The problems of medical education in a developing economy: The case of India

How to cite this article:
Aggarwal S, Sharma V. The problems of medical education in a developing economy: The case of India. Ann Trop Med Public Health 2012;5:627-9

 

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Aggarwal S, Sharma V. The problems of medical education in a developing economy: The case of India. Ann Trop Med Public Health [serial online] 2012 [cited 2017 Nov 14];5:627-9. Available from: https://www.atmph.org/text.asp?2012/5/6/627/109346

 

Introduction

Medical profession is considered to be the noblest of all professions because it deals directly with the lives of patients. The doctors earn high respect from the society because of the noble work they are associated with. Considering the sensitive nature of the profession, where even minor mistakes can have serious repercussions, it is highly imperative that the standard of medical education should be strictly regulated and regularly updated.

In a developing nation such as India, medical services play a very important role in the well-being of their citizens and indirectly play a very important part in the economic and overall development of the nation. The development of good medical services in the country is almost entirely dependent upon the medical education imparted in the various medical colleges of the country. Also, for the effective implementation of the various National Health Programs started by the Government of India, and research work in the field of medicine, medical colleges and teaching hospitals play a very vital role.

Currently there are 299 medical colleges in the country (including both government sector and private sector medical colleges) for teaching modern system of medicine with annual intake of 32,805 medical students who add to the existing medical manpower. [1] Despite this, India continues to face a poor doctor to patient ratio with only one doctor available for 1588 people in the country compared to 390 in USA and the ideal doctor to patient ratio being targeted as 1:500. [2] There are only 733,617 registered allopathic doctors in the country, [3] with most of them concentrated in the urban areas making condition worse in the rural areas.

So, to prevent the level of medical service provided from being compromised with the limited human resource in hand, the medical personnel have to be given a high quality education and training. However, we believe that the medical education system in India faces several problems which need to be immediately addressed.

To begin with, the first issue which draws attention is selection of students in the medical college. The selection of students in most of the colleges is based on the score obtained in the objective type exam (containing multiple choice questions on subjects of Physics, Chemistry and Biology) which are more based on the factual information rather than communication skills and humanistic attitude which are the basic foundations for the doctors. This issue was brought up by the Medical Council of India (MCI). [4] It was recommended that merit in the board examinations or competitive tests should be combined with an aptitude test so as to form the criteria for selection tests for admission of students. However, because of non availability of appropriate objective instruments for testing aptitude in large number of students, this could be tried-out in some selected medical colleges before large-scale implementation. [5] We believe that a pilot project can be initiated in autonomous body like entrance exam to All India Institute of Medical Sciences (AIIMS) for a couple of years before launching change in exam pattern to All India exams.

The quality of medical education in India is also marred by the issue of capitation fee in the private sector medical colleges. It allows for admission of non-meritorious students into the medical college run by private sectors, by charging a heavy fee from them under the management quota and non-resident Indian (NRI) quota. It greatly hampers the quality of input into the medical colleges and impairs the quality of medical services in the later period. The allocation of fixed percent of seats in the Government medical colleges to students belonging to a certain caste in society also raises similar type of problem. Concerns have been raised over it that it helps jeopardizing the quality of output from the medical school. Considering the seriousness of damage that can be caused by the slightest of mistake by the medical personnel, we believe that the quality of medical service cannot be compromised at any level. So, this issue has to be seriously looked into to seek out some remedial measures to maintain a high standard of medical education in India.

We believe that the curriculum of medical education in India needs to be revised a bit. Medical Colleges in India divides under-graduation course of MBBS into four and a half year of study and one year of compulsory rotating clinical internship training, with the study period being divided into one year of pre-clinical courses (Anatomy, Physiology and Biochemistry), one and a half year of para-clinical courses (Pathology, Pharmacology, Microbiology and Forensic Medicine) and two years of clinical courses: Part I having ENT, Ophthalmology, Community Medicine and Part II having Medicine, Surgery, Pediatrics and Gynecology and Obstetrics. No stress is laid on subjects like Medical Ethics and Behavioural Sciences. The students fail to learn the basic principles of medical ethics and are unable to deliver the due respect to the patients. Students overlook the general courtesies needed and it is not uncommon to see a group of students during their clinical postings in out-patient departments or in-patient wards, trying to simultaneously interrogate, palpate or auscultate the patient causing a lot of discomfort to him. The patients are approached in an insensitive manner. Sometimes to make the matter worse, the clinical manuals are kept open on the patients’ beds aiding them to visualize the distressing pictures, thus adding to the anxiety and fear of the patient. The students thence fail to develop a compassionate doctor-patient relationship.

We believe simple courtesies such as shaking hands, introducing themselves, providing a patient hearing can help doctors/students in establishing a good rapport with the patient and foster a healthy relationship. Explaining the disease pathogenesis and the treatment protocols to the patient in simplified language can also help to relieve the anxiety of patient. A compassionate view by the doctor certainly improves the quality of the medical service and this can be ensured by efficient teaching of the medical ethics to the medical students. A little more caution by the students and adequate guidance by the teachers can help them develop good skills. It will also help to reduce the quantity of increasing medico-legal suits filed against physicians in long term.

No impetus, whatsoever, is laid on research activities in under graduation course of MBBS in India. Organizations like Indian Council of Medical Research (ICMR) do help to initiate and inculcate research culture amongst medical students by promoting Short term studentship (STS) scholarship programs. Kishor Vaigyanik protsahan yojana (KVPY) also promotes the same cause. However, no serious stress is laid on this by curriculum by MCI. A project done during course of Preventive and Social Medicine is taken by students more as a formality than something as interesting. MCI needs to pay attention to this, since research is the backbone of development of medicine. They should modify policies and curriculum ensuring that medical schools in India produce physicians that are not only good clinicians but also great innovative scientists. A short research project can be introduced in first part of third professionals when students are relatively free and it can be made as a component of internal assessment in Preventive and Community Medicine, which can drive students to get actively involved in the research. [6] Also, MCI can make some amendments to selection of students for post graduation courses whereby students with active interest in research and publications in indexed journals be given a little extra advantage of few marks. A pilot project can be initiated in autonomous bodies like AIIMS to analyze how things would work out. This will certainly increase the research acumen in the students and help develop scientist-doctors who in later life can easily gather and analyze data from clinics and thus contribute to evidence based medicine. [7]

The selection of students for the post graduate (PG) courses also faces the same problem as that for the selection of students for graduate studies, i.e. the objective nature of multiple choice type examination with no emphasis on practical knowledge. It has serious consequences. Medical students in India are required to complete one year of compulsory clinical rotating internship training before degree of MBBS is awarded to them. Since the number of seats for the post graduation courses are very limited compared to the number of students being graduated, and the competition being very tough for the limited number of seats, the students pay lesser attention on the practical training and more emphasis on the theoretical knowledge to score high in the PG entrance exams. While the graduates generally possess reasonably sound knowledge of medical science, they are often found deficient in the performance of clinical skills and problem-solving which form the core of clinical competence. [8] The result is that students fail to acquire the clinical skills, leadership qualities and human resource management to their maximum potential thus affecting the quality of doctors being produced by the medical colleges in India.

This is in sharp contrast to system followed in USA, where students need to pass a practical exam of United States Medical Licensing Examination (USMLE) step 2 Clinical Skills (CS) in which one of the sub-component judged and evaluated is communication and interpersonal skills (CIS). [9] Thus students need to have effective practical clinical skills before they can get license to practice in USA or to be eligible for admission to residency (equivalent to MD/MS in India). A similar exam on similar line can be introduced in Indian setup, as a pilot project in AIIMS/PGI before implementing it nation-wide. It will definitely enhance quality of output from medical school and enhance health care provided by physicians in bigger prospective. Also, the two separate systems of exams for post graduates viz, MD/MS and Diplomate of the National Board (DNB) have been criticized by few and need of an alternate, parallel system of entry to post graduation course is questioned. [10],[11] Suggestions have been made by few to abolish the DNB and strengthen MD/MS program so that the country can have a single, transparent system of postgraduate medical education that produces desirable results. [12]

According to MCI, the standards of undergraduate and postgraduate medical courses including the syllabi, curricula, system of assessment and examination are periodically evaluated by the Council through its Inspectors who are required to be reporting on these aspects in required details. Although MCI has made loud claims that uniform standards of medical education in all the institutions in the country is ensured through an effective system of monitoring by regular and periodic inspections, including surprise inspections from time to time, it is not fully convincing. [4]

MCI has been putting a lot of efforts to improve the quality medical education in India. But we believe that still a lot has to be done to further the cause. Strict measures should be adopted to regulate the functioning and management of private medical colleges and evaluation for renewal of recognition of medical colleges should be done on a more strict and regular basis. We believe that MCI should revise the curriculum more frequently to update it and keep it at pace with the advancements in the field of the medicine to facilitate high level education and training and the management of the medical colleges need to implement these changes to upgrade the standard of the medical education.

References

 

1. Available from: http://www.mciindia.org/AboutMCI/AnnualReports.aspx. [Last accessed on 2012 Sept 24].
2. Available from: http://strangemaps.wordpress.com/2007/10/17/185-the-doctorspatients-map-of-the-world. [Last accessed on 2012 Sept 24].
3. Available from: http://www.deccanchronicle.com/latest-news/india-lagging-doctor-patient-ratio-192. [Last accessed on 2011 Apr 12].
4. Medical Council of India. Report and Recommendations of National Workshop on “Medical Education-An Appraisal” New Delhi: MCI; 1996. p. 4-5.
5. Available from: http://medind.nic.in/jac/t00/i3/jact00 i3 p210.pdf. [Last accessed on 2011 Apr 12].
6. Aggarwal S. Research oriented medical education in India. Indian J Med Res 2010;131:590.
7. Aggarwal S, Singh H, Bansal P, Goyal A, Saminder Singh K. Training in clinical research in India. Indian J Community Med 2010;35:446.
8. Verma K, Monte BD, Adkoli BV, Nayer U, Kacker SK. Inquiry-driven strategies for innovation in medical education in India. New Delhi: AIIMS; 1991.
9. Aggarwal S. Comment on medical education. J Postgrad Med 2009;55:318-9.
10. Poduval M. Diplomate of the National Board: Inefficient parallel education. Indian J Med Ethics 2010;7:22-5.
11. Sarbadhikari SN. A farce called the National Board of Examinations. Indian J Med Ethics 2010;7:20-2.
12. Sharma V, Aggarwal S. Do we need two systems for postgraduate medical education in one country? Indian J Med Ethics 2010;7:193.

Source of Support: None, Conflict of Interest: None

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