|Year : 2014 | Volume
| Issue : 1 | Page : 1-4
Reforms in medical education: Optimizing quantity and quality
Samir Dasgupta1, 2
1 Professor & Head, Department of Community Medicine, Burdwan Medical College, Burdwan, West Bengal, Member of Advisory Committee, Indian Journal of Public Health, India
|Date of Web Publication||5-Mar-2014|
Professor & Head, Department of Community Medicine, Burdwan Medical College, Burdwan, West Bengal, Member of Advisory Committee, Indian Journal of Public Health
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Dasgupta S. Reforms in medical education: Optimizing quantity and quality. Indian J Public Health 2014;58:1-4
Developing an effective health care delivery system and ensuring universal access to health care immensely depend on the status of the medical education system and the nature of medical manpower it produces. The quality of human resource produced by the country's medical education system is determined by the appropriate government support in terms of policy framing, funding and regulatory mechanisms. The common criticisms against the present medical curriculum are that it fails to inculcate appropriate skills and competence among learners to serve the community effectively. Developing a societal need-based and feasible medical education system is a challenging task. We will look into three documents, all published by different government agencies under directives of the Government of India with the objective of reforming the medical education system in the country.
The National Knowledge Commission (NKC) was established by the Government of India in 2005 to recommend reforms in professional education. As medical education have a significant impact on country's socio-economic development, NKC constituted a working group on medical education to identify constraints and challenges relating to curriculum, infrastructure, administration, and to suggest reforms.  The working group observed that the medical education in the country was mostly directionless, unregulated and non-standardized. The report identified the lack of competent medical professional manning the health facilities as the reason for our failure to achieve desired health goals. The need for curriculum revision in the light of tremendous advancements in medical science and technology and incorporating competency-based pedagogical methods has been emphasized. Maldistribution of training facilities was identified as another constraint. During 2005, majority (63%) of medical colleges were concentrated in only six states of India, namely, Maharashtra, Karnataka, Andhra Pradesh, Tamil Nadu, Kerala, and Gujarat. In contrast, only 3% of training facilities were located in North-Eastern States.  This must be another area of the reform to expand the opportunity of medical education equitably throughout all the regions. Reform process should start from the critical appraisal of the mechanism of policy framing at the highest level and an assessment of the regulatory mechanisms. The NKC report strongly recommended amendments of Indian Medical Council Act to make Medical Council of India (MCI) a "truly autonomous statutory body and not simply as a recommending body to the Central Government as is the present MCI."  MCI must play a key role in health manpower planning and forecasting, curriculum updation, faculty development, continuing medical education and monitoring and accreditation of teaching institutions. In our perspective, requirement of adequate manpower with expertise in public health and health management is of crucial importance. MCI may play a significant role in widening the scope of public health education in India.
Another document we will look into is the report of the "Task Force on Medical Education for the National Rural Health Mission" constituted by the Ministry of Health and Family Welfare, Government of India.  Revamping medical education with reference to the requirements of medical professionals was the first objective of the terms of reference of the task force. In the light of the changing epidemiological scenario, the report emphasized the need for revitalizing the health care system in the country with special focus on primary health care. The report admitted gross deficiencies in physical infrastructure, like, 61% deficiency of Community Health Centers, 31% Primary Health Centers (PHCs) and 29% sub centers.  Shortfalls of PHC doctors (13%) specialists (38%) were major concerns. It was admitted that the fresh medical graduates lack adequate hands-on training and lack the expertise to provide even primary care independently. Thus, both availability and quality of services suffered. The current curriculum is overburdened with information content at the expense of clinical skills. It was also admitted that the medical graduates fail to perform effectively at primary care settings without advanced diagnostic and multidisciplinary support. The task force recommended restructuring the curriculum to match with the community need, and to adopt training methods, which focus on attainment of clinical competence, through an integrated approach, preferably a modular one. The report also explored the scope of increasing medical manpower, like a possibility of a short-term certificate course for rendering basic primary care in rural areas, converting district hospitals into medical colleges and promoting private entrepreneurs in this sector.
All these reports recognized that the standard and quality of medical education in India is much below the desired level and admitted the need for reforming medical education system to produce doctors with enhanced skills and competencies to address the health needs and challenges in the present day's scenario. In the light and spirit of observations and recommendations of the above documents, we may look into the reforms undertaken in the medical education system.
The vision 2015 document published by MCI in March 2011, expressed the policies and strategies of Government of India regarding medical education in the coming years. The vision 2015 objective was to enhance the quality and standards of medical education and training in India and "to standardize the output of graduate medical education in the form of an "Indian Medical Graduate;" a skilled and motivated basic doctor." 
Coming to the foremost recommendation of NKC regarding the autonomy of MCI, what is the present status? The MCI Board of Governors was constituted some years back by Government of India through an ordinance, dissolving the earlier committee. This was done following some emergent situation, and the ordinance itself had a commitment of its time bound nature. But over the years, the status remained unchanged, MCI continued to be governed by the board of Governors nominated by Government of India. The spirit of "true autonomy" has, in effect, not materialized.
In recent times we have found some experimentation with the modalities of entrance examinations for selection of UG and PG students. But other vital areas of reforms committed in vision 2015, like restructuring the UG course, introduction of new teaching elements, horizontal and vertical integration, and competency based curriculum, early clinical exposure, monitoring and accreditation of the institutions, all remained mostly on paper. Same is the status with PG courses too.
The most visible component of the reform process that has been vigorously pursued in last few years was approval for new colleges and increase in UG and PG intake capacity. Amendments of the regulations, like relaxing the student-professor ratio for PG studies from 1:1 to 2:1, enhancing age for medical teachers to 70 years etc., are being done to facilitate the process. This is in tune with the most sensational component of the Vision 2015 document, setting a target of the doctor-population ratio of 1:1000, to be achieved by the year 2031. A doctor-population target of 1:1000 in effect means one doctor for every village, like ASHA or Anganwadi workers! Any policy should be country specific and realistic. It is well-recognized that in a resource poor setting like India, it may not be practicable to cater heath care to everyone through a qualified doctor, as may be feasible in developed world. Placing a qualified doctor for every 1000 population is irrational because effective utilization of such valuable human resource is not feasible at that level. All our National health programs are designed on the basis of the accepted policy that at the village and community level, most of the program interventions are to be catered by trained paramedical staff and the lowest level where a qualified doctor will be stationed is the PHC. Any belief that an increasing number of doctors and specialists will ensure availability and accessibility of health services will be an oversimplification. Availability and accessibility is determined by complex dynamics of social, economic and political factors, which became more complex in the present context of liberal global economy. One earlier draft version of vision 2015 depicted a model of targeted annual number of 50,000 MBBS doctors, 25,000 PG, and 7500 Post-doctoral (plus proposed 50,000 MMed and 25,000 Fellowship). Already we are producing 50000 plus MBBS doctors annually, and increasing steadily. Leaving aside all other issues like scope of effective utilization of a qualified human resource, should we not at least think about the job opportunities and career prospects of young medical graduates that will come out of our medical colleges in the coming years?
We may look into the trend of the number of colleges and intake capacity during 1995-2014 [Table 1]. Number of medical colleges has gone up from 152 in 1995 (admitting 12,249 students) to 262 in 2005 (admitting 28,349 students). In 2014, we have 381 medical colleges with yearly intake of 50068 students.  Considering 1995 as baseline, there has been a 205% increase in number of medical colleges conducting MBBS course, and intake has gone up by 408%!
|Table 1: MBBS: Number of medical colleges, yearly intake and ownership status: 1995-2014|
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This boom has largely been contributed by the private sector. In 1995, there were 105 Government Medical Colleges (including Central or State University and municipality run colleges) and 47 colleges under private management (including trust/non-governmental organization run colleges). In 2005, number of private colleges became same as government colleges, 131 each. In 2014, number of government medical colleges (176) has been surpassed substantially by the number of private colleges (205). Since 1995, there has been 168% increase in number of government colleges, whereas the number of private colleges increased by 436%. The annual intake capacity of private medical colleges (25,905) has also surpassed government medical colleges (24,163) in 2014.  In 2014, out of 50068 seats in 381 colleges, 10,350 seats in 95 colleges are in "permitted" category, meaning thereby, these has been permitted in last 3/4 years. 
Regarding PG courses, current intake capacity is 22,349.  There were 18,699 "recognized" seats, meaning thereby, there are 3650 PG seats "permitted" in last 2/3 years.  An attempt was made to see the status of the number of new applications for starting of new PG courses, or, increase in intake of existing PG courses, for the academic year of 2014-2015. MCI website showed a long list of 110 pages with 1606 entries, depicting the names of the institutions and courses names intended to start or increase existing intake capacity this year. 
Evidently, inspection by MCI has become a common event in almost all medical teaching institutions in recent years. One notable feature is that the inspections are held either with very short notice of 24-36 h or even without prior intimation. This has got a few significant fall-outs too. PG inspections are usually held from December/January each year. This is also the time for 2 nd Prof., 3 rd Prof Part 1 and 3 rd Prof Part 2 examinations in all medical colleges. Availability of external examiners is becoming difficult, as institutions are often not allowing senior medical teachers to leave station. The examination schedule and appointment of examiners are done much earlier by the universities; last minute non-availability becomes a great obstacle for smooth conduction of examination. Another, no less significant issue is that MCI inspection with very short notice or even without prior intimation is hindering participation of faculty and residents in the national conferences of academic associations, as authorities are not allowing leave apprehending sudden MCI inspection. Participation in scientific events is a way of self-development for medical faculty and residents. All stake holders must think about what may be the avenues for resolving the conflict of time.
None can deny that we need more qualified medical professionals to transmit the benefits of scientific and technological advancements to people. However, the contradictions between quantity and quality of medical education must be optimally addressed. All assessments, expert group reports and government documents recognized the present gaps in medical education, the core issue being the deficiencies in quality of training leading to a final product without the requisite skills and competence. Medical education is fundamentally a skill-development program. Principles of educational science recognizes hands-on training, interactive sessions in small groups, demonstration and practical lessons, bedside clinics, and exposure to real-life situations in hospital or community settings as the modes of effective learning for enhancement of skill. Didactic lectures play little role in competence building. Feasibility of all these are highly dependent on group size. Now that we are having institutions with an annual intake of 200/250 students at MBBS level, we have to think about applicability pedagogical principles.
It must be noted that there are significant socio-politico-economic issues involved here. Increase in intake capacity in MBBS and PG medical courses are naturally highly acclaimed by aspiring students, parents and community at large. One must keep in mind the strong presence of private entrepreneurs in this sector, and the patronage from the political leaderships. Increase in UG and PG seats in medicine is something that makes everyone happy. In such a situation, it may very difficult to present any alternate viewpoint and to make people rethink.
This article is not meant to contradict the need for increase in intake capacity of UG and PG medical courses. The primary intention of this article is to draw attention of the policy makers and all other stake holders to the issue of rapid quantitative expansion and the potential danger of compromising the quality further, and to seek modalities for optimizing the quantity and quality. The other intention is to sensitize all stake holders to the urgent necessity of reforms in other components of medical education, recommended in all policy documents mentioned earlier, but mostly remained unaddressed so long.
Note: Some of the documents discussed above dealt with all health related education like nursing and AYUSH, etc. For this editorial, only the issues pertaining to modern medicine have been considered.
| References|| |
|1.||Government of India. National Knowledge Commission. Report of the Working Group on Medical Education; 2005. |
|2.||Ministry of Health & Family Welfare. Government of India. Report of the Task Force on Medical Education for the National Rural Health Mission; 2005. |
|3.||Medical Council of India. Vision 2015; 2011. Available from: http://www.mciindia.org/tools/announcement/MCI_booklet.pdf. [Last accessed on 2014 Feb 17]. |
|4.||Available from: http://www.mciindia.org/InformationDesk/CollegesCoursesSearch.aspx. [Last accessed on 2014 Feb 04]. |
|5.||Available from: http://www.mciindia.org/tools/announcement/Status_PG_applications_academic_2014-2015_08.01.2014.pdf. [Last accessed on 2014 Feb 04]. |