraduate training. Additionally, 70.2% of residents from various medical specialty branches stated that they had the opportunity to treat both common and rare diseases.

Self-assessment of learning outcomes was done, and the graphical representation of the same is depicted below (Figure 1). Most of the residents expressed that the DRP postings in rural areas like PHC/CHC helped them improve their communication, decision-making, and managerial skills.

All the residents included in the current study did not receive reasonable and safe accommodation. Residents had to commute daily for approximately 40-50 km to reach the PCH/CHC. Many also faced difficulties due to a lack of frequent and direct public transportation to their assigned postings. About 48% reported that the place of their posting did not have any hotels or eateries providing clean and hygienic food. The sanitation facilities were also not clean and safe, especially for female residents. Female postgraduate students were particularly dissatisfied, as sanitation facilities were often unavailable for them. Additionally, they were concerned about safety compared to their male counterparts (P <0.05). About 79.1% of residents reported having been worried about their security and safety at least on, at least on, a few occasions. Around 78.1% of residents felt that there should be a committee or redressal body to address their grievances and take immediate measures. The study revealed that the most common security issue faced by students was ‘verbal or written abuse/threats from patients or their caregivers (46.5%), followed by interference from political representatives in rural areas. Though concerns existed regarding security and safety, 91% of the residents did not encounter any serious adverse safety events. About 85% of the residents reported difficulties in communicating due to language and cultural barriers, while 86% of residents felt that limited resources in the PHC/CHC restricted their ability to deliver optimal healthcare.

When asked for recommendations through an anony-mous feedback form, (32.1%) of residents felt that the three-month duration of the District Residency Program was too long and should be shortened. Some of the postgraduate students (3.1%) wanted the DRP postings to be shifted to the beginning of the third year. They also felt that with a short period, the positive objectives and the outcomes envisioned by NMC are attainable. Most of the residents made recommendations about the transport and accommodation facilities (24.5%) and also about the provision of specialty-focused training (12.3%).

Discussion

The District Residency Program was implemented to improve healthcare access and quality within the district. It was also launched with the goal of exposing postgraduate students to the district healthcare delivery system and providing them with a learning experience in delivering healthcare services close to the community, ultimately reaching underserved populations.^1,4 NMC, through its various guidelines, mandates that the teaching and training received during these three months of posting shall be closely monitored, supervised and documented by well-designed logbooks covering all the components, supportive supervision, and continuous assessment of skill and knowledge.^1,2 NMC has set a goal for postgraduate medical education in India to develop competent specialists. At the end of the course, the doctor should exhibit sufficient skills and obtain enough knowledge in the concerned specialization.^1,4 NMC endorses that postgraduate students should be able to work as specialty doctors with district healthcare teams during these three months and that they should be posted with the concerned/aligned specialty team/ services at the district / taluka hospital while serving in rural areas.^1,2

The data from 57 postgraduates were collected and analyzed in the current study. The results indicate that most of the residents were posted in Taluk Hospital, Hoskote (59%), while others were posted in different PHC/CHC’s. All the residents were aware of DRP objectives, likely because they were briefed before the commencement of their postings and were advised on certain dos and don’ts. 96.5% of residents spent two months in a PHC/CHC. Residents believed that the DRP improved healthcare quality, with 51% serving in their respective specialties. The skills learned were put to use independently, and it helped provide good health care, which was previously unavailable at the primary health care level. Residents reported improved communication (54.4%) and decision-making skills (45.6%). About 70.2% of residents participated in the implementation of the National Health Program, but only 63.2% were assigned relevant to their specialization. Many residents also opined that learning about various national programs and schemes could be beneficial in assisting lower economic strata patients later in their careers. Collaboration among residents and health bodies was good as expressed by 53% of the participants. The majority of residents (77%) considered their posting duration as optimal, but the number of patients they attended varied, with most residents treating 20-40 patients per day (36.8%). Residents gained hands-on experience while serving the community by applying their knowledge and skills. They enhanced their abilities by responding to emergencies, performing minor surgeries, managing labor and deliveries, vaccinating children, and providing OPD services.

The majority of residents did not receive mentorship and support during DRP from their parent institute, resulting in a negative impact causing stress during emergencies and a lack of learning outcomes. The other major challenges included transport (80.7%), accommodation (59.6%), security (33.3%), and others such as food (29.3%). A certain degree of dissatisfaction and teething problems are expected in the early years of any initiative, and these challenges should be addressed on a priority basis to achieve the desired goals and outcomes. Additionally, in our study, surgical branches reported higher dissatisfaction with training compared to other specialties. This may be due to the lack of surgical training opportunities, as well as inadequate support and facilities at the centres. These findings align with the intuitive notion that NMC’s ambitious initiative would meet learning outcomes and hence can be a motivating factor for medical speciality branches compared to surgical branches, given the greater opportunity for unrestricted clinical exposure.

However, this study found that all the postgraduates did not receive specialty-related work exposure and learning skills in this three-month posting, especially during their one-month posting at Namma clinics. Over half of the residents were never posted with their concerned/aligned specialty team/services due to the unavailability at the centre, while more than three-fourths never had the opportunity to learn skills relevant to their specialization. A report from Tamil Nadu reaffirmed that resident doctors opposed the DRP postings, as they believed that by the second year, students lacked adequate exposure and the necessary skills. The other major concern expressed by the students was that three months is a long duration for them to be missing out on learning for the acquisition of required skills in their parent institution.

The present study highlighted the grave concern of security and safety of the students, especially female residents working independently at primary health centres. All the female postgraduate students and their families were apprehensive about their safety. These findings aligned with the reports from Maharashtra, Andhra Pradesh, Telangana, and Madhya Pradesh that identified similar concerns faced by residents during DRP.⁵ These concerns are significant as the three-month posting is a residential training program conducted away from the safe confines of the residents’ parent institution, placing them in unfamiliar surroundings with limited support. Any adverse event faced by residents during their postings could jeopardize the goals and objectives set by the NMC, as it may severely demoralize them and discourage them from providing healthcare services at primary and secondary healthcare centres.

The authorities responsible for assigning postings at the state government level should consider the concerns of the residents and provide solutions. However, the present study found that they have not been addressed optimally. Almost all the residents opined that they had no access to decent and safe accommodation, clean and hygienic food, and clean and safe sanitation facilities. Female postgraduates particularly had concerns regarding clean and safe sanitation facilities. This issue poses a challenge for the authorities in finding and implementing appropriate solutions . 5 NMC has assigned the responsibility to the state governments to provide appropriate amenities, including suitable accommodation and security, especially for female residents.³ Stakeholders implementing the program at the state level should immediately seek corrective measures and address the issues on basic amenities and security to avoid any untoward incidents in any part of the country.

Limitation

The small study sample limits its generalizability. Additionally, as a cross-sectional study, it does not allow for hypothesis generation. As it was conducted at a specific rural center, it may not represent the diversity and various experiences of different locations. The perception of mentorship from the parent institution is subjective and may be interpreted differently by individuals. This is the first study of its kind to explore the perceptions and challenges faced by postgraduates, and its strength lies in its novelty.

Conclusion

The District Residency Programme (DRP) presents a solution for the critical shortage of medical professionals in the primary or community healthcare centers in a district. This study demonstrates that implementing the DRP not only enhances residents’ knowledge and skill, but also improves the quality of health in the district by addressing a wide range of diseases and providing specialty care at the primary level. The success of DRP depends on the collaborative efforts of residents and the health agencies in the district. As the most specialized residents are assigned, patients will receive the utmost care to ensure complete recovery. Additionally, these residents provide preventive and promotive care for diseases of public health importance, which significantly contribute to morbidity and mortality in the district. They do so by implementing National Health Programs, regardless of whether these programs align with their  specific specializations. The lack of expected treatment outcomes in a patient may be due to insufficient staffing, equipment, or other facilities. Mentorship and support from the senior residents, health officers, management, and faculty of the parent institute should be provided for better progression of the DRP. For the betterment of DRP, transport, accommodation, security and other facilities should be provided to the residents. Future evaluation, resource allocation, and community eng-agement are recommended to further optimize the program’s impact.

Future studies should consider conducting research with a larger, more diverse sample to enhance the external validity of findings. Feedback from logbooks must be taken for continuous improvement in DRP, incorporating insights from residents, supervising officers and healthcare administrators. Efforts should be made to address the challenges of insufficient resources, including staffing, equipment, and facilities in PHC/ CHC settings. Adequate resources are essential for residents to deliver healthcare services effectively and enhance their learning experiences.

Source of Support

None

Conflict of Interest

None

Acknowledgement

The authors would like to thank the Principal for giving permission to conduct the study. And also, the postgraduates who gave valuable feedback without whom the study would not be possible.