Medical education in Maharashtra: The student perspectiveRS Hira1, AK Gupta2, VS Salvi3, MW Ross4
1 MBBS Student, Seth G. S. Medical College and K. E. M. Hospital, Mumbai, India
2 Indian Institute of Management, Ahmedabad, India
3 Department of Obstetrics and Gynaecology, Seth GS Medical College and KEM Hospital, Mumbai, India
4 University of Texas School of Public Health, Houston, Texas, USA
Background: There is hardly any structured study reporting the perspective of medical students, with regard to the medical education system in Maharashtra, which is facing challenges. Aim: A perception study of students was conducted to explore the situation, challenges, and consequent solutions of medical education in Maharashtra. Settings and Design: A descriptive perception study. Materials and Methods: A structured questionnaire was e-mailed to 92 students, and interviews with seven key-informants comprising of faculty, administrators, and policy makers were conducted, to gather qualitative insights. Results: Thirty-seven student replies were received and analyzed. The satisfaction level of student respondents for various factors was as follows: infrastructure 18/37 (48.6%), quality of teaching 14/37 (37.8%), patient population 22/37 (59.5%), and administration 8/37 (21.6%). Ninety-two percent (34/37) of the students stated that the fundamental problem was the inability of the system to attract good, quality teachers. The reasons stated were low salaries, low level of job satisfaction, high level of bureaucracy, and high work load. Conclusions: The medical education system in Maharashtra is viewed as being stagnant. The respondents emphasized an urgent need for educational reforms, which should include better compensation for teachers, sharing of facilities between government and private medical colleges, and improved efficiency of the Medical Council of India. In the long run a public-private mix with sharing of resources may be a plausible solution.
Keywords: Maharashtra, India, medical education, reforms
The state of Maharashtra with a population of 90 million has a doctor to population ratio of 1:1328  compared to the national ratio of 1:1667.  In India, the concentration of doctors is heavily skewed toward urban centers, with six times as many doctors in urban India as in the rural areas.  Hence, the solution is the need to produce more doctors as well as provide incentives for them to stay in India and work in rural and semi-urban areas.
The medical education system in India is crumbling under pressure of the changed dynamics of our society. ,,, The total investment in the health sector is a mere 0.9% of the gross domestic product (GDP).  Maharashtra produces just over 4000 doctors annually.  However, nine of 17 private colleges in Maharashtra are reportedly short staffed by 50 - 63%. 
The medical education system in Maharashtra, which at one time was considered one of the best in India, seems to have deteriorated, and the 15 government (public) medical colleges and 22 private sector medical colleges have been under constant pressure for failing to meet the standards required by the Medical Council of India. 
Under such circumstances the need for finding out the students' perspective about medical education is overwhelming. Recognizing the absence of structured studies in India, we designed a perception study of students, to explore the situation, challenges, and consequent solutions of medical education in Maharashtra.
Institutional ethical clearance was provided by the Indian Institution of Management (IIM), Ahmedabad, and informed consent was obtained prior to participation. A four-part pretested questionnaire was administered to medical students and key informants via e-mail. A key informant was defined as a person whose organizational and/or professional role implied that they had knowledge about the medical education system, its challenges, and possible solutions. 
The questionnaire consisted of four parts: Part I covered personal details and level of education of the responder. Part II dealt with the admission experience into medical school and the determinants of that decision. Part III tried to explore the core issues in medical training, and therefore, included questions on teachers, clinics, examinations, and so on, and Part IV tried to elicit opinions on the aspect of institution-building and what could improve them. The sample size for the descriptive study was calculated using EpiInfo 6.14. In the absence of any published data regarding satisfaction rates among students, it was assumed that 50% of the students were satisfied with the existing system of medical education, with a worst acceptable satisfaction of 30% (satisfaction score of th > 3 on a scale of 1 to 5). The required sample size was calculated to be 24 at a confidence level of 0.95. Along with this, face-to-face interviews were conducted by two of the co-authors, following the same structure, with a total of seven key-informants: three faculty members, two administrators, and two policy makers. The key informants were not included in the analysis. The responses of the key-informants were written individually by each of the two co-authors around predetermined themes, in a structured interview, and a consensus was reached with the senior authors. These responses thus provided qualitative insights to interpret the results of student responses.
Thirty-seven (40.2%) of the 92 questionnaires e-mailed were received and analyzed. Of the respondents, 21 (57%) were from government medical colleges and the remaining 16 (43%) were from private colleges. The respondents represented 12/37 medical colleges in Maharashtra: Mumbai (4/5), Navi Mumbai (2/2), Thane (2/2), Pune (2/4), and Rest of Maharashtra (2/24). Nineteen (51%) respondents were doing their internship, 11 (30%) of them were still between their first and fourth year of MBBS, four (11%) had completed their internship, and three (8%) were enrolled in a postgraduate course.
Thirty-two (87%) students claimed that their HSC (twelfth grade) syllabus was adequate for answering the multiple choice question (MCQ)-based Maharashtra medical entrance test, 96% had taken multiple medical entrance tests all over the country and claimed that other entrance tests had substantially different syllabi and focus, and felt that they were not able to prepare adequately for the other tests. The selection of candidates for medical colleges was solely based on their score at this medical entrance test. Six of the seven key-informants felt that the merit of the candidate should also include his/her social quotient, ability to communicate, and dedication to public health.
This was the main focus of our study. For the four components of medical education itself, the satisfaction levels of students were: infrastructure 18/37 (48.6%), quality of teaching 14/37 (37.8%), patient population at their medical college 22/37 (59.5%), and administration 8/37 (21.6%). Infrastructure: The library was the most important infrastructure component perceived by the students (32/37), followed by hostel facilities and the reading or study room. Internet access and IT infrastructure was not considered as vital for education. Usage of e-mail, E-groups, and online libraries was still very limited in any college.
Quality of teaching: Student-teacher ratios during clinics varied more in private colleges as compared to government colleges. Greater than 60% (13/21) of government college students and over 80% (13/16) of private college students reported that the number of students attending bedside clinics per instructor was greater than ten. A majority of students 20/35 (59%) felt that the curriculum itself was too theory-oriented and the rest found it well-balanced. None of them felt any need to reduce the weightage (in terms of percentage of their grade) for practical examinations. Eighty percent (29/37) believed that more responsibility and accountability given to undergraduate students, in the overall treatment and follow-up of their patients, would be beneficial. Over 80% (17/21) of the government college and over 60% (10/16) of private college students felt there was a need for organized student feedback for each faculty member and department.
Twelve of the 35 students (34%) stated that they had never been taught how to handle emotional situations involving patients and their families in spite of it being an important skill for doctors. Additionally, 21/35 (60%) said that they picked it up informally during internship, clinics, etc. However, it was clearly not a part of any formal course.
Also, 25/32 (78%) students stated that there were not enough checks and balances in the system to ensure that students stayed dedicated during internship and learnt the practical aspects sufficiently. Thirty-four of the 37 students (92%) and most (5/7) key-informants felt that the fundamental problem of the system was the failure to attract good teachers and this was leading to the deterioration of medical education. The reasons for this were low salaries and stagnation among academia, leading to low job satisfaction and high work load.
Low salaries of faculty: Regarding faculty, most (31/37) respondents stated that their salaries and pay packets were not competitive when compared to that of private clinics and hospitals. Thus, many dynamic and intelligent teachers were lost to private clinical practice. There was no middle ground for academicians to make money and teach as well.
Low level of job satisfaction: One of the main issues that emerged from discussions with the key-informants was stagnation among academia. Stagnation of medical education was in terms of curricula, application, and economic value. Teachers in government colleges had long hours, excessive patient load, little recognition from the college or students, and low academic freedom. They had little ownership over their students' courses, assessment design, and evaluations. They also expressed concern that there was little freedom to undergo further training and pursue academic interests. As a result medical education was being deprived of any reward in terms of intellectual pursuit.
High work load: Although excessive work load was consistently mentioned by 25/37 respondents during the course of the interviews, this study did not quantify this work load. Students and key-informants felt that these teachers were expected to handle multiple administrative responsibilities along with teaching and treating.
Patient population: The most significant disparity in satisfaction between government and private college students lay in the availability of a patient population at their respective colleges. Government college students had a mean satisfaction rating of 4.8/5, while that of private college students was only 2.7/5.
Administration: Satisfaction level of students, overall, was lowest with the administration and the bureaucracy involved. Along with the key-informants, 6/7 felt that the medical education system was poorly managed by bureaucrats who were nontechnical people and had multiple other responsibilities. The University itself decided on the syllabi, while the Medical Council of India decided on the accreditation. However, neither played a role in faculty development and incentives, which lay at the individual college level. The system appeared to be broken into too many pieces, each running at their own pace, without synchrony. No singular regulatory body seemed to have the 'bigger picture' in mind. Students also stated that they played almost no role in governing their own education system and had no influence over the policies of the University or the college.
Most of the respondents (31/37) were sceptical of the effectiveness of annual college inspections by the MCI. Government colleges were perceived to have consistently improved through regular and sincere efforts duly verified by the MCI (40% students said so). However, 11/16 (69%) of the private medical college students felt that their college authorities tended to manipulate the perception of services and infrastructure when the MCI inspections occurred. The key-informants felt this was due to the threat of losing accreditation and suggested that perhaps the MCI requirements were too outdated and impractical for these institutions to fulfill. One of the interesting findings was that most students (25/37) thought research was not a good investment of their time, as this would not play a role in their academic evaluation and career progression. There was also no system of 'electives' for students interested in research, to be given time away from other core clinical rotations, to pursue a research project. This was a disincentive for student research.
The Medical Education System in India has continued to suffer from the same problems since the 1980s.  Although the study was limited by not having representation from every medical college and a limited number of respondents, several important viewpoints could be elicited. One of the important finding of this study was that a more rounded approach is needed to be incorporated in selecting students for medical courses, which had to include 'soft' traits, such as, compassion, communication, and dedication toward public health. Similarly, adequate credit needs to be given to those students who wish to pursue research and become physician-scientists.
Many basic science departments have been dying a rapid death due to the lack of teaching faculty. The government has tried to salvage the situation with multiple rules, the most recent being the "Non-Practising Allowance" which pays compensation to teachers for a ban on them having a private practice.  In order to implement several changes such as retaining good teachers identified in the study, the medical education system has to generate adequate finances for infrastructure and teachers. The WHO estimates that by 2025 national systems will need to spend at least $10 more per capita to overcome the shortages of their health workforce.  In India, this can be done both through appropriate structuring of tuition fees and treatment cost. The tuition fee in government colleges has not been recalculated to parallel the rising cost of medical education. Students now have access to low-interest-rate bank loans to fund their tuition fees. Thus, the authors concur with some of the key-informant's beliefs that tuition fees needs to be increased along with the provision of scholarships and financial aid given to those who are at an economic disadvantage. At present there is a huge disparity in tuition fees between Government (Rs. 9,000 per term) and private institutions (Rs. 175,000 or higher per term), which needs to be considered.
A part of the solution perhaps also lies in educating the educators in the art of education. For example, in Canada, it was only in the 1930s that they realized the need to educate their teachers in the methods and means of delivering quality lectures. Thus, their clinical teachers are well equipped today to integrate preclinical and clinical sciences in the way they educate students. Bedside and small group learning has overtaken didactic lectures in overfilled lecture halls, which had provided limited opportunities to students.  Teaching in India is more authoritarian and passed down from 'God Professors' rather than a problem-based and interactive approach. Also, a feedback system needs to be set in place where students have a say in their own education. Regarding faculty, perhaps the idea of a separate teaching unit with a focus on teaching along with treating could be a workable solution in decreasing their work load. The idea of sabbaticals for further education and specialty training deserves a thought as well.
As one of the policy makers suggested, there should be a system of sharing faculty, patients, and knowledge, among institutions. Treatment charges at government hospitals are subsidized, causing an overwhelming burden of patients, whereas, private colleges have trouble achieving 50% occupancy. This results in the education of both streams of students being affected. Government college students suffer from lack of attention from the faculty due to high work load, whereas, private colleges suffer from lack of patients. This could be rectified by excess patients in the Government hospitals being sent to the private ones for treatment, along with the transfer of a percentage of funds that the Government would have spent on their treatment. This would be in the best interests of the patients as well.
A more long-term solution suggested by respondents and echoed by several key informants was the need for provocative reforms in the healthcare system itself. Instead of the government managing and implementing the social sector services, including medical education and health care, these should be revitalized by bringing in a public-private mix. This seems to have worked in other sectors such as telecommunication and could bring about a desired impetus to rural health systems. Undoubtedly, these reforms will be fraught with multiple political and economic challenges along the path of implementation, but a beginning has to be made. Further study into workable options needs to be done.
The authors are thankful to all the respondents for their time and effort during the conduct of the study. Special thanks to Dr. Jai Narain, Director CDS, World Health Organization, South East Asia Regional Office, New Delhi, for reviewing this manuscript.