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by Maria Sabastin Sagayam, Priya Gupta, Ram Ramesh, Angan Sengupta
BackgroundThe Indian healthcare system continues to remain unstructured leading to sub-optimal health outcomes, not just in rural but even in urban areas. While physicians play a crucial role in shaping treatment trajectories and managing the referral process, their perspective on the referral system has received very limited academic attention in India. This study attempts to understand the archetypical physician’s referral mechanism and the factors influencing their referral practices. This study also highlights the challenges and possible solutions in operationalising an efficient referral process as suggested by the professionals.
MethodsIn-depth qualitative interviews were conducted with sixty-two physicians consisting of both general physicians and specialists from 19 different disciplines, associated with public and private hospitals in Bengaluru, India. The data, thus collected, was subjected to thematic analysis to generate relevant themes.
ResultsFive themes emerged from the thematic analysis from a phenomenological perspective based on the physicians’ lived experience. First of all, specialist physicians’ availability, accessibility, experience, and reputation strongly influenced referral recommendations. It was also observed that due to lack of a comprehensive healthcare provider database, personal connections and professional networks are utilised. Moreover, although physicians prioritize patients’ affordability and accessibility factors, referral counselling and caregiver-patient communication remained inadequate and required formalization. While the fourth theme clusters around several barriers related to communication, system inefficiencies, lack of awareness, accessibility and affordability among patients; the final theme suggests that the physicians emphasized on urgent need for clear guidelines, regulations and policies to streamline and monitor the referral system.
ConclusionThis research highlights that physicians recognize the systemic gaps leading to unsolicited health outcomes; yet they are helpless in most cases. The participants emphasized that robust information systems connecting all relevant stakeholders are essential. The exploration reveals that the system will not adopt a structured referral method without the government taking interest in it.
The growing complexity of global health issues underscores the need for a skilled workforce, achievable through competency-based training (competency-based curricula, CBC) that integrates knowledge and practice. Starting from 2022, medical and nursing CBC were harmonised across universities in Tanzania to ensure all graduates attain nationally defined core competencies. The reform aligned programme structure, learning outcomes and assessment methods to promote consistency and interprofessional collaboration. However, questions remain about whether harmonisation alone can ensure the development of practical clinical competencies among students. This study explored the experiences of medical and nursing faculty and students in implementing clinical training as a component of CBC in two health training institutions in Tanzania.
An exploratory qualitative case study was conducted with 67 participants, using 8 in-depth interviews with administrators and 8 focus group discussions with faculty and students. Data were analysed using Braun and Clarke’s thematic approach.
Two private, faith-based medical universities in the United Republic of Tanzania.
The study purposefully recruited a total of 67 participants. The participants included university administrators (including Deputy Vice Chancellors for Academics, quality assurance officers and deans), medical and nursing faculty and students (fourth-year medical and third-year nursing students).
Two main themes emerged: challenges in implementing clinical training and strategies used to enforce clinical training. Key challenges included curriculum design gaps, inadequate faculty and clinical instructors, a large number of students and a shortage of hospital staff. Strategies used were utilisation of clinical skills and simulation laboratories, involvement of non-academic clinical specialists’ staff, use of student-centred learning methodologies and leveraging regional, district and specialised private hospitals for clinical teaching.
Despite notable challenges in clinical training, the institutions in this study have implemented proactive strategies to support clinical training. Based on the findings, stakeholders should invest in increasing faculty and clinical instructors and expanding clinical placements to regional, district and private hospitals.
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