Sunday, June 14, 2015

What ails our Medical Education? Few suggestions

Let us face it straight; all of us have this question, but dodge it for various reasons.

What is the purpose of medical education in India? How is the curriculum decided? Why is it structured the way it has been running for last umpteen number of years?

This is twenty-fifth year of my joining MBBS. Throughout my graduate, post-graduate and super-specialty years, these questions have bothered me. I can vouch the questions have bothered all of us at some point of time.

One of teachers in P&SM had told, "The purpose of MBBS in India is to make a doctor to carry out all functions of any PHC (primary health centre - the basic unit of health delivery at government level) on completely independent basis, covering all essential medical needs and decide appropriate triage."

With this idea in mind, added on by exuberance of service orientation of youth, few of us take our internship very seriously. We want to make ourselves very useful to society by being good Doctors who manage the best PHCs! Whereas, most of our colleagues work hard on solving MCQs of PG Entrance exams.

After internship, forget getting a job in PHC, we are unable to get a job in any private nursing home also! Turns out our MBBS is no good at city level. No medical institute would give a permanent post for MBBS pass. Government service is ridden with reservations, nepotism and political influences. Only options are either work for a pittance in nursing homes/private hospitals (working mostly as clerks to senior consultants) or have clinic of our own (finance is a major issue) or go for PG course.

This was when we understand the futility of mere MBBS! We slowly lose all the fine skill acquired as interns! It is of no use if we do not get job of medical officer in PHC! MBBS is actually a certified qualification to write PG entrance exams!

Our friends were in the right track. Most of them did not take internship seriously. They maintained enough attendance and did minimal work to get completion from each department! They invested their time better by preparing for PG entrance exams. How stupid of us!

After horrifying competition and travelling across the nation by cheapest modality of transport to write various entrance exams (shamefully spending hard earned money of parents), we finally land with some PG seat. Many a times, the available PG course for our rank does not match our aptitude. But, we cannot be very choosy. Every year the competition increases. Even this seat may become a premium later! No chance-taking here! Just grab a seat and be a specialist!

This is, in short, what happens! Why is that the course pursued by the brightest students of this country so shabby and disorganised?

Five-and-a-half years of MBBS and now, government adds two years of rural service to it! No guaranteed job; no respectable income; no promise of safety; no assurance of secure future; no streamlining into PG courses! What's happening?!

Who decides the curriculum of MBBS? How many of us can remember what we studied in pre and paraclinical period? Was loads of information worth it? Applied courses should have an objective. What is being served for practitioner? When MD medicine Physician can be penalised by our court for treating myocardial infarction patient, why teach about complex surgical techniques at MBBS level?
Isn't it the time now to re-structure our medical curriculum to suit the present needs? Shouldn't we raise the voice for doctors of future? Just because we were given an unjust deal, should it pass on to every generation?

Some suggestions are enumerated here. This is an invitation to add all relevant suggestions.

The MBBS course should be cut short. One-and-a-half years for pre and paraclinical subjects put together. These subjects should be taught using visual imagery and 3-D teaching techniques. It should be interactive with periodic assessments. No anatomy dissections, no pithing the frogs, no instilling drops into the rabbits' eye and measuring pupils!
The next two years should be exclusively clinical. Didactic classes should stop. Small dynamic groups should be created to encourage group discussions and interactive discussions. The rotation should be similar to Family Medicine curriculum of DNB, but at basic level. After exit exam, 6 to 9 months of intense internship and 12 to 18 months of rural posting with pay of at least 75% of what the MO in PHC gets.
The overall duration including rurals should not exceed 5.5 years. The curriculum should include practical tips on how to establish a clinic or small sized hospital including economics and legal regulations.
Those who wish to stop here and practice should be offered interest-free bank loans for all the social service they have done by abiding to government policies (which no other professional in India does). They should form the first-tier of health care and should be encouraged the same way. This will lead to strengthening the family physician aspect of health care, which is glaringly lacking in India.

Post-graduation should be 4 years. First year exclusively for anatomy and physiology of concerned specialty. At this level, learning is super fast due to all the knowledge of MBBS. It should be on simulation and problem solving basis. For example, MS General surgery PGs should learn surgical anatomy and basic surgical techniques on cadaver. MD pathology PGs should learn histology and histopathology in great detail. The next 2 years should be spent on actual specialty learning.
The last year should be for developing practical skills or getting oriented for super-specialty, depending on the aptitude of candidate. They should come out as competent specialist to take on any challenge at their level of training.

Super-specialty should be for 4 years again. Three years of actual super-specialty with additional year of further sub-specialization. For example, a Cardiology super-specialty student should use last year in either coronary work or electrophysiology or transplant related heart failure and so on. They should come out as full-fledged specialist who can take on any centre confidently.

We are a huge country. Our health needs are diverse. We cannot just copy-paste the systems prevalent abroad. We need to make our own protocols. We need to have our own methods to ensure health-care delivery and check quacks. At the same time, we need to ensure an honourable life for doctors. The change cannot come by intervening half-heartedly at some random point of health-care delivery. It should happen at grass-root level - right at medical education. There needs to be a drastic restructuring.

Please pen in your views. Constructive criticisms of all variants are welcome! Please speak your minds. This forum should turn productive as it is meant and envisioned by its creator!

Tuesday, June 2, 2015


Yes; we are debating, quite fiercely!

How to prevent people from attacking doctors? By legislation? By police action? By employing bouncers? Or by not allowing our children from getting into this profession?!

We are scientific people! We detest quacks who treat on symptomatic basis. We seek an etiology, establish a pathogenetic scale and intervene at appropriate level using best of our discretion. Its all when we treat the ailments of others.

But, when it comes to tackling a serious question of our own safety, we never try to get into etiology; we are simply offering solutions at preventive level, damage control and rehabilitation!

The question that we need to ask and answer ourselves is, "Why are people attacking doctors?"

Didn't people attack doctors in the past too? Yes; but the incidents were extremely rare. Most of the times such attackers were not because some patient died.

But now, the reason for attack is the death of a patient. That answers "people attacking". Still, WHY and DOCTORS need answers!

WHY is a complex question to answer. Still worth a try.

Earlier when people moved around a hospital, they would see doctors at all important places. The chief of hospital, Medical Superintendent, CMO, Chief Physician, Chief surgeon etc were doctors. Most of the fees they paid were going to doctors. When a doctor wrote concession in bill, patient used to get it without much hassle. Doctors were most powerful part of the entire hospital system. Obviously for a patient, doctors were face of the system. The perception was fixed.

As of now, we are replacing hospitals with HEALTH-MALLS! Huge buildings, impressive interiors, expensive artefacts, eye-catching advertisements, discount coupons on health packages/lab tests, massive machineries, ultra-luxury wards, suites and what not!

These health-malls are managed by MBAs! Most of the decision makers are from business management background. They need not even know how a hospital looks like (let alone how it functions) before managing the complex system of healthcare delivery! They look at balance sheets, profit-loss charts, pie-diagrams instead of diagnosis, treatment charts and discharge summaries. They do "hiring and firing" instead of building a team of healers and counsellors.

But, unfortunately, for the patient, the doctors are still "face of the system". They do not realize that doctors no longer get bulk of the amount in their bill. They do not know doctors are not allowed to decide the cost of their treatment or to write concession. They do not even know doctors do not decide brand of medicine that patient should get! In the name of cost cutting, most of the Health-Malls ask doctors to write the molecule and will get the most profitable brand available in the market, irrespective of its quality or credibility of company! How would a patient ever know these things? How can doctors talk about such issues with all patients? Its neither professionalism; nor practical.

The moment an MBA is running a health-care delivery system, it is no longer a service oriented firm; it is a business organization! The priorities of such organizations are different from a humanitarian institute. So, the rules change. Doctors realize this and keep quiet. However, patients do not know this yet. For them, doctors are earning a lot from exuberant bills they pay! They think doctors are greedy that the cost of health care has soared to sky! They feel they deserve value for money!

This "value-for-money" in health care is ill-defined! For MBA admin, it is profit margin compared to other industries! MBAs feel that the profit margin of Health-Mall is less than other Malls! So, customer is getting more value for money! Simple economics.

For the patients, it is end-point of their treatment. "Don’t worry about the expenses; I just want my patient cured" is a common sentence used by patient's kin. That defines their "value for money". This "consumer mindset" which has replaced "care/service mindset" makes huge difference in perception.

When "value for money" is not met, Health-Mall MBA admin is unhappy. As earning members of system, doctors take the brunt. They fire doctors, break treating teams, lure few morally weak members to take up unethical stands, get a new consultant who is capable of drawing more patients into the system, change the pay-package structures of doctors and so on. The entire equilibrium in system turns chaotic and makes every doctor jittery and insecure.

When "value for money" is not met, patient party gets violent. They destroy property of Health-Mall, attack doctors/nurses, gather a crowd and manhandle hospital staff, threaten consequences, take legal course, go to consumer courts, hire a shrewd lawyer who picks at every loophole in the system; or worse, they blackmail the system to extract huge sums of money. As "face of the system", doctors are again at receiving end. The entire equilibrium in system again turns chaotic and makes every doctor jittery and insecure.

This explains "Why people attack"! But the question remains. "Why DOCTORS?"

We doctors have lot to blame and lot more to be pitied. We could do nothing when hospitals were replaced by Health-Malls. We could do nothing when power was taken away from us and given to MBAs. We could do nothing when money-hungry admins arm-twisted us to accept changed rules. Most of us were meek and weak to just nod our head to deteriorating standards of humanitarian consideration. Many of us just felt happy that we would earn more money and would be taken off the headache of managing "concession seeking" bunch. We had no idea of how future would turn against us!

Added to the woes were unscrupulous media and irrational policy-makers of Governance. Media has a huge role in demoralizing doctor profession. Even a 12th pass reporter or anchor gets judgemental without even making an attempt to understand reality. In fact, they don’t need reality; they just need "breaking-news", sensationalism, material to fill their 24 hour sojourn. They are not bothered about long-term impact of their stupidity and irrationalism over the society.

Government on the other hand cannot be left behind. With most of the politicians having a meaty portion in Health-Malls, the policy makers make sure their investment is safeguarded but a scapegoat is ready for blaming for any mishap. Doctors are such inevitable scapegoats! We are neither empowered to resist nor given an opportunity to explain our plight. We are just at receiving end of scathe. The worst part of the entire picture is that even the judiciary understands none of these nuances.

So, with no support from internal system, no understanding from media, no sympathy from policy makers or judiciary, we doctors are overexposing ourselves to angst and fury of the patients' kin. We have nothing to protect ourselves with. Our job makes us vulnerable.

This probably explains Why DOCTORS?

Overall, the scenario is complex. At one extreme is the vulnerability of hapless Doctors/Nurses; on the other end is the delirium and hysteria of patients' attendants. Given the complex nature of economic dynamics running the health-care today, conflicts are inevitable. Civilized conflicts like legal option damage the doctors personally and financially. Uncivilized conflicts like manhandling, assaults, media induced infamy harm us physically, emotionally and psychologically.

The most painful aspect of entire equation is that the actual culprits are not even in the scene. Business managers who run the Health-Malls and Policy makers of health care are the actual causes of conflict of this complex nature. But, they are not made accountable; no one asks them any questions; long term impacts their decisions are not even brought to the book. No one bothers to get into the roots of the problem to find a long-term solution.

By making counter-attack groups, asking for laws against attacks, asking our kids not to join this profession, we just applying Iodex over the abdomen for Appendicitis! It is either too short-living or being irrational. What we need is something as drastic as an emergency surgery to deal with a potentially life-threatening condition. There is no point in killing a mocking bird.

The million dollar question is: Is the government ready for taking any long-lasting action? Can we have a solid health-care plan that assures quality health-care at affordable prices for all segments of society? Can we regenerate the faith of public on the doctors? Can we restructure hospitals by deconstructing Health-Malls?

Can we? Can anyone?

Open criticism and caustic suggestions are most welcome!