Medical education--are we on the right tract?SK Pandya
Dept of Neurosurgery, Seth G S Medical College, Parel, Bombay, Maharashtra.
Keywords: Curriculum, Education, Medical, standards,Educational Measurement, Human, India, Teaching,
The panic generated as parents hunt for a suitable nursery school must affect the toddler. The situation worsens as the family joins the scramble for admission to primary and secondary school. Most households are scarred by the efforts at ensuring brilliant success at the 10th and 12th standard examinations. Every attempt is made by student and parents to obtain the best possible private tuition in all subjects from teachers known to assure 90% or more marks.
The definition of 'best' however does not include any reference to enthusiasm for the subject, a spirit of enquiry or even a broad-based understanding of principles and essentials. Rather it includes the prediction of questions appearing in the examination papers, the technique of answering them exactly as expected by dull examiners who teach and examine by rote, and the use of proven formulae guaranteed to fetch full marks. Deviations from the beaten track are strictly forbidden.
Add to these unethical practices such as the purchase of question papers, examiners whose 'assessment' of answers varies with the sum paid to them, or the manipulation of answer booklets and marks sheets at the boards of education or the university.
Any score less than 90 per cent has candidate and parents in a state of fright. In more such instances attempts are made to compensate for a low score by huge payments to ensure admission to a medical college -'donations' to trustees or 'capitation fees' to private medical colleges.
With this background, it is not surprising that undergraduates and postgraduates in our medical colleges continue to use these proven systems for success.
Teachers worthy of respect could correct this bleak situation. Over the four and a half years of undergraduate medical education, the inward God (en those - origin of the term enthusiasm) could have been irrevocably awakened in each student.
Does this actually happen? Or do our teachers continue to teach outdated concepts mechanically using techniques that bear no relevance to modern medical practice?
Do we teach our students the methods of science: deep study of existing knowledge, contemplation, conceiving a meaningful question, construction of a hypothesis, designing an experiment to find the answer, and integration of our findings into current intelligence? Do we encourage them to explore the frontiers of and the many uncharted areas?
Or do we thrust 'facts' down their throats and stifle questions? To what extent do we subordinate the transfer of wisdom and the fruits of experience to the modern God - the examiner?
Is the offer of private tuition in medicine to our undergraduates and postgraduates for a handsome consideration in keeping with the guru-chela tradition of passing on our art and science?
As an undergraduate, I was privileged to listen to Dr RJ Last, then Hunterian Professor of Anatomy at the Royal College of Surgeons of England. He was talking to us on his method of assessing a student appearing before him for an examination in anatomy. "Our goal is not to determine the extent of his ignorance. All of us are woefully ignorant. Rather, it is to find out what he knows of the subject." He gave us an example in osteology” do not hand him the pisiform bone and ask him to tell me whether it belonged to the right hand. Instead, I hand him the femur and ask if he knows where it lies in the body. Gradually, I lead him past the identification of its various parts to the muscles attached to it, important structures related to it and its centres of ossification."
I was also privileged to see such teachers as Drs RN Cooper, AV Baliga, SJ Mehta, RG Ginde, Homi Dastur and PK Sen examine candidates. Most of these giants possessed competence, vast experience, a deep understanding of the art and science of medicine and, at least as important, unchallengeable honesty. I have seen Dr Homi Dastur walk out of the examination hall for a brief spell after explaining to his fellow examiner that the candidate facing them was his student. He desired the other examiner to conduct his assessment without any hindrance or interference.
Questions in the papers were sharply focussed. Candidates were never asked to 'Discuss so and so'. Instead, 'what are the causes of acute pain in the right iliac fossa in a young adult female? How will you arrive at a diagnosis?' were the style of questions.
How do we select our examiners today? External examiners often come from relatively minor centres where little by way of complex procedures and nothing by way of research is attempted. Examiners from major institutions are cheerfully ignored. Who selects such examiners? By making such selections are we maintaining our standards or lowering them to that in the smaller centres? You will note that I do not even refer to raising our standards !
Are our examiners allowed to carry out their duties honestly? As an external examiner at some of our leading universities I have faced the following situations:
a) I was asked not to show candidates at the MCh examination in neurosurgery any intracranial or spinal angiograms as these were not commonly performed in that institute. 'Since the availability of the computerised tomographic (CT) scanner, why do we need angiography?' was a comment. I could not help asking how the department treated its patients with aneurysms, arteriovenous nalformations and vascular neoplasms. At another reputed institute I have been asked not to show plain X-rays. 'Since the availability of the CT scanner, our radiologists feel that plain X-rays are a waste!.
b) External examiners have been asked to pass obviously incompetent candidates for some strange reasons: (i) "He has already appeared four times and it is unlikely he can ever do better." (ii) "He is prone to marked nervousness and has therefore fared poorly but is, really, quite knowledgeable". (ii) "A near relative was ill shortly before the candidate appeared for the examination and he therefore couldn't prepare as well as he should..." (iv) "He is a candidate from the civil/armed services and if he is failed he will have to return to his original post and will be out of touch with the subject." (v) If the candidate can be passed, I (his teacher) will ensure that he will opt out of the teaching profession and restrict himself only to practice".
c) External examiners have been asked to disregard the results of the performance in theory papers and judge merely on the basis of the practical examination and, at times, even disregard the performance at the long/short case in favour of that at the other sections.
In our own university, despite the excellent system laid down wherein each examiner is asked to make independent assessment and submit individual grades, I know that this is followed more in the breach.
If we are so nonchalant about our standards of examination are we not doing irreparable harm to the system and to the public on whom we are letting loose obviously incompetent persons?
The University has a crucial role to play in the design of the curriculum, methods of teaching, monitoring the functioning of the various medical colleges and the examinations.
To perform each of these functions efficiently, without fear or favour, the university needs incorruptible individuals in all key positions. Do we truly have such persons in place?
These supposed watchdogs of the medical profession are intended to monitor general medical standards. The National Council also has the power to derecognise medical colleges not up to the mark. In the presence of obvious educational malpractices and total disregard for the basic, minimum standards in several teaching institutes, have these councils intervened for the better? How many of the manifestly and blatantlyso - wretched medical colleges has the national council derecognised? Are the teachers who from the inspection committees of these councils known for the excellence of their own centres? Are the councils reputed for their ability to stand up to political pressures?
The rot that pervades the medical establishment is compounded by the attitudes of those in power in Delhi and at the State capitals. Medical colleges are looked upon as sources of lucre and political gains.
Time and again we have been told that medical colleges and hospitals are a drain on the economy. Sadly, neither politicians nor bureaucrats see the tragedy in downgrading long established and reputed medical institutions in the public sector. The development of a scientific culture and fostering of research aside, even the day-to-day care of the sick poor and the making of what was once called 'the complete physician' has fallen by the wayside as the scramble for more 'capitation fee' medical colleges intensifies.
The answer must be a powerful 'No' for such an answer to be meaningful, however, it is necessary for the true believers in scientific medicine to develop close bonds and then act in unison to reverse the malignant current trends. If we turn away in disgust or voice a refrain often head on the streets (everyone is corrupt why fight the system?) then we leave the field open to those we privately condemn. The struggle to restore medicine to its rightful place as an art and a science, will be arduous, but is the end not worthy of it?