Clinical officer

Clinical officers (COs) are health care providers who practice modern medicine. They practice independently but may be supervised by a physician in some settings.

COs are key health care providers in many countries in Sub-Saharan Africa^[1][2][3] where they treat all diseases seen in general practice and refer those beyond their skills to physicians.

Training programs usually involve three or four years of undergraduate education, award of a diploma or a bachelors degree and completion of an internship year. COs take the Hippocratic oath and are registered by a statutory medical body to practice medicine.

Most curricula focus on topics relevant or applicable to clinical practice (actual patient care) and generally exclude non-clinical aspects of medical training. Their training is therefore shorter, requires less resources and, because of their high adaptability to local health systems, their qualifications may not be transferable to other countries - making them cost-effective clinicians who are easier to train and retain in their countries.

The general nature of their training prepares them to work at all levels of the health care system. Most work in primary care and casualty departments in hospitals where they diagnose and treat a wide range of common diseases in all age groups; and stabilise then admit, discharge or refer emergency cases. Those who specialise in a clinical field provide advanced medical and surgical care such as administering anaesthesia, performing general or specialised surgery as well as having significant administrative duties.

Their scope of practice depends on ones training and experience, jurisdiction and workplace policies. In Malawi, for instance, all COs are trained to perform routine surgical and obstetric operations such as laparatomy and Caesarean section but in Kenya, Tanzania and Mozambique they must undergo additional training before undertaking such responsibility.

In rural areas, where most Africans live, COs work with limited resources and must rely on their clinical skills and experience, often without much laboratory support, to make a reasonable diagnosis and provide treatment to mostly impoverished populations.

Those who work in urban centres generally have access to bigger and better equipped facilities, e.g., district, provincial and national hospitals, as well as universities and colleges, research institutions and private medical institutions. The United States' Centers for Disease Control and Prevention projects in Africa make extensive use of COs.

Improved access to HIV/AIDS prevention and treatment services on the continent is often attributed to use of COs to provide comprehensive care to patients in areas with few or no physicians.

Similar health workers are physician assistants in the US, Surgical Care Practitioners in the UK,^[4] Assistant Physicians in Saudi Arabia,^[5] Health Extension Officers in Papua New Guinea,^[6] surgical technologists in Mozambique, and clinical associates in South Africa.^[7]

Overview

Countries train and utilise COs in different ways. Tanzania, Malawi and Zambia train complete physician substitutes who have advanced skills in all medical and surgical specialties including performing major surgery - just like MDs - and the two are utilised interchangeably.

Elsewhere, COs are more medical-oriented (like in Kenya where physicians perform most major emergency surgery and COs can only perform major surgery within a specialty e.g. cataract surgery, orthopedics and reproductive health); or more surgical-oriented (like Surgical technologists in Mozambique who perform major and emergency surgery across specialties).

Some countries like Burkina Faso and Ghana retrain nurses to practice like COs. Unfortunately, such nurses have been associated with high rates of adverse patient outcomes. Ghana is currently shifting away from such.

Kenya

Kenya has trained COs since 1928 when she was a British colony. After independence the original certificate course was phased out and replaced with a three-year diploma in 1967. The Higher Diploma course in paediatrics, ophthalmology and other specialisations was introduced in the late 1970s and the Bachelor of Clinical Medicine and Community Health in 2006.

COs are trained by universities, the Kenya Medical Training College (KMTC),^[8] St. Mary's School of Clinical Medicine and other private institutions.

The Ministry of Health, through the Clinical Officers Council (COC),^[9] regulates their training and practice, accredits training institutions, and approves the syllabi of the universities and colleges. The Kenya Medical Training College, also under the Ministry of Health, has campuses all over the country and trains the majority of clinical officers. St. Mary's School of Clinical Medicine and St. Mary's Mission Hospital in Mumias, owned by the Roman Catholic diocese of Kakamega, was the first private institution to train COs in Kenya. Students sit the same examination as their counterparts at the KMTC and are examined by consultants from the public service.

The Clinical Officers (Training, Registration and Licensing) Act Cap 260

Clinical officers are legally recognised as qualified medical practitioners. They are required to see, examine and treat patients, sign legal documents such as medical certificates, death certificates and P3 legal forms, and to present medical evidence in a court of law, for instance, in cases of rape and assault.

The Clinical Officers (Training, Registration and Licensing) Act Cap 260 of 1989 of the laws of Kenya is the legal basis for the practice of Clinical Officers.^[10] It establishes the Clinical Officers Council whose functions are:

• To assess the qualifications of Clinical officers
• To ensure the maintenance and improvement of the standards of practice by clinical officers and to supervise the professional conduct and practice of clinical officers
• To register and license clinical officers for the purposes of this act
• To collaborate with other bodies such as the medical practitioners and dentists board, the central board of health, the nursing council of Kenya, the pharmacy and poisons board, in the furtherance of the functions of the council and those bodies; and
• To consider and deal with any matter pertaining to clinical officers including prescribing badges, insignia or uniforms to be worn by clinical officers.

Before this act there were many sub-cadres within the profession such as registered clinical officer (RCO), certified clinical officer (CCO), medical assistant, etc., who had different kinds and levels of education. All these were abolished by the act in 1989, in favour of a uniform Clinical Officer (CO) cadre. However the title RCO has persisted even in official publications.

Training

The first university to train clinical officers was Egerton University^[11] in 1999. Other universities followed suit and currently programs exist at Jomo Kenyatta University of Agriculture and Technology,^[12] Kenya Methodist University (KEMU)^[13] and Mt Kenya University.^[14] The diploma in Clinical Medicine and Surgery takes three years to complete on a trimester system. The Bachelor of Clinical Medicine and Community Health lasts four years and is offered as a direct entry, or a top-up degree for diploma holders.

The training follows the medical model. In the first year students learn human biology through in-depth lectures in Anatomy, Physiology, Biochemistry, Pathology etc. The second year involves intensive lectures in the clinical subjects i.e. Medicine, Surgery, Paediatrics, and Obstetrics and Gynecology. The last year concentrates on bedside lectures in a teaching hospital where they rotate in every department. They attend ward rounds, clerk patients and present medical histories, perform deliveries and act as first assistants in major surgery. They also attend clinical meetings and write prescriptions which at this stage must be counter-signed by a supervising clinician.

There is special emphasis on primary care with modules on community health taught throughout the course. In the third year students must spend at least one month in a Provincial Rural Health Training Centre where they immunise children, examine pregnant women and offer family planning services in mother and child health clinics. They treat in-patients and out-patients under the guidance of qualified Clinical officers. They also organise outreach services where they venture into remote rural villages, seeing patients and immunising children. During this time they complete a project in community diagnosis.

They also learn Health Service Management which prepares them for their management and leadership roles in health centres and other institutions.

Internship and registration

All clinical officers must work as full-time interns for one year at an approved public or mission hospital before getting a license to practice medicine. On passing the final qualifying examination, they take the hippocratic oath then apply for provisional registration by the Clinical Officers Council,^[9] the professional body representing clinical officers in the country. The internship involves three-month supervised rotations in the major clinical departments namely casualty, medicine, paediatrics, surgery, obstetrics and gynecology. They are supervised by consultants in the respective fields, who must grade their performance. Those whose performance is inadequate are given another three months to repeat the failed rotation.

Advancement

The Kenya Medical Training College offers post-basic courses to COs with three years experience. These last twelve to eighteen months leading to a specialised qualification in paediatrics, reproductive health, anaesthesia, ENT, ophthalmology and cataract surgery, orthopaedics skin and chest diseases, epidemiology, Community health or medical education. They are then able to provide advanced medical and surgical care including invasive procedures in their specialisation such as caeserian section, cataract surgery, tonsillectomy and administering anaesthesia.

Many COs hold advanced degrees and diplomas in Biochemistry, Microbiology, Counselling psychology, Management, Statistics, Sociology, Public Health, etc. A good number go on to medical school.

Famous clinical officers

• Karisa Maitha, the late former member of parliament for Kisauni and foreign affairs minister
• Ole Kiu, former Chief Clinical Officer, Ministry of Health
• Mohamed Abdi Haji Mohamed, Member of Parliament for Mandera West.

Uganda

In Uganda, the training is under the Ministry of Education and takes place in clinical officer training schools.^[15] Postsecondary programs last three years, focusing on medicine and hospice care, followed by a two-year internship.^[1]

Kampala International University offers a Bachelor of Clinical Medicine and Community Health.^[16] High school graduates take four-and-a-half years to complete this degree while practicing clinical officers take three years.

Tanzania

In Tanzania, training is under the Ministry of Health. There are numerous clinical officer training schools and programs last three years. Internship is not required for registration.^[1]

Experienced clinical officers may enrol for an advanced diploma in clinical medicine which takes two years to complete. This qualification is regarded as equivalent to a first degree in medicine by universities and the Ministry of Health in the country. The graduates are known as Assistant Medical Officers. A further two years training leads to a specialist qualification in anaesthesia, medicine, surgery and radiology etc.

Kampala International University has opened a campus in Dar-es-salaam where it is now offering it's Bachelor of Clinical Medicine and Community Health.

Sudan

Southern Sudan separated from the Arab North (Sudan) in July 2011 after years of civil war that left much of the southern part in ruins. The healthcare system is almost non-existent. AMREF started training clinical officers by setting up the Maridi National Health Training Institute.^[2]

The graduates supplement the efforts of COs trained in neighboring countries, e.g. Kenya, Uganda and Tanzania, most of who work for international humanitarian agencies.^{[citation needed]}

Ethiopia

The first medical school in Ethiopia was initially a “health officer” training institution. The training of health officers started at Gonder University in 1954 due to the shortage of physicians.^[3] Health officers hold bachelors degrees and undergo a three-year training program plus one-year internship. Those who complete the masters degree provide advanced care e.g. emergency surgery.^[1]

Zambia

Medical licentiates are qualified clinical officers who undergo advanced training in clinical medicine and surgery for two more years. They are awarded an advanced diploma in general medicine. They perform routine surgical and obstetric operations as well as providing expert clinical care in hospitals.^{[citation needed]}

Malawi

In Malawi, where physicians are in short supply and concentrated in the urban areas, clinical officers perform the vast majority of major surgical procedures in district and central hospitals.^[3] Clinical officers train for three years and undergo one year internship in order to be able to carry out all the routine functions of a doctor, including minor surgery, obstetric operations such as Caesarean sections, orthopedic care, dermatology and ophthalmology.^[1]

Medical assistants can enrol for an 18 month upgrading course to become specialised clinical officers; the upgrading course takes place at Malamulo and Malawi College of Health Sciences.^[17]

Mozambique

See also: Surgical technologist

In Mozambique, tecnicos de cirurgia, or surgical technologists, are experienced Clinical Officers who undergo further residential training in surgery under the supervision of senior surgeons lasting two years at Maputo Central Hospital, and a one-year internship at a provincial hospital. They are trained to carry out emergency surgery, obstetrics and traumatology and are deployed to the district hospitals where they are usually the sole surgical care providers.^[18]

Ghana

In Ghana, “Medical Assistants” (MAs) have traditionally been experienced nurses who have undergone a one-year post-basic course to become MAs. High school graduates can now attend a three-year diploma course to become MAs.^[19]

Burkina Faso

Many studies show that trained COs provide quality medical and surgical care with outcomes similar to physicians' providing similar care in the same setting. However, nurses re-trained to become COs are associated with more adverse outcomes as shown in a study done in Burkina Faso which associated them with higher maternal and neonatal mortality when they performed caeserian sections.^[20]

Liberia

In Liberia, the Tubman National Institute of Medical Arts (TNIMA) was established in 1945. In 1965, the physician assistant (PA) programme was established as a joint venture between the Liberian government, WHO and UNICEF. Initially it was a one-year course, but currently it is a three-year diploma course accredited by the Liberia National Physician Assistant Association (LINPAA) and the Liberia Medical and Dental Association Board. In order to legally practice medicine as a PA one must sit and pass a state exam administered by the medical board.^[21]

South Africa

See also: Clinical associates

South Africa trains clinical associates for three years and awards them the Bachelor of Clinical Medical Practice degree. The first program was launched by the late Health Minister Tshabalala Msimang on 18 August 2008 at the Walter Sisulu University in Mthatha. The first class graduated in December 2010.^[22] Programs also exist at the University of Pretoria and the University of the Witwatersrand.

International

United States

Main article: Physician assistant

Physician assistants in the United States train for at least two years at the postsecondary level and can hold an associate, bachelors or masters degree. Some institutions offer a Doctor of Science degree in the same. According to Money magazine, this is currently one of the best careers in the US.^[23] The profession is represented by the American Academy of Physician Assistants.

United Kingdom

The United Kingdom has in recent years employed physician assistants from the United States on a trial basis as it plans to introduce this cadre into their health care system.^{[citation needed]} Several universities are already offering a post-graduate diploma in Physician Assistant studies. However there are already other mid-level care providers known as Emergency Care Practitioners and Operating department practitioners.

Australia

The University of Queensland offers a one-and-a-half-year Master of Physician Assistant Studies to those with a bachelors degree. Those with a post-secondary healthcare qualification such as registered nurses and paramedics can access the programme via a Graduate Certificate in Physician Assistant Studies; as long as they have at least five years full-time working experience.^[24]

China

China has about 880,000 Rural Doctors and 110,000 assistant doctors who provide primary care to rural populations where they are also known as barefoot doctors. They typically have about one year of training; those who sit and pass government examinations qualify to be rural doctors. Those who fail become community health workers. However, there is a government move to have all rural doctors complete three years training.^{[citation needed]}

Fiji

Africa and the rest of the world are perhaps following a well trode path. In 1879, a group of Indians arrived in Fiji by ship having survived cholera and smallpox en route. During a period of crew quarantine, a small group was trained in vaccination. The experience was considered so successful that a few years later, in 1885, a group of young Fijian men started a three-year training program at the Suva Medical School, now known as the Fiji School of Medicine.^[25] The title given to the professional practice has had many names over the years, including Native Medical Practitioner, Assistant Medical Practitioner, Assistant Medical Officer, and Primary Care Practitioner (PCP). By 1987, the PCPs were training for three years before going back to their communities to serve one-year internship, followed by another two years of study after which they were awarded a MBBS degree.

India

In India, the Madras Medical Mission in Chennai, colloborating with Birla Institute of Technology and Frontier Lifeline has since 1992 offered a bachelor of science degree in Physician Assistant studies. The program duration is four years, comprising three years classroom and laboratory coursework then one year compulsory internship. Several other universities offer similar courses in patnership with US universities. PAs in India can pursue masters and doctor of science degrees.^[26][27][28]

As of 2009, the Indian government plans to introduce a three-and-a-half-year Bachelor of Rural Medicine and Surgery (BRMS) degree to train doctors who will work in remote Indian villages. On graduation they will undergo a one year internship period at a regional hospital before being licensed. Those with five years experience will qualify for post-graduate studies on equal standing with their MBBS counterparts.^[29]

Malaysia

Malaysia started training medical assistants in the early 1900s after independence from Britain. Also known as Assistant Medical Officers, they are trained for three years in an undergraduate academic program recognized by the Malaysian Qualifications Agency in order to practice. They are mainly deployed in public hospitals, parastatal institutions (e.g. military, prisons), rural health centres, aged care centres, or private specialist hospitals.^[30]

See also

• Allied health professions
• Healthcare in Kenya
• Assistant Medical Officers
• Surgical technologists
• Clinical associates in South Africa
• Feldsher in countries of the former Soviet Union

References

1. ^ ^{a b c d e} Mullan F, Frehywot S. Non-physician clinicians in 47 sub-Saharan African countries. Lancet; 2007, 370: 2158–63.
2. ^ ^{a b} AMREF. Clinical Officers. Accessed 6 April 2011.
3. ^ ^{a b c} Kruk ME et al. Human Resource and Funding Constraints for Essential Surgery in District Hospitals in Africa: A Retrospective Cross-Sectional Survey. PLoS Medicine; 2010 http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1000242
4. ^ [1]
5. ^ [2]
6. ^ [3]
7. ^ World Health Organization. Classifying health workers. Geneva, WHO, 2010.
8. ^ Kenya Medical Training College
9. ^ ^{a b} Kenya Clinical Officers Council
10. ^ Clinical Officers Council. The Clinical Officers (Training, Registration and Licensing) Act Cap 260. Accessed 6 April 2011.
11. ^ Egerton University, Kenya
12. ^ Jomo Kenyatta University of Agriculture and Technology, Kenya
13. ^ Kenya Methodist University
14. ^ Mt. Kenya University
15. ^ Health Training Institions in Uganda Information Portal. Accessed 6 April 2011.
16. ^ Kampala International University, Uganda
17. ^ Malawi College of Health Sciences
18. ^ Cumbi A et al. Major surgery delegation to mid-level health practitioners in Mozambique: health professionals' perceptions. Hum Resour Health; 2007, 5:27 http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2235883
19. ^ Narhbita College. The Medical Assistant Course.
20. ^ [4]
21. ^ Tubman National Institute of Medical Arts, Liberia
22. ^ Walter Sisulu University. First South African Clinical Associates take their pledge at WSU.
23. ^ CNNMoney.com. Best Jobs in America: #2. Physician Assistant
24. ^ University of Queensland, Australia
25. ^ Fiji School of Medicine. History. Accessed 6 April 2011.
26. ^ PRlog.org
27. ^ Bits-pilani.ac.in
28. ^ IAPAonline.org
29. ^ ABClive.in
30. ^ Management and Science University, Malaysia

External links

• Clinical officers - Ministry of Health, Kenya
• Kenya Medical Training College - Clinical Medicine Department
• Kilimanjaro Christian Medical College- Tanzania
• Egerton University (Kenya) - Diploma in Clinical Medicine and Surgery
• Kenya Methodist University - Department of Clinical Medicine
• Mt. Kenya University
• Malawi College of Health Sciences
• Maridi National Health Training Institute- Maridi
• Indian Association of Physician Assistants
• The Clinical Officers Council