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!

14 comments:

  1. Dilip _medical studentAugust 5, 2015 at 6:50 PM

    Hey sir!
    You have just nailed the point.Reading the article i felt as if all that I had been feeling has been written.
    India should produce quality family physicians who can if they wish to pursue further studies .But the scenario right now is as u pointed out MBBS is just a certified qualification to write PG entrance exams..Things should change.Strengthening primary care will translate to confident doctors and restoring patient's trust in first line care and an effective check on quacks.Hope the idea reaches far and to those concerned policy makers.

    ReplyDelete
  2. Very impressive sir. This message has to reach each education minister of state and central minister as well and also to judicial sector. MCI is busy only with giving recognition to new medical colleges. Has it ever thought of changing the present pathetic medical education system ? Is it looking forward to change the regulations?
    The system is producing degrees not the quality doctors. The system making the the doctor greedy instead of service mind.
    We have to force to bring the changes....

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