LAUSR

Ecuador a mid-income country has more than 15 million inhabitants with one third (36%) living in rural areas and 17.6 physicians per 10 000 inhabitants, mostly working in urban areas.1 Obstetrical complications account for the high maternal mortality rate of 87 per 100.000 live births.2 Medical undergraduate training in Ecuador is provided in the large cities by public and private universities. Students have little or no contact with rural areas until their sixth and final year of general medical education. The under-graduate medical curriculum comprises three years of instruction in pre-clinical subjects followed by two years of clinical education in teaching hospitals. The sixth year is an internship program divided in five rotation areas: clinical, surgery, emergency, gynecology and obstetrics, and pre-rural.3 The recent graduates doing their compulsory rural year are called ‘‘rural doctors’’. Health services in rural areas are different from those in urban settings. They are very likely to provide obstetric care and to perform more procedures than their urban counterparts due to a lack of specialists in rural communities.4 A recent quantitative study showed that the skills needed in rural areas were not trained in the final undergraduate years. We assessed the possible mismatch of obstetrical skills between the training offered in Ecuadorian medical schools and the tasks required for compulsory rural service. Many perinatal skills were found to be important by the rural doctors, but they were not trained during the undergraduate curriculum (episiotomy and repair, umbilical vein catheterization, speculum examination, evaluation of cervical dilation during active labor, neonatal resuscitation and the more advanced skill vacuum-assisted vaginal delivery). The simple skill episiotomy and repair was seen as important to all respondents, but during the undergraduate curriculum ‘ t b s L % even only once during the internship, similar pattern is een in the others.5 A subsequent qualitative study confirms the main findngs, i.e. the lack of teaching at the medical schools does ot meet the needs of the rural doctors. We do not know what share the observed high mortalty rate may be due to the way the graduates were trained n the preceding medical education. But from the pubic health point of view innovative teaching of students is eeded. The magnitude of the mismatch between training n the medical schools and medical practice in rural areas eeds to be addressed. Although in 2008, fourteen univerities were closed down by the government.6 One of the iggest reasons of the observed translation on poor training f the graduates may be that the faculty is very volatile and he teaching methods are not meeting modern standards.3 here is no clear profile of the recent graduate medical octor at the national level. The need for a common, comrehensive doctor profile that addresses health needs and linical competences in line with real settings encountered fter graduation requires a continuous updating of university urriculum. Important issues to address include: What are the skills hat young doctors need in rural areas? How well are they repared to use them? How can we best train them and onitor the quality of their clinical work? Answering these uestions like this could be a powerful first step in improvng medical education nationwide. In the two universities e have knowledge of, senior faculty changes vary rapidly. or instance, at one University the Deans staff changed three imes over the last 5 years, leaving partly finished innovative urriculum changes. The medical schools of Ecuador deserve ore and more managerial stability and a clear vision of heir essential tasks which is to provide competent young octors.