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Seeing the Whole Child
by Isabel M. Estradas-Portales
A different focus
Teamwork is strongly encouraged by IMCI as a way to ensure quality health services and use time and resources more efficiently. (Photo ©Armando Waak/PAHO) |
For many--if not most--physicians, learning to use IMCI involves rethinking key aspects of their professional orientation and behavior. The strategy's emphasis on a holistic approach and the need to involve mothers and the community in the care of children represents a change from what most doctors have been taught as medical students.
Dr. Gonzalo Franco Ramírez, professor-in-chief of pediatrics at the Clínica Corpas in Bogotá, has seen IMCI training have a profound impact on his staff. In the past, he says, physicians tended to focus almost exclusively on analyzing and treating children's immediate symptoms. He attributes this to traditional medical education, which places greater emphasis on diseases that, "while not very prevalent, made an impression on the students," citing as examples malignancies, immunological disorders, and endocrine diseases. For Franco, IMCI's "holistic, biopsychosocial view of the child" is a welcome and needed change.
"Traditional training emphasized only clinical training in the prevalent pathologies," concurs Dr. Jaime Tellería Guzmán, a physician working in Bolivia's Ministry of Health. He notes that areas such as acute respiratory infections, acute diarrheal diseases, breast-feeding, tuberculosis, nutrition, and growth and development have generally been taught separately. "The IMCI strategy has made it possible to integrate these programs and use systematization to comprehensively address the main problems, linking prevention, treatment, and counseling for caregivers," he says.
Tellería also points out that, although IMCI's integrated approach requires doctors to spend more time with patients, it means less time in training than traditional disaggregated learning, which required health professionals to be absent from their clinical jobs for extended periods. "This has saved economic resources and time," he says.
The strategy also runs counter to the "specialize or die" trend in professional development in medicine. "Under the old system, it was believed that to be a better physician one had to practice a subspecialty--a vision that is disjointed, in many cases, even totally fragmented," says Mesa, who trains colleagues in the IMCI strategy.
Dr. Carlos Alberto Bernal, a Colombian pediatrician, received training in IMCI after more than 20 years of pediatrics teaching and practice, specializing in diarrheal diseases. At the Children's Hospital of Medellín, where he worked, "we had an oral rehydration ward for children with diarrhea...and right next to that room was the unit for children with respiratory infections. Training in IMCI gave me the opportunity to work in a more integrated fashion and pursue teaching and research activities in areas other than diarrheal diseases."
Health workers trained in IMCI learn to view mothers as the best source of information on their children's health. (Photo ©Armando Waak/PAHO) |
Bernal says he and colleagues established a new Child Life Unit in the small town of Turbo using IMCI as the guiding strategy. Each patient who visits the Uunit is assessed according to IMCI guidelines. The Uunit also carries out research on issues associated with IMCI and provides training and education in the strategy to other health professionals.
"Traditional education has always sought to emphasize the taking of a good clinical history," notes Bernal. "This includes a review of systems, similar to the search for related problems in an IMCI consultation. But in practice, attention has often focused very narrowly on the reason for the consultation. IMCI represents progress in that it permits systematic exploration of the most prevalent problems, including important aspects of nutrition, vaccination, and good treatment." He adds, "It also provides for careful management of some good techniques for communicating with mothers, which may be the most innovative feature of the strategy."
Indeed, IMCI's emphasis on the role of mothers or other caregivers and their relationship with of health workers with them is for many supporters a key advantage. Franco, of Clínica Corpas, says that before receiving training in IMCI, health workers "placed little value on dialogue with the mother." They also tended to overlook what he terms "basic aspects of daily practice with the child...such as vaccination, growth, nutrition, and simple indications of simple problems that the mother might be experiencing when it comes to her child's health."
With training in IMCI, "Wwe saw a radical change in student attitudes," says Franco. "This has led to better relations with mothers and improvements in their behavior and the management of childhood illness." The change has proved beneficial for the clinic, Franco notes, in that better doctor-patient relations have attracted more users.
From a trainer's perspective, Mesa says she has observed that IMCI's "module" on counseling mothers seems to have a particularly strong impact on professionals taking her course. "The common denominator here is that career programs in medicine and other health professions have not stressed communication, an aspect that is key to achieving what we want."
At the Ciudadela Medical Center, the only health center in Bogotá where all staffers follow the IMCI strategy, director Dr. María Lucía Mesa has seen changes in attitude in physicians and students alike. She notes that the center's general practitioners regard IMCI training as professional updating that "makes them more secure in their decision -making and furnishes them with arguments to explain to mothers or other caretakers why they do or do not prescribe drugs."
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