https://meditropics.com/medical-education-in-india/
Medical Education in India – “Change”: Is it an integral part of the continuous process of improvement or has it brought it at the crossroads!
*Anupam Prakash
*Director, Professor, Department of Medicine, LHMC
परिवर्तन प्रकृति का नियम है। “Change” is the rule of nature. Days give way to night and vice versa, seasons change, life changes from in utero to birth and through the phases of life until death, and so things are bound to change. Change begets continuity, it keeps life on the roll, and that is the characteristic of Mother Nature. Medical education in India has also been continuously changing, and a major change came with implementation of the “Competency-based medical curriculum”. At the time of its launch, it was believed that Competency-based medical curriculum would serve the larger cause in the domain of “quality centricity”. This in turn means that it will help in improving the quality of medical education. So, was the quality of medical education inferior, or it was getting obsolete with time, and required a greater impetus or change to remain contemporary and consequential with the changing times?
Coming back to “Change”. What necessitates “change” is important to fathom! Unless and until one understands the root cause of the problem, the change that is made will only be cosmetic in nature.
Medical doctors graduating in India during the middle of 20th Century would be considered to be complete doctors, as MBBS doctors would be doing medical as well as surgical procedures. But gradually, it was felt that the knowledge base is expanding and newer specialized procedures required training, and so postgraduate degree courses came in vogue. During the fag end of 20th century, further specialization became the norm with DM/MCh and DNB courses in Neurology, Cardiology, Gastroenterology, Nephrology, Urology, Neonatology, Pediatric Surgery, and the likes. So, the sanctity of Undergraduate Medical Education which used to have a 4½ year MBBS curriculum + 1 year compulsory rotatory internship, became supplemented by a 3 year MD course and another 3 year DM/MCh course. It was always considered that the cream of the society entered into MBBS course since the aspirants had to face entrance examinations to get choice of their medical college. However, the long duration of the MBBS course and the daily grind of long study hours, clinical postings, patient welfare expectations did have its own toll. Facing competitive examinations at the end of completing MBBS to get entry in to their choice of postgraduate stream also added to the burden. A trend started emanating that those who worked religiously during their internship, could not devote time to their studies and prepare adequately for PG Entrance examinations and hence, either could not get choice of their MD/MS degree or had to drop a year. Gradually, students started devoting less time to their internship postings, which were necessary for the exposure to patient management and developing procedural skills. At the beginning of the 21st century, commercial ventures capitalized on this scenario and started coaching classes beginning from MBBS 1st year itself, ensuring the students are well-prepared for the PG Entrance Examinations. So, the academic burden on the MBBS student became two-fold, firstly of the MBBS curriculum being taught in the medical college where he/she took admission, and secondly of the studies of PG entrance through coaching classes. The stress of MBBS curriculum in itself had been quite a lot, and ironically, psychological stress and psychiatric disorders had been rising among the MBBS students.
During this period the three professionals of 1½ year each (cumulative 4½ years MBBS course) were changed to reduce the pressure on students, with the First professional being made of 1 year only and the Final professional being divided into two parts. The well-meaning governments also increased the MBBS seats as well as the PG seats to increase the doctor-patient ratio in the country and also offer more seats to the student aspirants.
However, the increase in seats did not ease the students’ pressures, since the rise was not proportional to the population that had increased, and the increase in seats was for a particular segment only. Further, the increase in seats was not associated with increase in infrastructure or the increase in faculty in medical colleges. The faculty in private medical colleges had been lacking, and government procedures take time to recruit new faculty. Infrastructure up gradation in itself varies from college to college, in the government set-ups.
Lack of new or upgraded infrastructure and shortage of teaching faculty further made students disinterested in their MBBS studies including clinical postings.
Therefore, the deteriorating standards of quality of medical education among the Undergraduate degree holders, could not be arrested. Policy makers in India and the medical teachers were naturally concerned about the same, and in another attempt to improve the quality of medical education, introduced the Competency-based medical education (CBME) for the MBBS curriculum. Several of the components of CBME are in fact very good, but it is to emphasize that CBME is resource-intensive. Introducing CBME without actually completing the faculty requirements of medical colleges is foolhardy. In fact, during the last couple of decades, National Medical Commission (NMC) has diluted the faculty requirements for medical colleges. On one hand, the faculty requirement has been reduced, and on the other hand, CBME is resource-intensive. It is easy to fathom that we are shooting ourselves in the foot. Furthermore, just by ensuring that the students know only the respective competencies in the different subjects as mentioned in the CBME MBBS curriculum, the medical curriculum does become finite, but the problem remains that the patient who comes to a doctor does not conform to that finite subset. Hence, we have left the learnings for the MBBS doctor for a later level. This in turn means, that we accept that we cannot impart everything to an MBBS doctor, and that the MBBS doctor cannot be a complete doctor. This is contrary to the fact, that for the country to benefit, we require MBBS doctors only, who are well-versed with medical knowledge in entirety, and very few in the far reaches of the country actually require specialties or sub-specialties.
Several measures have been taken over the previous decades to improve quality of medical education, and the concern for the society and nation has been the foremost, and interests of doctors have also been taken into account. However, the policy-makers have to come to the level of the aspiring student and understand why medical career no longer is as lucrative as it was earlier. A person as brilliant as a doctor, who gets through a National level entrance examination, has to be offered a security of job and career, which does not at all exist. Administrative services in India offer a life-long job security once selected after the UPSC procedures. For good doctors to be retained in the country, the nation needs to offer job security and career avenues to them.
As the government is contemplating, bridge courses, and students of non-science backgrounds to enter medical colleges, a reverse option to go back to university colleges at the end of first professional, for those who have taken MBBS, but do not want to continue, should exist.
Just like the IITs offer an Integrated M.Tech course, similarly, MBBS+MD should be an integrated 7 year course. At the end of the second professional (2½ years in Medical college), an aptitude-based examination may be conducted, to understand if the MBBS student wants to go to medical specialties or surgical specialties, and then should be directed to those streams only. Why teach Eye or ENT to a student who wants to seek MS (Obs. & Gynae.), and vice versa. Similarly, why do MD Medicine or MD Dermatology or MD Psychiatry need to study Surgery/Orthopedics. Yes, these thoughts may be radical, but may need to be considered and adopted at some point of time, if we do need to reduce stress in medical profession, and want good quality doctors.
Similarly, posting of PG students for District Residential Programme may be a very good option, but then it should be reciprocated with Medical officers from those centers working in medical colleges during that time. Medical colleges have postgraduates working under them, because of a number of considerations which include thesis and research and trainings. There is no comparison of standard PG training in medical colleges to the unsupervised training provided at other centers. People may take offense to this statement, but constructive criticism needs to be adapted into our policymaking.
When the government is supportive and is into reforms, it is imperative that suggestions from all quarters are invited and if any attempt can be made to improvise the system, the same should be incorporated.
No step will result in magical outcomes, CBME has lent objectivity in to the UG medical curriculum, but the buck should not stop at CBME. Reforms are the need of the hour, and sincere attempts need to be taken to reduce stress on the medical student. They are future health leaders of the country.
Change!
Change we must and change for the better,
Imbibe today and evolve for the future.