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

Convocation 2013

My dear young doctors, my dearest students I congratulate you on reaching this stage after all these years hard work. I should congratulate your parents too on supporting you during the course.

Today is the culmination of many years of your hard work and effort, which has been recognized by the award of this professional degree. You are now a true professional. This is an achievement in which you are entitled to take great pride. No doubt it also reflects the support and encouragement which you have received from your teachers and family members, and I trust you will give due recognition to that support and encouragement.

I am sure you do not need me to tell you about the competitive world which you are entering - a world where there are no boundaries. The way in which we have practiced is no more relevant now. Even the layman knows the minute details on all aspect of a disease. We have to consider this also when we treat patients. This is a new challenge which today’s doctor face. You are entering this arena with enormous advantage of a degree from this institution.

How you use this advantage is, of course, entirely a matter for you, I feel that the sense of fulfillment you achieve is through using your knowledge, your talents and skills to serve others, the needy, poor patients. You have the great advantage of a good education, which you can use not only to advance yourself in life, but also to help others.

As a principal I have been attending five consecutive convocation ceremonies. I should say this one stay high of all others. I have seen this batch through the years and during their internship. I am really happy to see your commitment and love to this institution. What ever small things have happened towards the growth of this institution, you are also a partner to that. I thank you for your contribution.

I wish you good luck through out your life

Thank you very much

Dr C Ravindran

Principal

Orientation Speech at WIMS Wayanad for the first batch of MBBS students on 19/09/2013

Dr C Ravindran

Principal

Govt. Medical College, Kozhikode

Dear students and parents

First of all I want to congratulate you, new students on reaching a destination like this. Your parents truly deserve the compliments. It is your hard work and their determination which brought you here. This day is yours. I am sure you are excited. There are few days in human life when one is truly elated.  The first day in college is one of them. 

As students especially the first batch of a new college you are extremely lucky. One of the truly great things in my view, about joining such a new institution, is the opportunity to truly build something new, and to do so with relatively few constraints, at least in comparison with most established institutions of higher learning.  I was thinking of my college, Govt. Medical College at Kozhikode probably the largest college in the state and one among few such colleges in the country. It is a 56 year old college. Every thing is well set. Students have only to move with the tide. But you can set new trends. Make this a new campus truly modern campus. I have only one or two things to tell you. Studying medicine is not that difficult. Only thing is to set reasonable goals, balance everything and not to take things too seriously. The biggest challenge for most students is time management. Please make sure that you use your time effectively. More than that, this course is not only for studying and writing examination. It is about experiencing everything in life. You have to observe everything around you. Then only you become a good doctor.

There are certain situations which you have to overcome like for example, disappointment, frustration due to loneliness. These are all what we experience in real life. It is good that you face this once in a while. Meeting these challenges in life and tackling these are all good experiences which will help you in future.

I share your sense of anticipation of the experience that awaits you all.  We all relish opportunity and challenge we have to change the way a college education is delivered, Of course in the long run, our success will be measured primarily by the accomplishments of our students, and the level of leadership they assume in the nation and world.

You, my dear students are lucky to have a campus like this. The newly designed buildings, the finest location in the country and the festive atmosphere are all great. I am sure that your enthusiasm and your commitment will take you and this institution a long way.

You have here finest teachers in the profession and a truly professional management. What else you need for a carrier. My only request is to use this opportunity and be a true professional.

Wishing you good luck

 Thank you very much.

Key Note Address- 1st Anniversary of ANGELS (18/02/2012)

Happy to participate in the 1^st anniversary of ANGELS (Active Network Group of Emergency Life Savers). It is nice to see that this is celebrated as Golden Hour 2012 with a caption: Caring for the people –bridging the gap”. We know that ANGELS is bringing a new culture in emergency medicine. It is bridging the gap-the gap between knowledge & practice.

I am only a fellow traveler of ANGELS, once in a while attending meetings like this. But I could palpate the pulse of this organization, the enthusiasm of its activists. It was evident when we experienced the mock drill at the air port.

I was thinking of pre angels era. Our attempt of emergency care was limited to hospital casualty. We know many patients are brought very late. They need management at spot, management at golden hour were we have to provide care for better outcome. Now at least we know that we could do something if not all.

Think of a cardiac arrest. It can happen at home, on the road, in the hospital. Those occurring in the hospital can be saved to an extent. What about others. Of the more than 300,000 cardiac arrests that occur annually in the United States, survival rates are typically lower than 10% for out-of-hospital events and lower than 20% for in-hospital events.^[When brought to the hospital the valuable time is already spoiled. Suppose we can give cardiac massage at site or defibrillate at site we could have saved the patient.

Targeted education and training regarding treatment of cardiac arrest directed at emergency medical services (EMS) professionals as well as the public has significantly increased cardiac arrest survival rates. Variation of CPR known as “hands-only” or “compression-only” CPR (COCPR) consists solely of chest compressions. This variant therapy is receiving growing attention as an option for lay providers. it is currently accepted that COCPR is superior to standard CPR in out-of-hospital cardiac arrest. The 2010 revisions to the American Heart Association (AHA) CPR guidelines state that untrained bystanders should perform COCPR in place of standard CPR or no CPR. Additionally, studies have shown that survival falls by 10-15% for each minute of cardiac arrest without CPR delivery. Bystander CPR initiated within minutes of the onset of arrest has been shown to improve survival rates 2- to 3-fold, as well as improve neurologic outcomes at 1 month.

Improvements in pre-hospital care have led to more rapid stabilization and transport of critically injured patients to definitive care. Despite this, cardiac arrest caused by trauma carries mortality rates of 81%-100%, even if managed early and aggressively. Increasingly, it has been recognized that continued CPR efforts on a trauma victim in the ED after failed pre-hospital resuscitation are futile and expensive. Study found that patients requiring CPR did not survive if they lost vital signs prior to hospital arrival.

Severely injured trauma victims are at high risk of development of the multiple organ dysfunction syndrome (MODS) or death. To maximize chances for survival, treatment priorities must focus on resuscitation from shock, including appropriate fluid resuscitation and rapid hemostasis. Inadequate tissue oxygenation leads to anaerobic metabolism and resultant tissue acidosis. The depth and duration of shock leads to a cumulative oxygen debt. Resuscitation is complete when the oxygen debt has been repaid, tissue acidosis eliminated, and normal aerobic metabolism restored in all tissue beds. Many patients may appear to be adequately resuscitated based on normalization of vital signs, but have occult hypoperfusion and ongoing tissue acidosis which may lead to organ dysfunction and death.

Another area is mass casualty and disaster management. At present this area is full of chaos. That is because of poor preparedness. There should be a disaster management team always. We know that they will not have any job for most of the time. But they can handle a situation much better than a naïve unit. Better training, available resources and good coordination are all important here. I am sure angels with its net work of life saving ambulances and dedicated team under able leadership can handle any situation what so ever

We are fortunate to have a unit like this in Calicut. Within one year it has spread its wings to whole of Malabar. More attempt at public awareness, targeted training to professionals and public are all need of the hour. In Medical College our attempt is to have a separate emergency medicine department with state of the art facilities and trained man power. We are looking forward to start MD in Emergency medicine and Critical care Medicine so that skilled man power will be siphoned out to this field. Medical College administration consider this as a challenge and a sizeable share of central fund under the scheme PMSSY will be utilized to improve emergency and trauma care. In this venture I request ANGELS to extend a helping hand to us for planning and executive at least in the initial years. Calicut medical College and ANGELS can have a mutually co operative and complimentary role in improving this particular discipline of medicine.

Thanking you and wishing you good luck

Dr C Ravindran

Photos of Book release

Hand Book on "Paediatric Respiratory Illness" Edited by Dr C Ravindran being released by Hon Chief Minister Sri Oommen Chandy on 11.02.2012