Enhancing the quality of clinical clerkships in a resource limited settings Medical School: Northern Tanzania

Chrispina Narcisa, Charles Muiruri, Ahaz T. Kulanga,Gibson Kapanda, Esther Lisasi, Lucy Mimano, John A. Bartlett
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Background: To reduce healthcare worker shortages in sub-Saharan Africa, medical schools have increased enrolment. However, this expansion has not been accompanied by adequate increases in faculty size or physical infrastructure. Consequently, classes are overcrowded, and may lead to reduction in the quality of training, especially during clinical clerkships. Aiming to expose medical students to rural working environments and reduce overcrowding at the main teaching hospital, in 2012 Kilimanjaro Christian Medical University College (KCMUCo) introduced a 12-week rural clerkship rotation.

Method: 19 hospitals operating in the northern zone of Tanzania were identified as potential sites, and Memoranda of Understanding (MoU) were drawn between 8 hospitals in Kilimanjaro and Arusha regions, District Medical Officers (DMOs) and KCMUCo. Minimum standards for providing clinical training in these hospitals were established. Preceptors in the peripheral hospitals were trained by KCMUCo faculty, and they were awarded adjunct faculty positions at KCMUCo. Acceptable minimum and maximum numbers of students rotating at the hospitals were established. Monitoring and evaluation was embedded in the intervention to support continuous quality improvement strategies. To assess effectiveness of program implementation after the first rotation in 2013, a paper-based questionnaire was anonymously administered to students after their peripheral clinical rotations in 2014. The questions addressed student satisfaction with their ability to apply knowledge and skills gained from previous training. Descriptive statistics, tests for significance (p<0.05) and strength of consensus measure (sCns ≥80%) were applied.

Results: Of 148 MD3 students, 111 (75%) responded to the survey; 62% male and 62% < 25 years. Overall student satisfaction was high with 19.4% very satisfied and 61.6% satisfied. All questions regarding student satisfaction had a high degree of consensus (81.9-83%) with the exception of accepting deployment at a peripheral hospital in the future (73%). Students felt that it was easier to practice clinical skills in a peripheral hospital (p=0.028), learned new clinical skills (p=0.028), and expressed the desire to return to practice clinical skills (p=0.004), Student-preceptor contact was rated highly by nearly 80% of students (sCns=79%). Students described limited laboratory support for clinical care, but only 39% attempted to utilize their own laboratory skills to address shortcomings. Students also expressed concern that access to learning resources was not adequate at the rural practice hospitals, and poor Internet access was identified as a challenge.

Conclusions: Overall student experiences in peripheral clerkship rotations were positive with high levels of student satisfaction. Student-preceptor contact was rated highly. Opportunities exists for medical schools in Sub Saharan Africa to enhance clinical training through the use of peripheral hospitals. From our experience careful implementation with elements of quality improvement and the inclusion of stakeholders is critical.