Year : 2014 | Volume
: 2 | Issue : 1 | Page : 96--99
Humanization of medical education: Need of the hour
K. A. Kumar
Professor of Psychiatry and Sr. Consultant in Behaviour Medicine, Sree Gokulam Medical College and Research Foundation, Former Director of Medical Education, Kerala and Former National President of the Indian Psychiatric Society, Trivandrum, Kerala, India
K. A. Kumar
Sree Gokulam Medical College and Research Foundation, Trivandrum, Kerala
Though the importance of psychological factors in maintenance of health, as well as etiology and prognosis of diseases have been recognized in ancient medicine by discerning and thoughtful clinicians in all ages, for the large majority of the practitioners such a perception has not been there. A cross-sectional, organ-based, and symptom-centered clinical approach was largely prevalent in day-to-day medicine. Medical training also followed more or less the same path. The positive psychological and behavioral qualities needed in the physician are left to the individual student to develop on his own during studies or to the physician afterwards. Some do, many do not. The importance of communication, doctor-patient relationship, empathy and psychological sensitivity in the making of a physician started getting identified in advanced medical universities in western countries by the middle of the last century. Since then behavioral science and medical humanities have been incorporated as important modules in the graduate medical training curriculum not only in advanced western medical universities, but also in good universities elsewhere. The situation in India, till now has been quite unsatisfactory. The undergraduate medical students had only 2 weeks of clinical posting and few hours of lectures, allotted for psychiatry: Even these were not actually carried out in many institutions properly. Responding to repeated representations from mental health experts in the country and abroad, medical universities and educationists, the Medical Council of India in 2012 has made 2 weeks of Residential Internship in Psychiatry (CRRI) mandatory, and also recommended incorporation of medical humanities in the MBBS curriculum. The paper presents a brief outline of how a Clinical Behavioral Sciences Training Program l incorporating medical humanities can be developed and carried out as a mainstream component for the undergraduate medical training in the country. The author points out that, if medical administrators and medical teachers take it up in right earnest, it would be the most significant contribution to humanize medical education in the country-which is precisely the need of the hour in the field.
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Kumar KA. Humanization of medical education: Need of the hour.Arch Med Health Sci 2014;2:96-99
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Kumar KA. Humanization of medical education: Need of the hour. Arch Med Health Sci [serial online] 2014 [cited 2020 Aug 7 ];2:96-99
Available from: http://www.amhsjournal.org/text.asp?2014/2/1/96/133847
The importance of mind in gaining maintaining and enhancing health has been recognized by thinkers and philosophers from times immemorial. In ancient times, the role of psychological factors, in the causation, course and prognosis of diseases have been recognized in clinical medicine. This has been stated in the history of modern medicine and evident in the prevailing concepts and clinical practices of many indigenous systems of medicine as well. , The importance of positive attitude, hope, prayer, meditation and such, in facilitating and augmenting therapeutic of benefits of treatment has been well recognized by native healers, indigenous therapists and by thoughtful practitioners of modern medicine in all ages conceptually, and more significantly, practically.
The limitation and reductionist nature of a mechanistic organ-based and symptom-centered approach in clinical medicine has been well-recognized by thoughtful physicians in all ages. A nondualistic clinical approach, taking into consideration the mental status and processes of the sick person, along with the pathological aspects of the illness and technical aspects of treatment has been the hall mark of the a "good clinical practice," they all evolved and carried out.
Of course, the terms bio-psychosocial and holistic were not yet born until few decades ago but the message and the mission the terms embody, have been already imbibed by the discerning ones in the "healing profession."
While perceptive, thoughtful and sensible clinicians have had always realized the importance of psychosocial and behavioral factors in good clinical practice, and incorporated it in their clinical approach, such a perception and practice were not there in the day-to-day clinical care executed by the large majority of medical practitioners. They have not moved beyond the patients' symptoms and signs and laboratory data in evaluation, and beyond the drug formulary-often the manufactory's brochure or product manuals - in treatment planning and delivery. Meaningful communication with patients and family members is often at a very low and functionally inadequate level, the doctor-patient relationship is shallow and insipid and delivery of clinical services is mechanical and routinized.
The situation is more unsatisfactory and unfortunate in the higher levels of medical care. While the primary physician, working in the rural, and to some extend even in urban areas, would necessary imbibe some psychological sensitivity and behavioral skills, as he works with its population, most of specialists and high end consultants, often wedded to their clinical skills and latest technologies (and as much to their professional pedestals, as well) neither feel the need or have the sensitivity to imbibe such psychological sensitivity or acquire such behavioral skills. The cardiologist who keeps on doing catheterization on patients, one after the other, the gastroenterologist who complete a heavy "scopy" list each day, the psychiatrist who has a long daily list of electro convulsive treatment or narco-analysis, or for that matter any consultant or specialist or super specialists - all of them undoubtedly help many patients and serve well the institutions they work. However, a clinician who lacks psychological sensitively is liable to miss out the psychosocial co-factors that could be important in causation, and course of his clients' morbidity. Lacking the communicative and behavior skills, his therapeutic potential also could be impaired. This handicap in clinical approach is more seen prevalent and consequential when handing chronic diseases, where the interplay of psychosocial and psychosocial factors is much more significant. The clinico-pathological profile of the patient population getting transformed, with the preponderance of chronic life style diseases and enduring disabilities, effective clinicians, needs to have the psychological sensitivity, sensibility and behavioral skills, as much as technological skills and competence.
Lacuna in Medical Education
Given this situation, the meager coverage, rather the noncoverage, of Mental Health and Behavioral Sciences in the curriculum for Undergraduate Medical Education in our country that prevailed until now has been a gross deficit and glaring lacuna. Psychiatry was included as a minor course content that comprised of 12-14 theory classes and just 2 weeks of clinical posting, to familiarize the medical student with signs and symptoms of common psychiatric disorders and their treatment in a general way. Even this minimal course content was not adequately imparted in many a medical college, which did not have a proper Faculty Unit in Psychiatry, or if it were there, was not functionally active or viable on the teaching side. Psychiatry Departments of many medical colleges had been attached to mental hospitals and neither the teaching faculty nor the students regularly visited these institutions or felt comfortable, teaching or learning in the squalor and misery prevailing in these institutions. From 1975 onwards, more and more General Hospital Psychiatry Units started getting opened up in teaching hospitals, district hospitals and faculty positions in psychiatry got attached to these units. This was a welcome change and medical students could enter into clinical realms of general hospital psychiatry settings, with an easy and facile mind set just as in to other clinical disciplines. Though not all, most of the psychiatrists in the faculty have been enthusiastic about taking classes for students. However in many institutions, the academic administration was not inclined to give more teaching hours or more suitable teaching hours to cover psychiatry topics. Often the clinical posting in psychiatry could be set on the forenoon of sessional examinations or close to university examinations, or clash with college festivities or general festivals. If the psychiatry clinics are taken well a good number of students would sacrifice their last hour examination preparation or festivities and come for their clinical posting or classes in psychiatry. If the teacher or class in psychiatry is not good this does not happen. Since there was no systematic/mandatory coverage in examination, neither the student nor the academic administration used to take the teaching deprivation in psychiatry seriously. Any student could pass MBBS, without attending to a single day in the psychiatric clinic, even with distinction.
Initiatives, Changes, Promises
Efforts to bring home the importance of ensuring a reasonable coverage of psychiatry and mental health in undergraduate medical education started in 1970s. Indian Psychiatric Society has conducted a series of workshop, interacting with Medical Council of India (MCI) and Ministry of Health (MOH). The teachers and medical educators who had occasion to visit or involve themselves with medical education in advanced western universities realized the importance and emphasis given to psychiatry, Mental Health and Behavioral Science in their graduate medical training programs.  Many of the young medical graduates from India who proceeded to USA or UK for postgraduate studies had to get additional training in psychiatry to get into the selection field. The MCI, and the MOH, Government of India have decided to enhance the coverage of psychiatry and behavioral science in MBBS curriculum in response to these perceptions and efforts. Two weeks of clinical psychiatry training has been made mandatory during internship, which ensures that no medical graduate would get eligible for full registration to practice medicine, unless he has 2 weeks of training in basic tenets clinical psychiatry.
Behavior Medicine Inputs
Clinical psychiatry is not just the essential mental health component of be importance to the young physician. Psychological sensitivity, empathy, and communication skills are essential behavioral skills, needed to build up a good doctor-patient relationship. These also need to be imparted to the medical graduate in an effective way. Systematic exposure to medical humanities during the graduate course in a phased manner through role modeling and participatory group learning methods could set up the inner psychological substrate in the student to develop their behavior skills. It is gratifying to note that the MCI has taken cognizant of the role of and need for medical humanities in undergraduate medical education and has recommended incorporating it in the curriculum. 
While his is welcome and promising, the real issue is how effectively the training in medical humanities, communication skills and clinical behavior skills can be imparted to the medical students.  There is no point in arranging few lectures by so called Communication Experts/Behavioral Scientists or Humanity Specialists or even entrusting them to arrange few "workshops" on these topics. What is required is to groom up a set of clinician teachers, from among clinical teachers who have an interest in imbibing the behavioral and humanistic dimension of clinical medicine and learning the skills to impart it to their students, using the clinical situation as teaching substrate. Possibly quite a few faculty members in psychiatry are suited for taking such a role, but, I would state based on my experience, certainly not all of them. Similarly, there would be other clinical teachers (physicians and surgeons) who can be sensitized, trained and drafted into the program. It may be a practical idea to designate the Department of Psychiatry of all medical college, and Department of Psychiatry and Behavior Medicine and to make this department the nodal unit to impart the training in communication, clinical behavior skills and medical humanities. A trainer's training program needs to be developed at the level of Medical Universities/Medical Directorates. With the trainers, medical teachers in psychiatry, medicine and other clinical disciplines who have interest and aptitude in the program should be selected and trained regularly. All medical teachers should undergo a 1 month inception training within 3 years of appointment and 1 week refresher training once in 3 years.
A trainer's manual may be prepared first by a core group and a series of trainers training program carried out at regional/state/university levels. From there onwards 1 month of inception training and 1 week refresher training should be regularly imparted to all medical teachers in a regular way. I can imagine the eyebrows rising and leaves of objection flying up in the air-lack of time, heavy load of work for teachers, dearth of teachers with interest in "such things" etc., already heavy syllabus for medical students and many more. However, honestly I feel humanization of medical education, and thereby medical care, by inputs of behavior science and medical humanities and incorporation of a bio-psychosocial dimension is precisely the need of the hour in medical education in our country. It would be unfortunate if we fail to note that all advanced universities abroad (not just western ones) incorporate these course contents in their graduate medical program in a systemic way, devoting much time and faculty resources; if they do so it should be with valid reason and established perception of benefit in the quality of the trained medical graduate. The MCI, after several years of searching and studying, has gained an insight into the importance of inputs of behavior science and medical humanities in the making of a doctor and MOH has endorsed follow-up action. The rest of the task is to be taken up by those who are actually governing and manning medical education. If the medical administrators in universities and directorates perceive the MCI and MOH instructions in a positive spirit and in right earnest and initiate steps to develop an effective Clinical Behavior Sciences Training Program in the lines outlined above they would be making a signal ever significant contribution towards achieving the most deeply and dearly felt the need in medical education today-humanizing medical education.
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