Clinical officer

Overview
In sub-saharan africa, Clinical officers are clinicians who are trained and licensed to provide primary healthcare services. In kenya they developed as a separate profession in the 1920s when kenya was still a british colony to provide healthcare services to the native population. Their training was thus focused on the diagnosis and management of local health problems which were mostly infectious diseases such as malaria and diarrhea. They also learned to diagnose the more serious cases and to refer them appropriately. They were mostly trained on the job in hospitals and had titles such as hospital assistant, medical assistant etc.

After kenya gained independence in 1963 their training was formalised and standardised, following a compressed medical model. In 1989 the Clinical officers (training registration and licensing) act was passed and hence the profession entrenched in the constitution. They were mandated to prepare legal documents eg medical certificates and fill P3 forms and to produce evidence in a court of law. The act abolished all previous titles and henceforth only the title Clinical officer was legally recognised.

However the term registered clinical officer (RCO), who were the crème of the profession, was in common use and has persisted to date, even in official documents. In other countries such as malawi, this cadre was introduced in the 80s as a temporary solution to the shortage of medical doctors. Contrary to the situation in kenya, Clinical officers are often the sole care providers for a whole district and are trained to take on the full functions of a medical doctor including emergency surgical procedures such as caeserian section and laparatomies.

Kenya
Training institutions:
 * 1. Kenya medical training colleges (15 colleges countrywide)
 * 2. St. Mary's school of clinical medicine, Mumias
 * 3. Egerton university, Nakuru
 * 4. Jomo kenyatta university of agriculture and technology, Nairobi
 * 5. Lake institute of tropical medicine, Kisumu
 * 6. Kenya methodist university, Meru
 * 7. Mt. Kenya university, Thika

The Clinical officers council under the ministry of health regulates the training and practice of clinical officers. It accredits training institutions and approves their syllabuses. Programmes last three years and are followed by one year internship in accredited hospitals before one is registered to practice as a qualified clinical officer. The training is rigorous and involves classroom instruction as well as bedside tutorials. The first year is dedicated to the basic sciences including nursing and clinical skills. Students learn to take a complete medical history and perform a thorough physical examination. They also spend some time in a medical laboratory where they learn to perform common laboratory tests such as gramstain and microscopy. In the second year the clinical subjects are introduced as they polish their history taking and physical examination skills. Much emphasis is placed on community health which is studied throughout the course. The third year is mostly spent in the teaching hospital where they attend wardrounds, clerk and present cases, write progress notes, assist deliveries, learn to set up iv lines/drips and assist major surgeries as first assistants. At the end of the course, they sit for the final qualifying examination which is prepared by the clinical officers council. The examination lasts two weeks. The first week comprises written exams. There are six papers each with two sections. Section one has the notorious multiple choice questions each with five answers to tick as true or false. You lose a mark for each wrong answer, gain a mark for each correct answer and no mark for no answer! Section two has short essay questions and comprises 40% of the paper. The papers are all marked at the clinical officers office in nairobi. The students rest for one week then have the practicals. These are conducted by consultants in the respective subjects namely medicine, surgery, gynecology/obstetrics, paediatrics, community health and health service management. Marks are awarded on the same day and each practical failed earns a six-month referral and has to be repeated. Those who pass both exams can obtain internship booklets from the clinical Officers council and start their one year internship. The booklet outlines the minimum skills a student must attain in each rotation and the students performance is graded by the supervisor. Those whose performance is unsatisfactory repeat the failed rotation before they are registered.

Further training
The law requires clinical officers to work in a government institution for ten years before joining the private sector or openning their own clinics. However, due to the limited employment opportunities in the public service and more than 200 COs graduating yearly, most graduates join private sector immediately after graduation but are not allowed to run their own clinics. Those with three years experience can join the KMTC for a higher national diploma in clinical medicine where they can specialise in paediatrics, reproductive health, orthopedic surgery, ear nose and throat, skin and lung diseases, anaesthesia or epidemiology. Those who obtained the minimum university entry marks in high school can join local universities to study medical degrees. Other COs go on to study other degrees at the university such as sociology, administration, microbiology and biochemistry. Many colleges also offer certificate and diploma courses in counselling psychology, hiv aids management, healthcare management, community health etc. Even without further training, most COs rise through the ranks in the public service to become senior clinical officers after ten years. At this level they are equal to a medical doctor but with a different set of skills.

Critical issues
It has been postulated that COs provide a lower level of care compared to medical doctors. However (this is a personal opinion) it should be borne in mind that most COs practice in resource-limited settings where for instance, they may be required to diagnose malaria without the benefit of a laboratory or interprete xray films without a radiologist. Furthermore the quality of diagnostic facilities at their disposal may not be the best hence directly affecting the quality of care provided. In such settings even the most experienced doctor is basically throwing a coin! Several studies have been conducted comparing patient outcomes after caeserian or laparatomy with one set performed by COs and another by doctors. Results show negligible differences in patient outcomes. In kenya COs are deployed at all levels of the healthcare system starting from the remotest rural health centre to the two referal hospitals- kenyatta national hospital and moi teaching and refferal hospital where they provide crucial services.

The future
COs have always been an integral part of the healthcare system in kenya but other countries introduced them as a temporary solution to their healthworker shortage. The cost element is an attractive and viable option because it takes a shorter duration to graduate a CO and costs much less than training a doctor. They are also cheaper to remunerate and allow doctors to concentrate on the more complicated patients and carry out research hence improving efficiency in the system. For this reason most countries train them at diploma level to contain costs and prefer to retain them by limiting access to traditional medical schools. In ethiopia health officers graduated from universities long before medical schools were established and all hold bachelors and masters degrees. South africa started training clinical associates in 2008 and opted to award a bachelors degree. The study duration however remains the same. Kenya, uganda and tanzania have maintained the diploma model although the latter allows them to train to become assistant medical officers who have additional 2 to 4 years training and are regarded as equivalent to doctors. This is now changing because at least one university in uganda and another in kenya are now offering a bachelor of science degree in clinical medicine and community health. Notably, in the US the doctor of medicine (MD) and doctor of osteopathic medicine (DO) which incorporates osteopathic manipulative techniques are the only two degrees accepted for licensure as a physician. The DOs existed as a separate profession until, after much resistance and lobbying, they were granted equal practice rights and recognition. US trained DOs can today practice in 47 countries as qualified doctors including the UK. Elsewhere they are not recognised or are allowed limited practice rights. Some countries such as Australia recognise osteopathy as a separate profession and require at least a masters degree to practice. Other countries such as france and germany require medical doctors to undergo additional training in osteopathic techniques before they can practice osteopathic medicine. Considering the developments outlined above, the US model is definately going to unfold in east africa.

International

 * The united states started training physician assistants in the 1960s. The first class was composed of former army corpsmen from the vietnam war who were assembled by Dr Eugine Stead of Duke university medical centre in north carolina. Over the years the profession flourished and according to money magazine is currently one of the best professions in the united states. Few colleges offer an associate or bachelors degree while most have transitioned to masters degree training. Some offer a doctor of science degree in physician assistant studies.
 * The united kingdom is currently in the process of enacting legislation to formalise the practice of physician assistants. American PAs are already working in the NHS on a pilot program and universities have started offering the course at postgraduate diploma and masters level.
 * India started training physician assistants in 1992 at the Madras medical mission. Programmes last four years comprising three years coursework and one year internship. The indian association of physician assistants (IAPA) registers graduates of accredited programmes.