Sunday, 1 January 2017

Medical Education Reforms in India - Too Little Too Late?

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
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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1 comment:

Anonymous said...

this is very good idea to raise the district hospitals to teaching level. It will sove lot of problems like malpratice and non ethical pratice and better quality patients care.