Medical
Education in
Prof K.R. Sethuraman. *
General
Issues
The number of registered doctors in
The country had 67,576 government doctors:
meaning one doctor was serving roughly 15,980 people. The urban-rural skew is
well illustrated by
On the other hand, one doctor might be
responsible for more than 200,000 people in some rural areas. 1
STRENGTHS
Healthcare
Infrastructure
Over the last five decades
-
Number of Colleges
The Health Survey and Planning Committee of 1961, for instance, had recommended that one medical college should be available for five million people. This amounts to 200 colleges for the country's roughly one billion population. By this reckoning we have made the grade. By August this year, the number of medical colleges has crossed 260 (see the table)
|
State |
Public |
Private |
Total |
|
A P |
11 |
21 |
-32 |
|
|
03 |
-- |
-03 |
|
|
06 |
02 |
-08 |
|
|
01 |
-- |
01 |
|
Chattisgarh |
03 |
-- |
-03 |
|
|
05 |
-- |
-05 |
|
|
01 |
-- |
-01 |
|
|
08 |
05 |
-13 |
|
Haryana |
01 |
02 |
-03 |
|
Himachal Pradesh |
02 |
-- |
-02 |
|
Jammu & Kashmir |
02 |
02 |
-04 |
|
Jharkhand |
03 |
-- |
-03 |
|
Karnataka |
06 |
29 |
-35 |
|
Kerala |
05 |
13 |
-18 |
|
M P |
05 |
03 |
-08 |
|
|
19 |
20 |
-39 |
|
Manipur |
-- |
01 |
-01 |
|
Orissa |
03 |
01 |
-04 |
|
|
01 |
06 |
-07 |
|
|
03 |
04 |
-07 |
|
Rajasthan |
06 |
02 |
-08 |
|
|
01 |
-- |
-01 |
|
Tamil Nadu |
16 |
09 |
-25 |
|
Tripura |
01 |
01 |
-02 |
|
U P |
10 |
06 |
-16 |
|
Uttaranchal |
-- |
03 |
-03 |
|
|
09 |
-- |
-09 |
|
All |
131 |
130 |
261 |
Source: MCI website (www.mciindia.org)
Student Quality
Competition for
medical seats is intense, entrants to medical school are usually of a high
academic standard, and their application (at least with respect to passing
exams) is often exemplary.3
The President of Michigan State Medical
Society, Dr M Appa Rao has recently said, 'The
standard of medical education in Indian colleges is better, compared with that
in the
'25 meritorious
'While only 70 per cent of US students were
able to clear the Board Certification, more than 95 per cent of Indian doctors
easily overcame this hurdle.' 4
National Curriculum
MCI regulation of 1997 has given Indian
medical colleges a good traditional curriculum to adhere to. In the name of
innovation, a lot of experiments are being done across the world without any
strong evidence that any one of them has a superior outcome. Traditional
curriculum is resource efficient and till date, as good as the more expensive
innovative curricula. If all the colleges adopt the 1997 curriculum in letter
and in spirit, then,
AREAS
OF CONCERN (Weaknesses)
In the last two
decades the growth of medical colleges has been several folds faster than that
in the first three and half decades after the independence, thus earning the
epithet 'mushrooming of medical colleges'. The pliable Universities and
Councils were used to bend rules, fuel corruption and violate standards of
quality for accelerating the business of medical education. It is therefore not
surprising that many of those involved in establishing the money-spinning
colleges are power-brokers working in tandem with the leading lights of medical
profession and the industry.5
Awareness of the ailing state of medical
education is neither recent nor confined to the inner sanctum of deans'
offices. Even two decades earlier, an editorial from the Indian Express (Jan.5,
1985) had thundered thus: 'The continued
lack of concern about the unhealthy state of medical education in
Does
medical education address the social need for healthcare?
There is no correlation between the number
of medical colleges and the availability of doctors in a state.
Data from the Medical Council of India
(MCI), as of August, 2006, shows that 130 out of 261 colleges are private.
Also, the proportion of private seats raised from 6.8
per cent in 1960 to >50 per cent in 2006. A study by
The mushrooming of private medical colleges
on extraneous considerations other than merit have attracted even the attention
of lay people and were amply exposed by the media. On 26th Dec 2003,
regional television channels in Andhra Pradesh showed that a
Some argue that private college are better
because their courses are well-planned and the faculty pays more attention to
students; they update their educational systems, which, the government colleges
may not do. This may be true of some of the reputed private colleges. However, as
wikipedia reports, Private colleges generally suffer from poor
quality and low quantity of faculty, poor infrastructure and facilities
(despite being private institutes), lower student quality, lesser clinical
opportunity and exposure (because being a charging hospital that chases away a
large chunk of patients) thus generally resulting in overall a lower academic
level and quality. 8
Proponents of public funded education say that
infrastructure in private colleges is to no avail as there are very few
patients for the students to learn from. This is true, observers say, because
most students from private colleges gain experience by taking up residency jobs
in public hospitals. Teaching faculty in public colleges is not allowed to
practise unlike their counterparts in private colleges. This, they say, makes
for teaching of better quality. Except for a few well provided Central government institutions like AIIMS,
JIPMER and AFMC, most other government medical colleges are comparable in terms
of the faculty, student quality and good clinical exposure for the students (as
all are attached to Government Hospitals which offer free treatment and thus
attract huge number of patients). Some of the colleges may lack the latest diagnostic
equipments such as MRI, CT scanner, etc which are essential from a Post
Graduate point of view.9
The growth of private medical sector deprives public
institutions
Even aiims
is facing a shortage of manpower. The college had 479 faculty members against a
sanctioned strength of 543 (Rajya Sabha news item of May 12, 2006). If aiims cannot
hold on to faculty members, it is unlikely other institutions, especially those
in smaller centres, will be able to do so. This is in fact the case, with
grievous repercussions. Exodus from JIPMER,
Uneven distribution of colleges
Payment for Education
With growing privatisation, the government
had to ensure that medical education did not get limited just to those who
could pay. The Centre set down some ground rules: 50 per cent of seats of a
private institute would have to be filled through a state-level exam and the
fee structure for these seats would be the same as that of a government
college. Rules were set down by mci
in 1997 to reduce these wide variations. But this kind of control has not been effective
in most cases. 6
While litigation has been extensive, three
cases have been significant; a lot of do-undo
in judgments has created its own share of confusion. On August 12, 2005, the
Supreme Court delivered a unanimous judgement in the case of Inamdar and others versus the State of
In the judgement delivered on October 31,
2002, (the Pai Foundation
case) the court suggested that a certain percentage of the seats could be
reserved for the management from among students who had passed a common
entrance test held by itself or by the relevant state/university, while the
rest of the seats could be filled on the basis of counselling by the state.
6
In the other judgement delivered on August 14, 2003 (Islamic Academy of Education and another versus the State of Karnataka and others) the Supreme Court interpreted the 2002 judgment and said that the unaided professional institutions were entitled to autonomy but at the same time they would have to take into account the criterion of merit as specified by the government. Secondly, it upheld the earlier ruling on reservation of seats for management filling seats on the basis of counselling by the state agency. The court also suggested that unaided professional colleges should also make provisions for students from poorer and backward sections of society.
The fate of the controversial Private
Professional Educational Institutions (Regulation of Admission and Fixation of
Fee) Bill, 2005, which proposes a division of seats that is largely in favour
of private colleges, is uncertain, given the reservation debate that is
dividing the society.
The real tragedy however, is that the privatisation and reservation debates
risk getting lost in a morass of detail about percentages, jurisdictions, and
debated with rhetoric, passion and prejudice.
The fundamental issue totally lost in all this is: the
delivery of quality health care to the people.6
On the one hand, the state sector has been
on the point of collapse for some time now both in the areas of health education
and health care. This has facilitated the growth of the private sector, which
the state is trying to regulate, or, indeed, control, with mixed results. The
casualty is public health. 10
Inadequate Funds for Rural & public Health
The national health policy also suggests
that a two-year rural posting should be enforced before awarding the graduate
degree, but the idea remains strictly on paper. There are rules about
compulsory service in rural areas, though they differ from state to state.
Medical students are supposed to sign a bond saying they will work in villages
for a stipulated period. But in most cases, the states are unable to provide
jobs. Vacancies are often not filled because governments do not have the money
to pay salaries. 11
Medical Council of
In 1992, MCI was transferred under the control of the Centre and the imc Act was amended to give extensive powers to mci. This has created many controversies. It has been alleged that mci used its powers to issue orders directly to the state government by-passing the Centre, which argued that it was blocking public-private partnerships and private initiatives.
It may be highlighted that the Engineering
in IT Education, which is controlled by the All India Council of Technical
education (AICTE) has been able to expand at a much more satisfactory level,
primarily because AICTE is far more constructive and displays a highly positive
approach. 12
In 2005, a bill to amend the imc Act was approved by a group of ministers and sent to the Union cabinet. It asked for an increased role for the ministry of health, with government nominees placed in mci. It was argued that such nominees would have no vested interests and be better placed in improving transparency and accountability in running health education. It was also suggested that since the people controlling mci did not have much administrative experience, the induction of the director-general health services would lend teeth to the body. This move was widely opposed by the medical fraternity, with its representative organisation, the Indian Medical Association (ima), saying this would lead to arbitrary government action. 7
But the controversy over jurisdiction continues: mci is supposed to carry out physical verification of medical colleges and not quality assessments. It is also supposed to regulate and update the curriculum.
In December 2003,
journalists found that a
Curricular
deficiencies
The curriculum set out by MCI in 1997 does not allow for contact between medical students and patients in the early years and perhaps desensitises prospective doctors from the needs of patients.
Most countries, especially developing ones,
are focussing their energies on issues of manpower and health care delivery during
who-decade (2006-15) dedicated to
increasing human resource for health (HRH). It's unfortunate that in
Internship
Training
The four-and-a-half
years of undergraduate medical education is followed by 12 months' internship
when students are meant to enhance their clinical skills and understand health
care delivery in a community/rural setting. Internship is currently implemented
only on paper; various universities have started the PG entrance examination,
making learning practical skills during internship redundant, rather harmful to
their PG aspirations. Throughout his/her internship, a medical graduate
prepares for the MD/MS postgraduate entrance examination and loses out on a
once in a lifetime chance of skill learning at patients' bedside. 14
Quality and Stakeholders
A medical student's experience is shaped by four different stakeholders:
The education provider, which is
interested in a student's fitness
for award of license to practice.
The professional and statutory body,
which is interested in fitness
for practice in order to determine whether an
individual can be licensed/registered as a professional practitioner.
The potential employer, who is
interested in a graduate's fitness
for purpose in terms of the competencies and
capabilities which s/he is able to demonstrate in the workplace
There is a fourth one in Indian context - the financier of private -education industry, whose primary motive, in many instances, is profit. India Today has exposed how some private, unaided medical colleges fake the facilities and flout the Medical Council of India norms, affecting the credibility and quality of education. 15
The health seeking public, who should have been the main stakeholder, is totally left out of stake holder debates and claims. This is an avoidable tragic lapse.
A mechanism for quality assurance in
medicine must therefore involve all the stakeholders and must have the capacity
to demonstrate the extent to which professional education meets the ultimate
aim of developing medical practitioners who are fit for purpose, practice and
award.16
Suitability of Out-dated
Western Model
Two of the
main criticisms of medical education are: i) the neglect
of rural and remote areas and ii) overproduction of highly trained persons with
no corresponding increase in gainful employment.
The root cause of our problems may arise from the blind imitation of the older
version of Western model. This obsession with the Western model and standards
has made our products misfits in our own society and perhaps unwittingly
promoted brain drain. The truth is that the
medical graduate finds himself more at home outside the country than at home. So,
the changes in the curriculum have to be brought about in a more rational way
by assessing our own needs. 17
Who should determine these needs? Whose
needs - the needs of learners, their parents, planners, the financiers or those
of the society at large? The west has changed its curriculum in the 80's to
include behavioural aspects and has adopted integrated, problem based approach,
while in India, we are stuck with the same old discipline oriented curriculum
and 'one size fits all' approach that leaves little scope for innovation.
13
Teaching Faculty
& Resources
MCI says in it website, It was felt and observed that a large number
of doctors are claiming employment as medical teachers in more than one medical
college at the same time, and has displayed a list of teachers claiming
employment as medical teachers in more than one medical college and whose names
have been removed temporarily from Indian medical register. 18
Teaching faculty on their part, seem to have
resigned to the sorry state of affairs: Talking
to pillars of medicine when I visited
Corruption
Let me only quote the chairman of the
Karnataka Health Task Force, Dr H. Sudarshan: Corruption is at various levels: In medical
education, starting from joining the medical college - you can buy a seat, you
can buy the examiner, the examination system, you can buy the question papers.
This is much less now with the University trying to bring in some reforms, but
still, in the viva-voce and practical, many people continue to pay and pass; we
are not sure if we have plugged that. 20
CHALLENGES
Globalization
Despite high marks that
Countries struggle with the fact that the
market for talent has become global.
Second, globalization has made benchmarking
in education global. While
Third, globalization has made education an
extraordinary business opportunity with a great impact on employment. While
there is some R&D outsourcing to
Fourth, the ability of an economy to
compete depends on the character of its education system.
The four challenges of globalization - the flight of talent, benchmarking to global standards, the possibility of education as a business opportunity, and the mismatch between supply and demand - have a common thread running through them. Inflexible and overtly regulated education systems are unlikely to respond to these challenges.
The Indian education system is one of the most tightly controlled in the world. The government regulates who you can teach, what you can teach them and what you can charge them. It also has huge regulatory bottlenecks. There are considerable entry barriers: Universities can be set up only through acts of legislation, approval procedures for starting new courses are cumbersome, syllabi revision is slow, and accreditation systems are extremely weak and arbitrary. The regulators permit relatively little autonomy for institutions and variation amongst them. 21
Low Development Index
The countries that
*
Infant/Maternal Mortality Rate per thousand live births. $ Life
Expectancy at birth.
# As a percentage of the total population. For poverty, measured as percentage of population below the $1 a
day line. -@ Per Capita in US
Dollars at purchasing power parity (PPP) rates.
Is it not our duty as teachers and educationists to do something about it? What is the use of having the largest scientific and technical human resource if we can not improve human development in our mother land? All the other claims sound hollow when faced with such hard facts.
Scientific Research
During 1980-2000, the number of scientific
papers from
"Unfortunately India's scientific
research capability - whether measured in the number of research papers
published in journals or the number of patents registered - is slipping. This
bodes ill for Indian society because without the constant development of
science and technology capability through original research, there can't be
meaningful development," said Mehta, director of Indian Institute of
Science, in an interview. 22 Indeed, most universities in
OPPORTUNITIES
& SOLUTIONS
In 2001, Dr H Sudarshan called for a moratorium on starting new medical colleges in the Karnataka? He explained why:
'If you look at the health needs, there are
two issues. One is commercialisation of medical education - open a college and
run it like business. The second is that these medical colleges also have
accountability to the people of the state. This is the model, which
'Secondly, mushrooming of the medical colleges is not good... If we can provide good quality medical education, with good infrastructure, and good faculty, we have no problem; we can produce good quality doctors. What is happening is that some of the colleges are really good, but some are really bad and they need to be closed down. Let us promote good quality medical education that is need based and that has accountability to the people of the state.' 20
Correction of Imbalances
Under the Pradhan
Mantri Swasthya Suraksha Yojna, a scheme has been
launched to offer all Specialties and Super-specialties medical care in the
states where there are gross imbalances in the availability of tertiary care
Hospitals/Medical Colleges providing Super-Speciality services and improve the
quality of Medical Education in
There are two components of this
scheme: One component is to set-up six
institutions of national importance (like All India Institute of Medical
Science) in the States of Bihar, Chattisgarh, Madhya
Pradesh, Orissa, Rajasthan and Uttaranchal
within three years. These institutions will be established and maintained by
the Central Government. The other one is
to up-grade one
To meet the demands of globalization, the
government must spend more on education, increase student access, and also
extend greater autonomy to its universities. More funding combined with greater
flexibility will strengthen research capability and secure talent within the
country's borders.
Globalization demands a paradigm shift in
the regulation of higher education. In
Information Communication Technology (ICT)
ICT is a great opportunity to improve access to medical education, to improve the quality of education and to facilitate collaboration amongst individual learners and institutions. challenges do exist, especially for rural areas. These include
- technological (e.g., overcoming barriers like cost, maintenance, access to telecommunications infrastructure)
- educational (using ICTs to best meet learners' educational priorities) and
- social (sensitivity to remote needs, resources, cultures).
Finally, there is a need for more rigorous
research to more clearly identify advantages and disadvantages of specific use
of ICTs in medical education, to determine the
specific conditions under which they are effective, and to understand the use
of complex educational systems using multiple ICTs. 25
Way
ahead
Global patterns of funding clearly show
that medical education remains very much a state-dominated sector. In countries
belonging to the Organisation for Economic Cooperation and Development - such
as
One of the major causes of science
education losing its sheen is the artificial division between science research
and teaching, which obstructs automatic contemporisation
of syllabuses. In this
Growing Academia - Industry Partnership
The pharmaceutical industry notches up about US$6 billion in domestic sales and US$4 billion in exports annually. There are at least over 10,000 registered companies in the country. Major players control 35 percent of the market and the sector is growing at 8 percent a year. With the implementation of the Patents Amendment Act in 2005, the companies are investing in a big way in their research and development wings. -
Importance is given to clinical research by
pharmaceutical companies, particularly to clinical trials, which is getting a
major boost in the country. Trans-national companies are conducting
international trials in
Summing
Up
Fundamental
issues:
- Is privatisation of medical
education hurting the capacity of the system to deliver appropriate health
care to the majority of people?-
- The answer is yes.
- Is the distribution of colleges
badly skewed?
- The answer is yes.
- Is the quality of education
good enough?
- The answer is yes and no.
- Why is the state health
education sector on the brink of collapse?
- It is multi factorial and involves all the major stake holders
including the public.
Let Each of Us Do Our Bit
'It is ultimately left to each one of us in
the educational field to move one small step forward towards this
transformation of vision towards reorientation of values and objectives of
education. Not only in
Let each of us - the participants of APPICON 2006 -
take a New Year pledge to do our bit to improve the system of medical education
in
Jai Hind!
References
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Report for 2006 (downloadable from www.who.int)
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India, 2004 (www.mohfw.nic.in)
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13-06-06; URL: www.thehindu.com/2006/06/13/stories/2006061309020500.htm
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education in
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Quality Assurance to Quality Improvement
Quality Assurance
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http://www.ifmsa.org/scome/wiki/index.php?title=Quality_Assurance_in_Medical_Schools
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http://www.india-seminar.com/2000/489/489%20duggal.htm
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* Author Details:
Dr K.R. Sethuraman. MD, PGDHE,
Dean & Senior Professor of Medicine,
AIMST University,
(Formerly Head of Medical Education Department, JIPMER)
e-mail - <sethuraman@aimst.edu.my>