A clinical analysis of medical education
Visit a country of paradoxes. India has the largest number of medical colleges in the world (more than 350), and we get a significant number of medical tourists, a reflection of the high-level of medical expertise that we possess. However, a majority of our citizens have limited access to quality healthcare — less than half of our children are fully immunised. Similarly, the minimum of three checkups during pregnancy remains unavailable for half of our pregnant women. To understand this anomaly, we have to go back to the clinical settings where doctors avail training.
Problems at the macro-level
Controversies, discussions and conflicts surrounding the state of medical education in India are like the common cold — it keeps surfacing every now and then. The challenges that it often confront are that of poor government control over the accreditation process, lack of skilled faculty, curriculum with inconsequential detail, complicated nature of the selection process, etc. Garima Ray, student, KJ Somaiya Medical College and Research Centre, Mumbai, says, “There should be a proper induction programme in terms of introducing students to the world of medicine. In the introductory year, when Class XII graduates step into med schools, life is not a cakewalk. We are shocked by the sight of bodies, urine examinations and blood tests. By the time we overcome our inhibitions, seven months would have gone by. Only in the second year, do we get used to the surroundings and recoup our spirits.”
BM Hegde, scientist, and author, notes, “Key players have questioned the validity of selection on the basis of pre-medical tests consisting of multiple-choice questions. The universities are just degree-selling shops. Medical schools should make radical changes in the curriculum, adopt innovative pedagogical strategies for enhancing students’ learning, improve the methods used to assess students’ performances, and focus on the professional development of faculty as teachers and educators.” Garima adds, “In India, we follow a rote method of learning, so the clinical bedside knowledge is far below the requirement. How is this going to make us reliable doctors? While preparing for PG exams to study abroad, one realises the importance of adequate clinical skills. The system must emphasise more on this than on distinctions.”
The Medical Council of India’s (MCI) Vision 2015 draft committee report has proposed sweeping reforms. The report cites three main reasons for India’s healthcare woes — shortage of physicians (both generalists and specialists), inequitable distribution of manpower and resources, and deficiencies in the quality of medical education. They have proposed the following reforms: Increase production of doctors, curricular reform, lay emphasis on primary healthcare and family medicine, and strengthen medical institutions by investing in technology. “At the essence of curricular reform is the transition from a science-based curriculum to a skills and competency-based curriculum. The final goal, as the report states, is to produce world-class Indian doctors,” says Dr Vishal Marwah, physician leader and health promotion consultant.
Dr Narendra Saini, secretary general, Indian Medical Association (IMA) feels the proposed reforms are a half-hearted attempt. “Earlier, MCI had announced that National Eligibility cum Entrance Test (NEET) is necessary for admissions to undergraduate and postgraduate courses in all government and private medical colleges that come under the ambit of IMC Act, 1956. However, after hearing the pleas of opposing States and private medical colleges, the Supreme Court on December 13, 2012, permitted them to conduct them to conduct entrance examinations but restrained them from publishing results till the outcome of pending cases. Uncertainty continues and imagine the plight of students,” he says. Divya Aggarwal, a student of Lady Hardinge Medical College, laments, “It is seriously pathetic on the part of the government to treat us like guinea pigs, starting something which they are not sure of, bringing forward exam dates and postponing the results; what an immature step!” MCI is finally going to conduct NEET for UG admissions on May 5.
To address the issue we need to understand the medical education scenario in India. Based on a 2010 report, which is available on the website of Union ministry of health and family welfare, there is considerable disparity in availability of opportunities for students across states (Refer graph). Such disparities also suggest that there is no such concept called India as far as medical education is concerned with states like Assam, Bihar, Jharkhand, Uttar Pradesh and West Bengal barely visible on the graph. Just four states — Andhra Pradesh, Karnataka, Maharashtra and Tamil Nadu — constituting for just about 20 per cent of India’s population account for about 1.3 lakh out of nearly 2.4 lakh seats across India.
More the merrier
The aftermath of such inequalities has led to irregularities as well as concentrated effort by lobby groups. Dr Devi Shetty, former governor of MCI and chairman, Narayana Hrudayalaya (NH), says, “India has approximately 300 medical colleges producing 30,000-35,000 graduates every year, whereas the need is that of 500 new medical colleges, producing one million doctors every year.”
By creating new medical colleges, we bring in uniformity, fill the demand-supply gap and even beat the constant breach of racial and cultural diversity among students. Dr Shetty says, “The MCI’s ruling that a medical institution shall have a unitary campus of not less than 20 acres of land is unwanted. For instance, Guy’s Medical School, London, is spread across three acres of land and is one of the best in Europe. This is what we need to follow. Along with it, east and north Indian state governments need to change their myopic view with regards to setting up new institutes.” Dr Alfred Daniel, principal, Christian Medical College, Vellore (CMCV), adds, “Central and State Governments may look at public private partnership models for constructing new medical colleges in states, which are identified as needy areas.”
The bigger picture
Hegde believes healthcare leaders who possess an interdisciplinary view to reform the system are the need of the hour. Dr Marwah urges us to look at the bigger picture. “It is quite alarming. Amidst all the nit-picking and finger-pointing there has been little substantive and meaningful conversation. Despite various levels of diagnosis, surprisingly the right questions have never been asked. Some of them are: What values should the new medical education system espouse at its core? What type of professionals are needed to address the emerging healthcare challenges in India? And the much broader issue — What model of healthcare system should India back as we undertake a healthcare transition over the course of this decade?” he asks.
There needs to be a strong desire to better align medical education with societal needs and expectations than work in isolation. If all of this sounds utopian, one may want to look at models like CMCV, where there is a strong emphasis on values, and sensitisation to social and rural issues. “At CMCV, medical education aims to progress by training compassionate, professionally excellent and ethically sound individuals who will go out as servant-leaders of health teams and healing communities. Their service may be in preventive, curative, rehabilitative or palliative aspects of healthcare in education or research. Here, students get a wide exposure on various aspects of the healthcare ministry ranging from primary healthcare in villages to various postgraduate and super specialty courses, and research opportunities,” says Dr Alfred.
It is an undisputable fact that we need to deliver the ‘right kind’ of health professionals, who are qualified to address everyone’s needs but unfortunately needs vary considerably. It may vary from providing quality healthcare in remote corners of rural India to treating complex and rare illnesses by using the latest medical technology. Colleges must be able to provide a glimpse of all these aspects to students.
As MBBS students are unable to find jobs, they are forced to specialise in a particular field. “Specialisation in medical disciplines is becoming an essential requirement. This may be due to the trend in (bio) medical sciences towards increased dependence on technology, and the desire to migrate to first-world countries or live in areas that have advanced medical facilities,” says Hegde, who authored What doctors don’t get to study at medical school. “The importance of research and teaching, which is the essence of postgraduate medical education, has just been usurped by the market of specialised clinical practice. At the same time, private healthcare is ailing under the weight of unhealthy competition, which has resulted in unreasonable medical practices and unwarranted diagnostics, which may be socially wasteful and personally taxing.”
As a result of this tunnel vision, research has been sidelined. The other casualty of this system is rural health services. “Each medical college needs to identify its strengths, and prioritise its focus in conjunction with state health authorities and state medical education authorities. The colleges can then guide their students along these lines,” says Dr Alfred. Dr Marwah believes the Indian healthcare system should incorporate the Psycho Socio Ecological (PSE) model of health and wean itself away from the existing biomedical model of disease, as PSE embraces the theory of social determinants of health and lays a strong emphasis on health promotion and disease prevention.
Considerable progress needs to be made in medical education pedagogy. Schools need to incorporate problem-based and team learning, group discussions, and learning through simulation. The curricula also need to include inter-professional and community-based education. Hegde vouches for Whole Person Healing, which combines alternative medicine with the power of modern sciences to advance human healing. American Medical schools are already integrating Complementary and Alternative Medicine (CAM) into existing course work. The initiative includes a mind-body class to help students use techniques to manage their own health and improve self-care. The School of Medicine in Georgetown University, USA, has seamlessly weaved CAM into existing classes. For instance, an acupuncturist gives a presentation on ‘Anatomy of acupuncture’ for first-year students. The students then explore how acupuncture can be applied to alleviate pain in neurosciences.
The use of health information systems (electronic health records, mobile health applications, telemedicine, etc) has made it possible to shift tasks that were earlier done by physicians to healthcare workers, without affecting the quality of care. Doctors need not be physically present in village clinics and their roles get elevated to that of a technology manager. “The medical education system needs to evolve with these trends, and ensure that students get exposed to these emerging technologies and models of healthcare delivery early on in their training,” says Dr Marwah.
The path ahead
Whatever the final shape of the regulatory mechanism, it owes it to the citizens to create some basic changes in medical education. Dr Shetty says, “Although recruitment of highly-skilled surgeons ensures quality is excellent at NH and the Rabindranath Tagore Institute of Cardiac Science, it only scratches the surface of the gap between demand and supply of doctors. To address this issue, the Tagore Institute launched Udayer Pathe (Towards dawn), a programme that identifies talented rural students in Class VII and funds their education. The child’s living expenses are covered, which effectively results in the child becoming an earning member of the household at an extremely young age. When the student becomes a doctor, his/her people will receive free medical treatment at institutes affiliated to Asia Heart Foundation.”
Policymakers, physicians and those who teach physicians must open their eyes to the opportunities, realities, and responsibilities. We need a holistic, radical surgery to restructure the entire medical education system in India.