MEDICAL EDUCATION- WHERE DO WE STAND?

MEDICAL EDUCATION- WHERE DO WE STAND?

Medical teachers have been vested with the enormous responsibility of producing competent doctors. In a sense, they are the ones who safe-guard the health and well-being of millions of our population. The first step in safeguarding patient safety is the implementation of high-quality medical training and maintaining its standards by periodic assessment. The decision to permit a person to practice medicine cannot be taken lightly as it has enormous consequences for the health and safety of patients who may seek the services of this person at a later date. However, what goes on in the name of training and examinations during the medical course is far below the level of expectations. There is always a debate as to whether medical education in the country has deteriorated over the years. Older generation accuses of dilution in standards which is always questioned by present day students. Is this because of the angle through which one observes or is there any truth in any of these arguments?

Our challenge is to ensure that medical education reflects the evolving knowledge and ideas of contemporary practice, and the ever-changing expectations of society, while standing firm and resisting change to the core values of professional practice. Universities and medical colleges are responsible for operating a quality management system that designs, delivers, monitors and reviews medical curricula and assessment programmes to meet the standards. At what point should a medical student be held to account for upholding the standards of the profession which they will join in the future? Are we fully trained to meet the challenges of providing present day health care? Bearing in mind our purpose, which is to protect the health and safety of the public, it was important that we had the ability to investigate and satisfy ourselves that a graduate’s fitness to practice was not impaired. Good education and mentoring lay a solid foundation, but equally important is the attention paid to professional standards. Being a doctor is about more than being a scientist. It involves a commitment at the highest level. Commitment and ethics can’t flourish if the medical student neither cares nor understands their importance. It is a fact that our own graduates loose out in the competition for positions, based on merit. This applies to medical schools and residency programs as well.

The Medical Council of India (MCI) is the statutory body for establishing uniform and high standards of medical education in India. The Council grants recognition of medical qualifications, gives accreditation to medical colleges, grants registration to medical practitioners, and monitors medical practice in India. The Indian medical education system, one of the largest in the world, produces many doctors who emigrate to the United States, the United Kingdom, and several other countries. The quality of these physicians, therefore, has a broad global impact. Medical schools in India have rapidly proliferated in the past 25 years, reaching a current total of over 350. Accreditation by the Medical Council of India (MCI) emphasizes documentation of infrastructure and resources and does not include self-study. Initial assessment and periodic reassessment by the universities and MCI are not fool proof. India's large private medical education sector reflects the market driven growth in private medical education. Since the number of private institutions out number government institutions and income-generating "payment seats" are the norm in these private medical schools, achieving high standard will always remain a dream. Student selection need not be exclusively based on merit. Definitely their performance lack depth and need extra push to come out successfully. This ‘extra push’ is being provided in private medical schools, of course with the help of medical teachers. We do not have enough medical teachers to satisfy the needs. Hence visiting faculty is the norm in many institutions. They do come for assessment and examinations. What are they going to evaluate? The attitude of many medical teachers who accept examinership and come as examiners is appalling. The internship year under the aegis of medical schools in India, has suffered from lack of supervision and minimal assessment; it is often used predominantly as a time to study for residency entrance examinations.

This unregulated unequal growth leads to failing quality of medical education in the bargain of addressing an artificially created shortage of doctors. The doctor-population ratio has already exceeded that required by the country and there is mal-distribution of their services. This mal-distribution of medical manpower is centered on biased political will and seat purchasing power in the community. Whether increased numbers of doctors mean a higher quality health care delivery system is debatable. The menace posed by the unplanned growth of substandard medical colleges has to be curtailed and efforts should be made to ensure maintenance of standards. There is a strong case for a review of the entire system of medical education and examinations in the country.

The need of the hour is to generate highly committed medical practitioners who are willing to serve in the villages. Most of the doctors are pooled in the cities. Primary health care facility in the villages is far below the expected level. Medical council of India needs to take urgent steps to modify the curriculum keeping in mind the ever growing health needs of common man. More stress should be give for family practice. It should be made mandatory that medical graduates should spent at least one year after graduation in the rural villages before they are permitted for residency. Emphasis on family practice and promoting residency in Family Medicine are the two important areas to be focused. Family Medicine has consistently provided dedicated primary care and rural care doctors. Furthermore, family medicine residency slots are less in this country, and the overall goal of teaching and producing family physicians has been consistently discouraged by other specialties. I would like to point out that internal medicine residencies do not produce "primary care physicians," since the vast majority of internists will go for super specialization and turn away patients who want a primary care doctor. Health care administration should value primary care family medicine for its emphasis on longitudinal prevention, chronic disease control, and public health at lower costs.

Today because of technological advancement there is a fancy towards interventions. Every other disease is being treated with multiple interventions. Medical graduates always look towards this lucrative means of medical management and hence are after specialization and super specialization. Many fail to believe that most diseases can be managed with conventional methods. Patients are also driven towards this culture spending unnecessarily. This can be controlled by strengthening family practice. Many learned friends have questioned the methods followed in United States and United Kingdom. Their argument is that these systems will delay treatment. But our system is unscientific leading to multiple interventions and over usage drugs leading to high economic burden. Strict regulations to curb this practice should come from the Government. At the same time Medical Council and Universities should review the existing system of medical education in the country. There should be revision with a view to strengthen basic health care, rural practice and family practice. The three tier system of general practitioners, specialists and super specialists need to be retained but with a pyramidal structure where the broad base is constituted by general practitioners. The present system will only generate a pattern just opposite to this. More over unless we have adequate trained teachers, there is no point in opening new medical colleges. Medical council regulations are to be strictly followed and assessments made fool proof. There should be ways and means to penalize if MCI directions are ignored. Many a time this is not being followed or in rare instances the college will challenge the decisions in the court.

Dr Ravindran Chetambath MD, DTCD, MBA

Dean, Govt. Medical College, Kozhikode, Kerala