Medical education reforms in India - Too little too late?
India is the second most populous
country in the world with a population of 1.3 billion. The numbers are an issue,
however, the diversity of our population is an important consideration as well.
This diversity is reflected in almost
every aspect of our culture and policy including education; this often is
worthy of celebration. However, when it comes to healthcare, this diversity
results in fragmentation. Without a unified approach we cannot improve our
performance in public health, which lags far behind other countries on nearly
every health and human development indices.
Therefore,
the need of the hour, is a robust system of medical education, which improves
the quality of doctors it produces.
When
we discuss health education we need to look at three important aspects:
a) the
selection of students,
b) their
training and
c) their
evaluation when they complete the course.
Till
this year we had problems beginning in the very first step, the selection of
students. In a country with multiple certification boards of school education
and varying standards, we obviously did not have a single system of entrance
examination. This meant every state conducted its own entrance examination. To
add to the complexity some of the private medical colleges indulge in
malpractices helping students slip through the cracks of such a fragmented
system. One of the most apparent manifestations
of such malpractice was the concept of “capitation fee”. A student who had
obtained a seat in one such medical college last year stated under anonymity
that he “booked” his seat in advance and entrance test was a mere formality. The
admission tests conducted by state funded colleges are not free from
malpractices either. In the newly formed state of Telengana, the admission test
was conducted thrice possibly because of similar issues in 2016, putting the
students through a lot of inconvenience and extreme uncertainty.
The
National Eligibility cum Entrance Test (NEET) was introduced in 2012/2013 for
entry into postgraduate and graduate courses. With the NEET it is mandatory
that a student should have a minimum qualifying mark to be in the merit list, which
is applicable even to private medical colleges as they also come under NEET
unlike earlier times when there were no such criteria. For political reasons
some of the states and the private medical colleges appealed against it in the
apex court. The court ultimately quashed the exam, calling it illegal. This
verdict was unfortunately pronounced after students appeared for the test and
exams had to be conducted again by the respective states for admission.
Again
after three years it could be reintroduced for graduate entrance in 2016. This
year too, plagued by confusions it was conducted twice. Later because of lack
of clarity the states were given the option of accepting or rejecting the test.
This resulted in windfall for private colleges which increased the fee steeply
because parents of children who would have let them repeat the test in the
normal course next year, if unsuccessful in the first attempt, crammed for the
seats paying hefty donations.
From
this academic year we are going to have NEET on regular basis for graduate, postgraduate
and specialty courses. This would at least curb manipulations in the conduct of
the test because it is an online test. This also ensures the students get a
qualifying mark to be in the merit list.
Dealing
a double blow to merit is the system of
reservations which being primarily caste
based instead of income based, results in quality medical education being put
even further out of reach of meritorious but economically backward students. Even
with NEET, this system of caste based reservation has not been done away with.
Moving
past the testing process, we find issues with testing methodology too. We still
persist with methods which tests only memorized knowledge and not the student’s
analytical skill. Likewise ,there is a gap in testing the student’s aptitude. There
is no method at the time of admission to check if a given student has what it
takes to become a doctor. The Charaka Samhitha, an ancient medical treatise
which dates back to 2nd century BC candidly describes the attribute
of a medical student. It states: ”The ideal medical student should be of mild disposition, noble by nature, never mean
in his acts, free from pride, strong of memory, liberal minded, devoted to
truth, likes solitude, of thoughtful disposition, free from anger, of excellent
character, compassionate, one fond of study, devoted to both theory and
practice, and seeks the good of all creatures”. No one could have put down more
succinctly what is required of a medical student. Not paying heed to these
words of wisdom over the years has resulted in generations of doctors who are
poorly informed and unprofessional.
The
problems, unfortunately, do not end with selection process and continue into training.
There has been no major change in the curriculum, which continues to encourage
rote learning. It is not formulated according to requirements of the population
which the doctor under training would be catering to, but focuses on a learning
a lot of theory. Such a curriculum fails to inspire students, whose studies are
getting so diluted that they would choose to read study guides instead of text
books. None of these augur well for the training of good doctors. This issue
was addressed in the Vision 2015 document, which was drafted by a Board of Governors
who took over from the MCI. The blueprint, which covered both graduate and
postgraduate education, detailed an entry level exam which is common, a
curriculum which has both horizontal and vertical integration where the
students are trained in basic sciences, lab sciences and clinical sciences from
first year onwards and a nationwide common exit level exam before the degree is
awarded. The whole process is yet to be effectively implemented though the
document was drafted in 2013.
The
infrastructure in government funded colleges leaves a lot to be desired, due to
the inadequate budget allotment to health and education. A mere 4.05% of the
GDP is spent on health, which funds government hospitals which are supposed to
be training the medical graduates. Even what is allocated is not fully spent, due
to the leakage of funds at all levels. Added to this is the shortage of faculty
who, because of better remuneration choose to work in private hospitals. The
private institutions also do not spend their revenue on upgrading the
infrastructure after their approval and do not most often have required staff.
Realising
the need for the long awaited reforms in medical education, a three member
committee of the NITI Aayog drafted the National Medical Commission Bill 2016
which would replace the Indian Medical Act, 1956.This in itself is a topic for
discussion. The draft bill, aimed at bringing about a complete reformation has
flaws which require immediate correction. The most important one is the issue
of fee capping in private colleges, which is not clearly spelt out, which means
deserving students inspite of a good rank in NEET, may not have access to most
of the seats due to non affordability.
The
next major feature of the bill which may be self defeating the purpose of
improving the quality is the proposal of allowing “for profit” medical
colleges. Though the rationale for this may be the need for increasing the
number of colleges to meet the demand, this would once again bring in the
private players whose intention of starting a college would be commerce. We
have now 426 colleges, nearly half of which are private. One proposal that
frequently comes up to overcome this problem is to upgrade large district
headquarters hospitals to teaching hospitals.
If we
need to have a medical education system that would be comparable to the rest of
the world, we need to pay attention to student selection which should be purely
merit based, infrastructure, training and their evaluation. This is the only
way to produce doctors who would be able to face the unique challenge s faced
by the society and health care industry.
Dr
Usha
Physician
Hyderabad, India
All
views in the above write up are the personal views of the author (and not that
of this blog site)
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