Year : 2013 | Volume
: 1 | Issue : 1 | Page : 80--84
Medical education in India at crossroads: Issues and solutions
Vice Chancellor, Yenepoya University, Mangalore, Karnataka, India
Vice Chancellor, Yenepoya University, Mangalore-575 018, Karnataka
India has not been able to achieve the target of «DQ»Health for All«DQ» so far. The burden of diseases in India still remains large. There is a wide gap between the requirements and availability of doctors especially in rural and outreach areas. Even the available doctors do not have the clinical competencies or mental make up to meet the healthcare requirements of the village population in India. Hence an overhauling of medical education has become inevitable at this point of time. Significant curricular changes reducing the theory component to the minimum and transaction of the curricular content through electronic learning mode with horizontal and vertical integration of pre-clinical, para clinical and clinical subjects assigning more time for clinical teaching will bring up a new generation of clinicians of first contact with the required clinical competencies and right attitude.
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Chandramohan P. Medical education in India at crossroads: Issues and solutions.Arch Med Health Sci 2013;1:80-84
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Chandramohan P. Medical education in India at crossroads: Issues and solutions. Arch Med Health Sci [serial online] 2013 [cited 2020 Jul 3 ];1:80-84
Available from: http://www.amhsjournal.org/text.asp?2013/1/1/80/113588
Today, we are living in the era of knowledge explosion where availability of healthy and knowledgeable human resources have become the most crucial factors for development of any society. So much so health and education have become the top priority items for all the countries in the world, and India with a second largest human capital cannot shy away from the responsibility of effectively utilizing the rich human capital available with it.
The present status of health in India if critically analyzed one can easily understand that we are far behind the targets we ourselves had set. Government of India had been a signatory with many other countries in the world to achieve the target of "Health for all by 2000 A.D.," but, this national goal is yet to be achieved. While the disease load in developed countries is mainly due to the non-communicable disease, India has a dual challenge of facing both communicable and non-communicable diseases.
As MCI rightly points out, the burden of disease in India still remains large and the availability of doctors to handle this challenge is quite inadequate in quantity and quality.  There is a conspicuous disparity between the rural and urban population with regard to access to even primary health care.  There is a wide gap between the availability and the requirement of physicians of first contact and specialists in rural and outreach areas, which Mahatma Gandhi described as Soul of India. Needless to say that there is a need for further expansion of medical education facilities at graduate and post- graduate levels.
The present doctor population ratio is 1:1700 in India,  and the MCI is targeting to achieve the doctor population ratio to 1:1000 by the year 2031. This statistics in fact does not reflect the gravity of the situation faced by the rural India. The need of the day is to have more number of doctors who are well equipped to tackle the healthcare requirements of the 21st century. But, increasing the number of doctors alone will not solve the problems in the healthcare delivery system. The graduates coming out of our medical colleges are somehow not found to be competent to face the emerging challenges in the healthcare sector, especially in the rural and outreach areas. Our Physician of first contact available in the villages are more theoreticians, and they rely on investigations, which are prohibitively expensive for the diagnosis of diseases prevalent in the poor village community. They lag behind in clinical competencies, communication skills, and ethical literacy. They do not have the right attitude towards the ailing and obviously are not able to gain the confidence of their patients. In short, the graduates coming out of our medical colleges are not properly equipped to tackle the healthcare needs of our society. Training imparted in our medical colleges neither makes them competent in clinical skills and problem- solving skills, which are the vital components of clinical competence, nor does it make them conscious about their moral, ethical, and legal responsibilities.  This eventually results in increased number of litigations and even physical assaults on doctors and hospitals alleging negligence, misconduct, and other unethical practices. The situation is made more complicated through commercialization of medical profession, which further undermines honesty and integrity of the medical professionals and promotes unethical practices of the worst variety.
The only lasting solution to this most undesirable situation is to put in an all out effort to bring up a new generation of medical professionals with strong conviction and commitment to moral and ethical values and profound knowledge in clinical and communication skills. To achieve this target, a total overhauling of medical education is required.
• Selection of the right student with the right aptitude and attitude for medical education
In the present system, the students are selected on the basis of various entrance examinations conducted by various agencies where the cognitive ability and the memory power alone are being measured. So much so, very often, the candidates selected does not have the right attitude or aptitude to enter into the medical profession where they are expected to learn the divine art of 'healing the ailing.' In this context, it is worth examining some of the unique features of the healthcare delivery system in India during the pre-colonial period. In fact, India has one of the richest heritages in medical education and healthcare delivery system. Healthcare delivery in India can be traced back to the time of Indus Valley Civilization; Excavations of Mohenjo-Daro and Harappa had revealed a well-developed healthcare delivery system giving importance to primary level of healthcare. Excellent drainage system for the disposal of waste, availability of unpolluted drinking water, environmental hygiene, personal hygiene, etc. were some of the salient features of Indus valley civilization. A formal education system seems to have been evolved by the Buddhist through the University of Nalanda. The Chinese traveler Hiuen Tsang has given a vivid description about the department of medicine at Nalanda University. Athreya was the first head of the department of Medicine, and Charaka was his student. Charaka subsequently made a historic creation 'Charaka Samhitha,' which apart from describing the human ailments on the basis of tridoshas and the formulations to treat a wide spectrum of diseases, he prescribed a procedure of selecting a student for learning the art of healing the ailing.
• Innovative strategies to revamp medical education
Dr. M. S. Valithan has given a vivid description about this procedure, through which candidates with high level of cognitive and emotional attributes are selected for medical courses at University of Nalanda. Medical Council of India has also accepted this principle of conducting an effective screening test to ensure that the medical student joining medical education has the aptitude and right attitude with strong moral and ethical conviction to learn the art of healing the ailing. But, somehow, the Medical Council could not find out an effective and objective method of evaluating the aptitude of the student seeking admission to various medical courses. One of the challenges that medical education is facing today is the formulation of effective gadgets that can be used to measure the aptitude of candidates seeking admission to the medical courses. If Medical Council of India is not able to do this job, they can seek help from agencies like Indian Institute of Management to formulate a procedure, through which emotionally competent candidates from the crθme of intelligentsia can be identified for medical education.
• Curriculum Development and regular updating
In this era of knowledge explosion, curriculum development is one of the most difficult task in education, especially so in medical education. , Concepts are changing, and techniques are changing on a day-to-day basis. To keep pace with the changing scenario, basic curriculum proposed by the regulatory bodies viz., MCI, DCI, INC, etc. need to be regularly updated at the university level. Apart from updating the content, the members of subject wise Board of Studies in each University should seriously consider the volume of the content also, especially in the undergraduate curriculum. There is no definite demarcation defined between graduate and post-graduate curriculum. With the result, the undergraduate students are over burdened with too much of theoretical knowledge, but with less time assigned to acquire clinical competencies. So much so, the curriculum needs to be re-designed in such a way that the content is divided into essential for graduates desirable for graduates and not to be taught at undergraduate level.  The Board of Studies must be able to allocate the optimum hours required for transacting essential theory content assigning more time for giving proper clinical training. In the revised syllabus prescribed according to VISION 2015 document, this purpose is taken care of. After two months of foundation course, the students get clinical exposure from the first year onwards and student becomes a part of the medical team treating the patient, and the student is to be designated as student doctor or clinical clerk. Each student is to be assigned with specific number of patients, and student will be actively involved in the documentation process and execution of treatment. He will be allowed to do procedures under supervision. This sort of intimate contact with patients will enable the student to acquire clinical competencies and moral and ethical literacy required to build up the right attitude expected from a doctor or a clinician of first contact. The new syllabus proposes horizontal and vertical integration of basic sciences, lab sciences, and clinical subjects, which should be the right policy for tomorrow. Case-based learning of Anatomy, Pathology, Physiology, Pathology Physiology, Microbiology, etc., after demonstrating the clinical case and getting the students involved in the diagnosis and treatment of the case will certainly equip the future medical graduate with more clinical competencies.
• Teaching Learning Process
The existing MBBS course is divided into 3 phases. The first phase is dedicated to learning basic sciences or pre-clinical subjects, Anatomy, Physiology, Biochemistry and lasts for one year. The second phase is dedicated to learn the lab sciences or para-clinical subjects viz., Pathology, Pharmacology, Microbiology, and Forensic Medicine, which lasts for 1 years. The 3rd phase is the last 2 years of MBBS and is divided into part I consisting of Community Medicine, ENT and Ophthalmology and Part II consisting of Medicine, Surgery, Pediatrics, and OBG.
Each subject is taught as a water tight compartment, and horizontal and vertical integration is quite minimal, even though MCI regulation just mentions about the importance of horizontal and vertical integration. A combined horizontal and vertical integration making an opening into contextual learning certainly gives an unique learning experience. For e.g., show case of goiter to the student and start with clinical presentation and then anatomy and physiology of thyroid, biochemistry of thyroid hormones, pathological anatomy and patho-physiology of goiter, other lab investigations, diagnosis and treatment gives a learning experience different from just learning anatomy of thyroid or physiology of thyroid separately.
As envisaged in VISION 2015 document published by MCI, the clinical exposure should start from the first year and every student should become a part of the medical team concerned with the clinical management of every patient. 
The duties and responsibilities of each student doctors should be well -defined, and the clinical skills to be acquired by the student doctor in each year should be spelt out in the curriculum and meticulously monitored.
• Problem-based learning ,
Actually, the bedside learning during the clinical posting of MBBS is a form of problem- based learning, and the student acquire problem-solving skills if they are made an integral part of patient management system. While looking after the patients in the ward as student doctors, they get plenty of opportunities to face a variety of problems related to patient management and they learn to solve them.
• Introduction of e-learning system - Yenepoya experience
To inculcate self-learning and interactive learning, Yenepoya University has introduced e-learning system  for MBBS and BDS courses through an in-built software "YENGAGE." The content to be transacted in each class is uploaded by a specific faculty assigned by the HOD. The content is always followed by a PowerPoint presentation, which is also uploaded before the lecture. In this way, the student gets an opportunity to go through the content of the PowerPoint presentation before the lecture. After the lecture, the faculty opens a forum, which is an online interactive session where the teacher posts questions and the student responds. The students also post their doubts and questions, and the teacher has to respond. The students are being continuously evaluated objectively on the basis of forum activity by the faculty. After each topic, the teacher arranges an online exam also. This is one of the simplest forms of e-learning that can be emulated by others.
• Sensitization of students to Hospital Information System - Yenepoya experience
On the clinical side also, the students are to be made familiar with hospital information system. University has managed to procure suitable software for the purpose and named it as Backbone. The post-graduates and interns are now assigned with the responsibility of entering the clinical findings, investigations, and treatment dictated by the faculty into the Backbone in the outpatient departments and inpatient wards. When the student doctor system is implemented, the entire documentation will become the responsibility of the student doctors.
• Problem of getting enough clinical material for teaching purposes
One of the great problems that the medical education institutions are facing today is the lack of clinical material for teaching purposes. Fortunately, in India, in 1970's and 1980's, one of the advantages that our country had in medical education was the availability of a large volume of patients willing to be examined by medical students. This facility has considerably come down due to various factors in the last few decades. But, the situation can be solved through a multifaceted approach.
By introducing student doctor system, where student becomes an integral part of the treating team, he gets an opportunity to build up an intimate relationship with the patient, which can further develop the level of confidence in the patient and create a feeling that the student also is his own doctor who is actively involved in his treatment. This will also go a long way in motivating the students to build up ethical and moral values and communication skills so as to enable him to influence the patient to be co-operative to discharge his duties as a student doctor.
As envisaged in the VISION 2015 document, when the platform for clinical training is extended to primary and secondary level hospitals, the volume and variety of clinical material for teaching purposes will naturally increase considerably.
In spite of the above measures, in future, most of the patients will not like to become clinical material for teaching purposes like what is already happening in the developed countries. Under such circumstances, we have to reduce the usage of clinical material for teaching purposes to the barest minimum possible. To achieve this, the following alternatives are found to be effective.
Training of clinical examination including general examination, systemic examination, and local examination are demonstrated in role players or simulators. The students are taught to elicit clinical signs similarly in role players and simulators. Hands on training can also be imparted on simulators. Investigations and therapeutic procedures can also be taught on simulators before the same procedures are carried out on patients by the students and the interns. This new development necessitated the requirement of establishing a central simulation lab and a skill lab in most of the standard medical education institutions.
The existing evaluation system has become obsolete and evaluates only the memory power and gives no room for an objective assessment of knowledge and skills. With the introduction of choice-based credit system, continuous evaluation has become the choice of evaluation in the Arts and Science Colleges. In medical education also, we have to evolve the indicators for a continuous objective observation and assessment of each student by his own faculty instead of conducting summative evaluation at specific intervals as is followed now. Instead of using patients as clinical material for evaluation of clinical competencies of medical students, time is ripe for us to bring in healthy role players and simulators to the maximum extent possible and minimize the use of actual patients for educational purpose. OSCE  and OSPE should be made integral components of clinical and practical exams for various subjects.
Three basic objectives of education whether it is medical education, technical education, or general education are to acquire knowledge, disseminate knowledge, and create new knowledge. Though India has the largest number of medical colleges, we are far behind in the creation of new knowledge. This is far from desirable and needs to be addressed in a systematic way. A research culture is to be developed in all our medical educational institutions starting from graduation. Such a provision is available in the UG curriculum prescribed as per Vision 2015. In the case of PGs and faculty, MCI has already initiated some regulations insisting on minimum number of presentation and publications. But, further efforts are required at the university and institutional levels to promote research at UG, PG, doctoral, and post-doctoral levels.
Community medicine postings give an exposure to community-based approach to the various components of healthcare delivery, and this can be further strengthened when clinical training is extended to primary and secondary care hospital.
• Extension activities
Yenepoya University, apart from the activities of the Departments of Community Medicine, Community Dentistry, and Community Nursing, has established a separate Directorate of Rural Health to take healthcare to the rural and outreach areas and sensitize the students to the healthcare requirements of our rural population. Special programs in the form of "Yen Care on Wheels," Door delivery program, Awareness programs on an relevant health issues like HIV, AIDS, tuberculosis, malaria, cholera, dengue fever, etc. are conducted. Students initially mix with the rural and tribal population, and while solving their health problems, develop the qualities of love and compassion for the less privileged.
As was mentioned earlier, today we are living in an era of knowledge explosion. The entire world is open to the graduates and post- graduates coming out of each medical education institution. But, "Struggle for existence and survival of the fittest" has become the rule of the day. The current mission of medical education is to bring up a new generation of international medical graduates who can compete with their counter parts anywhere in the world and come out as the fittest after even the toughest struggle.
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