Edu-leaders

AIIMS, AIPMT, AFMC, BHU-PMT, CMC, JIPMER, DUMET, PGI ... a cloud of acronyms casts a shadow over students when they decide to take the entrance exams for medical colleges. For most, these exams are the culmination of years of stress and study, with the odds stacked against them.

Since numbers often speak louder than words, here are some figures: the All-India Pre-Medical and Dental Test for filling up just 15% of the MBBS seats in India has an intake of about 2,500 students – chosen from over 200,000 applicants. The situation is tougher for those entering the world of postgraduate medicine, with the number of seats being roughly half of those available for undergraduate study. In a situation like this, clearing the exams becomes an end in itself and more than half the potential doctors in the country fall by the wayside, or leave for foreign colleges if possible.

But after the struggle and strife, what do students study when they finally get into medical colleges? What is the quality of education they receive and is it relevant to the medical needs of the country?

The Medical Council of India (MCI) has also taken a hard look at these questions and is busy trying to find the answers. By the end of March 2011, MCI intends to roll out a reformed curriculum which aims ‘to make undergraduate education competency-based, open and participatory’. In this atmosphere of self-assessment and improvement, academicians and leaders from the top medical colleges are warming up to the idea of reviving the curriculum.

Dr A.K. Agarwal, Dean of Maulana Azad Medical College (MAMC), says, “An MBBS in India should be able to look after the common elements of human suffering and should know when to refer and where. These common ailments vary in different regions of the world. He should also be equipped with basic skills to handle an emergency. While we are working to achieve this goal, it is important to know that we are imparting all this knowledge to students theoretically.”

This theoretical approach to teaching, with an emphasis on rote learning and knowledge rather than aptitude, is at the heart of the matter. At the entrance level, students are tested for their knowledge of the sciences and little else. Given the sheer number of applicants, testing aptitude and attitude through interviews may seem impractical, but there is also no attempt to include life skills or ethics in the test.

Professor S. Mahadevan, of the Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), says, “If you have a good capacity for rote learning, you can come out with flying colours at the entry level. But we need to find out whether a candidate has an inquiring mind or is skilful. I don’t think we do any of those things.”

Once in college, the syllabus focuses almost exclusively on increasing scientific knowledge further, with only sporadic time and attention given to other areas. On the other hand, a quick survey of medical curricula in American and European colleges reveals the inclusion of subjects such as clinical and problem-solving skills, team management, ethics and legal responsibilities, areas that the curriculum in India tends to neglect.

Mahadevan, who believes in the need for such courses along with practical exposure, rues the current state of affairs. “The western world looks at the quality of each module that is adapted and whether or not the objective for which a module is formed is fulfilled. So an evaluation is inbuilt into the curriculum. But here, evaluation is an option. It is a luxury probably,” he says.

However, the future looks brighter as many medical colleges are now getting innovative with their curricula and working to ensure that graduating doctors possess the skills necessary to do their job. MAMC, for one, has identified some key areas and is using technology to fill in the gaps wherever possible. “Life support is an important area so we have started a surgical course to train undergraduate and postgraduate students. Nobody gets a completion certificate unless he passes the course. We also started simulation of basic surgical skills – how to pull sutures in a cut or wound, for example – and other areas where simulations are useful,” Agarwal says.

Manipal University (MU) has also revised its approach to medical education. Dr K. Ramnarayan, Vice Chancellor of MU and a man deeply committed to medical education in the country, feels a need for reform in the pedagogy. Of the curriculum in MU, he says,“Students are introduced to ethical and behavioural science principles, and basic cardiac life support. Problem-based learning (PBL), OSCE (Objective Structure Clinical Exam) and OSPE (Objective Structured Practical Exam) are regular activities within the curriculum. Research in medical education and the presence of a large number of Foundation for Advancement of International Medical Education and Research (FAIMER) Fellows in Manipal ensures that the curriculum is revisited regularly,” he says.

Manipal University also introduces students to aspects of humanities, social and behavioural sciences that are relevant to medicine.

While these individual efforts are laudable, the need for binding measures and change at the national level is being felt. Taking the biblical injunction “Physician, heal thyself” to heart, MCI recently introduced a flurry of new initiatives. While some proposed measures (like a common entrance test for all medical colleges) have met with opposition in a few quarters, most heads of colleges see the MCI’s involvement as a good thing.

Reiterating the need for change, Agarwal says, “There is no element of value addition in our system. Keeping this in mind, MAMC took the initiative and added subjects such as practical skills, ethics, doctor-patient interaction, etc. But instead of this being optional, I hope the MCI makes it mandatory so that students and colleges fall in line.”

The governing body of the MCI has, meanwhile, set itself a clear mandate for the future. Some of the key points include:
Increasing the current intake in medical colleges to target a doctor-population ratio of 1:1,000 by the year 2031 (at present the ratio in India is 1:1,700 as compared to a world average of 1.5:1,000)
Restructuring the MBBS course
Converting conventional education into competency-based modules to develop basic skill sets for a doctor
Clinical teaching from first year onwards to ensure early clinical exposure
Focus on integrated modular teaching

Of course, achieving these goals would mean surmounting another major obstacle in medical education – a dearth of good teachers. Lack of good teachers has become a refrain in many medical colleges as some qualified people prefer to practise in private hospitals and earn higher salaries, while others stagnate and don’t keep up with the changing medical environment.

As administrators deliberate over routine upgrading and assessment of teachers, technology might prove to be an invaluable ally when it comes to dealing with the abysmally low numbers.

Dr Ramnarayan says, “E-learning is now an established method at Manipal University. Teachers can produce learning materials that use a wide range of media for maximum impact. For students, it provides the ability to direct their own learning and explore teaching materials in a manner that is most efficient for them. Computers are a part of life for today’s generation of students, and barriers to the use of computer-assisted education are almost nil. Also, a lot of the equipment used in hospitals, pharmacy practice or engineering needs expertise in computer-based technology for their operations.” Technology can not replace the teacher, but it can be a time-saving device and learning tool.

It is clear that the medical fraternity in the country is aware of the challenges it faces. What remains to be seen is whether this awareness can translate into action so that aspiring doctors receive the education that they deserve. Mahadevan cautions, “We have models from other parts of the world and I think some of that will filter into our teaching and evaluation. But if we want things to look up, it should not stop with people in a meeting discussing all this over a cup of tea and then forgetting about it.”