Medical education in India.
Education needs no definition. In a hence, all life is a process of education. Its end can only be the improvement and extension of knowledge and its application to the life around us. Medical education occupies a crucial position as it involves a close and deep study of life itself and its vital proceses. It is no more a study of human illness and cure but a comprehensive body of knowledge dealing with health, and hence the productivity and well-being of the citizens. There is a growing awareness of the role of health development as a vital component of socio-economic development.
I have been impressed with the changing roles of medical colleges and medical education, as I do feel that inspite of all the criticism, medical education has made enormous strides in this country and elsewhere in the world. At the same time, there is also a growing awareness of our shortcomings and the constant need to change and modify. We see this as we go through the various conferences and seminars held by the Indian Association for the Advancement of Medical Education. We have several reports of commissions ranging from the Bhore Commission to Mudaliar Commission. Quite a few changes have been brought about, though not very speedily and effectively, but the main preoccupation and concern seem to be to make quantitative changes. We have achieved a ten fold increase in the number of medical colleges and the output of doctors, resulting in a large number of specialists and an equally impressive number of superspecialists. This has been largely unplanned and has only resulted in a marked increase in output without any thought for finding rewarding careers for them. Most of them get frustrated and join the westward flood. The promotion of medical colleges in the smaller cities in the districts has not made much of an impact on the distribution of medical manpower. The products of these colleges are more hardhit and the result is brain drain within the country. The overflow from the cities has always been to the west and now the flow is towards the African and Gulf countries. It is time we made a close study of this problem which is basically a study of manpower requirements. Perhaps it may involve painful decisions but these have to be made.
Regional considerations and communal reservations have caused considerable bitterness, because inspite of the good intentions, the seats seem to be grabbed by the relatively affluent classes. Backwardness has to be decided not on simple hereditary criteria but also rational grounds like economic backwardness. It is only when such persons are selected that proper justice would be done.
The present system of deciding the eligibility and merit on the performance at a single qualifying examination like 12th standard is also fallacious. There should be a premedical test and a paper to assess the motivation and aptitude. Such a screening would prevent recurrence of sordid episodes like the Kerala marks scandal.
We have tinkered long enough with the curriculum and contents of the course. But we have never considered the suitability of a single uniform course when it is known that the final evolution as a General Practitioner or a Specialist or a Scientist requires different courses at the undergraduate level itself. It is time to consider the feasibility of multi-channel courses (say an honours course like B.A. or B.Sc. in a subject deemed eligible for specialization) to suit different groups. This would cover the big gap now seen between the undergraduate course and specialities.
Three such broad channels can be identified, say for a family doctor, the specialist and the health scientist. In this way, it may be possible to plan manpower supply to fulfill the needs of a region or a state.
The next area of expansion is the scope and range of responsibility of a medical college. These have grown beyond the traditional boundaries. The role of a teaching hospital as a static centre to which people come for specialist treatment is no more valid. Preventive and promotive aspects of health have been added in recent years along with physical medicine and rehabilitation. The concept of convalescent homes and homes for aged has, however, not fully matured and leaves a lot to be desired as the number of old people increases. The problem of the aged and retired person is now engaging worldwide attention.
We also find growing interaction with social sciences, thanks to the introduction of Psychology and Psychiatry in teaching hospitals. The increasing use of sophisticated equipment has highlighted the need for close collaboration with engineering, electronic and computer sciences. The traditional medical college has grown into a medical centre of great complexity, bringing in tremendous problems of management.
Inspite of all this change and expansion, we do find a lot of dissatisfaction expressed, both by the people and their representatives. The main criticism is that of neglect of rural and remote areas and overproduction of highly trained persons with no corresponding increase in gainful employment.
The root cause of our problem arises from a mistake. This was the blind imitation of the Western model, which perhaps suited the English situation. This obsession with the Western model and standards has made our products misfits in our own society and perhaps unwittingly promoted brain drain. The truth is that the medical graduate finds himself more at home outside the country than at home.
So, the changes in the curriculum have to be brought about in a more rational way by assessing our own needs. But, who will determine these needs?
Every country, and within each country, a geographical region has its own problems. In a way, the socio-economic groups, the rural-urban settings and other parameters differ from country to country and from state to state.
There are broadly the medical needs of an individual and a community, and the mental health needs. The disease patterns and prevalence rates also determine the needs. These are best analysed by a statistical approach and sample surveys. Having scanned data, the priorities should be set up. Changes and reorientation should be brought about to make the education relevant to the needs of the largest group.
Proper vocational guidance should be made available to the medical graduate, so that reliable data and rationale thinking precede the choice of future career. Perhaps, we might even think of a larger share and inputs in public health so that such a career becomes attractive. To the traditional approach of how to provide clinical cure for individuals, we must provide and add care of well defined populations so that the medical student knows how to be useful to the community at large.
Excellence in medical education is not merely a vertical expansion and achievements. Maximum improvement of health, and relief of suffering within available resources should be our goal. There is thus a clear need to set up innovative models and bring about qualitative changes.
All this means a certain collective approach on the part of the medical faculty which is at present divided into rigid departments. This can be done by establishing a medical education cell, if not a department, in every medical college. The staff for this should be deputed by rotation from different departments for fixed period of 1-2 years. This cell should constantly review the methods of teaching, changing of curriculum, preparation of materials like audio-visual aids. Such a cell should also have a responsibility of conducting seminars and symposia, so that the medical teacher learns how to teach. We have for long assumed that a good student will become a teacher by simply observing another teacher. This has only produced stagnation. It is time we brought the modern concepts of pedagogy, educational psychology, etc. nearer to the medical colleges.
In due course of time, such a unit should be designated as a centre for educational development, at least one for each region or large state. This would also ensure a live contact with people and their needs. The task of continuing education is receiving attention everywhere. The expansion of knowledge is occurring so rapidly that apart from General Practitioners, even specialists working away from teaching institutions get. outdated and obsolete. Refresher courses for both these categories have to be organised so that the practice of medicine keeps up with recent advances.
As a medical administrator with an experience of running two large institutions, I can only add that all the changes suggested can only be brought about if there is freedom for doing so. This means granting a substantial autonomy or even the status of University. If Colleges of Pharmacy, Medicine, Dentistry and Nursing are grouped together they can form a viable University. A department of Life Sciences can be added to give a scientific base for such a venture. Such a step has proved beneficial for fields like agriculture and engineering, who have secured University status for their faculties. If a University is not feasible, provision of autonomy and freedom to run institutions be granted so that on the spot decisions are possible. It is time we realised that medical institutions have their peculiar problems and they cannot be run as a department of the Government.