NEP 2020: Why there is need for change in medical education
The National Educational Policy (NEP) is out with sweeping policy changes in the right direction. However, very little is said about reforming allopathic medical education as such. The document only alludes to integrating the various systems of AYUSH and allopathy. Yet this could be the opportune time to revamp modern medicine too.
While the number of doctors per 1,000 people is three in the UK, it is less than one (0.8) in India. This is in spite of about 76,000 allopathic doctors passing out of the medical colleges every year. The health scenario is made worse by the paradox of a glut of doctors in the urban areas. Almost 80 per cent of doctors are concentrated in urban areas serving about 20 per cent of the population. And most of these urban doctors are ‘specialists’. Added to this is the problem of unemployment and underemployment among doctors. After graduation, most of the medicos do not practice their newly-learned skills. Instead of ‘healing’, they are ‘reading’ for the post-graduate (PG) entrance exams. Taking a liberal estimate of about 50 per cent of candidates getting PG seats would leave about 38,000 doctors without a PG seat every year. This has left many young medicos disillusioned. This is one of the reasons why doctors migrate to greener pastures. Worse still, we see many doctors quitting the medical profession and opting for other professions like civil services, management and business.
What are the causes of this rut in the medical profession? The present medical education has not changed since Independence. While the rest of the world has progressed in leaps and bounds, medical education is mired in a time warp. And while the world of medicine has made tremendous progress, graduate medical education has failed to keep up with the times.
As a fallout of this, the present graduate programmes do not produce competent doctors. Post-graduation and specialisation have become a sine qua non. Add to this the craze of getting ‘degrees’ and we get doctors sitting at home preparing for entrance exams instead of treating patients and earning a living. So unlike engineers, accountants and lawyers, the medico has a long waiting period before she/he gets a decent earning.
The problems plaguing the present medical education is:
1) Lack of adequate training at a graduate level making PG training a necessity.
2) Emphasis on ‘degrees’ rather than training.
3) Long waiting period before decent earning.
We need to have a serious introspection and find a solution to these maladies.
A strategy to reform medical education to make it more relevant was submitted to the Parliamentary Sub-Committee For Reforms In Medical Education in 1996. The principles behind the new career plan for medical students will be:
1) Early specialisation.
2) Creation of well-trained primary doctors.
3) Removal of irrelevant curricula.
4) De-emphasise degrees.
5) Creation of two streams of careers.
Basically, the new scheme would consist of five years of study consisting of ten semesters. The entry would be based on the common national entrance test, which will test academic knowledge and aptitude. A central computerised matching programme would ensure fairness and transparency during admission. At the entry-level itself the student chooses an area of specialisation (like the engineering courses). A wide range of specialities would be available. To name a few, we could have specialities like family practice, hospitology, traumatology, paediatric cardiology, neurosurgery, infertility, forensic sciences and many more. However, the lion’s share of seats would be in family practice.
The first year of two semesters would be for relevant studies in anatomy, physiology and biochemistry. The second year of two semesters would be for relevant studies in pathology, pharmacology and public health. The two semesters in the third year would give exposure to selected related specialities. For example, a student taking up cardiology could get exposure to cardiac surgery and pulmonology. The fourth and fifth years of four semesters would be devoted to the in-depth study of the chosen speciality. However clinical training would start from the second year onwards giving an effective period of four years of study in the speciality. An elective in humanities should be incorporated into the course to produce more humane doctors. On completion of the course, the candidate is awarded the degree of MD (Doctor of Medicine) in the speciality, like MD (Neurosurgery) or MD (Family Practice). This would replace the degrees like MBBS, MD, DM, MS, M.Ch and DNB.
Next, the career prospects branch into two streams — academician and practitioner.
The student opting for the ‘academician’ stream will have one-year training in medical pedagogy. This is a new concept. Most of the medical teachers are not trained for teaching. Such training will create professional teachers. The next five years will be ‘lecturer’, followed by five years as ‘assistant professor’ and finally ‘professor’ after ten years of experience. The institutions will award these designations.
A student opting for the ‘practitioner’ stream would have a one-year ‘internship’ under a senior consultant in the speciality. The next five years will be ‘specialist’ followed by five years as ‘consultant’ and finally ‘senior consultant’ after ten years of experience. The medical councils will award these designations. An academic can go into practice, but not vice versa. A practitioner can enter academics only after the stipulated one-year training in medical pedagogy. A provision for continuing medical education sans examinations would be integrated in the practitioner’s stream. The only higher degree awarded will be the PhD for outstanding research.
Some salient features of this scheme need to be emphasised. All medical colleges need not have all the courses. And one can start innovative courses depending on the need. As the medical practice is now technology-driven and capital intensive, private institutions can be inducted into the teaching programme for certain specialities. Also note that specialities like general medicine and general surgery which have lost their relevance, need to be removed. And certain specialities like obstetrics and gynaecology have to be split into components.
The most important innovation in the scheme is the introduction of family practice as a speciality. Maximum seats will be available for family practice. And since family practice will be on par with other specialities with assured time-bound career advancement, it will become the preferred branch. The family practitioner will also progress as specialist/ lecturer, consultant/ assistant professor and senior consultant/ professor. This will give self-respect to the practitioner of this very important speciality and give her/him the motivation to practice with confidence. India needs more family practitioners and this scheme will satisfy this need. The course content of family practice will be the identification and treatment of outpatient type problems in every other clinical speciality with an emphasis on the preventive aspects. Similarly, in conformance with the NEP, some elements of the AYUSH streams could be integrated into this speciality. A suitable curriculum needs to be prepared for this. Further, suitable curricula have to be developed for emerging specialities.
It is high time we gave up the current archaic medical training programme. This was made during the early days when there were only two major branches of medicine and surgery. With the proliferation of medical specialities, the degrees of MBBS is outdated. It is like saying ‘Bachelor of Mechanical and Bachelor of Electrical Engineering’. By applying the current medical career path (MBBS-MD-DM) to computer science, a student would have to go through MBBE (Mechanical and Electrical), followed by ME (Electronics) and finally EM (computer sciences).
Early specialisation is a must. It is to a certain extent happening in the specialities of ophthalmology, orthopaedics, dermatology and psychiatry. What we ought to do is widen the range to include all specialities at entry-level.
In the existing system, much time is wasted on irrelevant topics. This was accepted as a flaw by the Medical Council in its 1997-reforms stating “a reduction is made of six months of I MBBS course, increasing the training period of II and III MBBS. The reduction of six months of I MBBS is meant to reduce the quantum of the teaching of pre-clinical subjects and to give time during the later years for revising pre-clinical subjects with relevance to clinical teaching”. For example, a student opting for a surgical speciality needs more knowledge of anatomy than physiology, with special emphasis to the region of his speciality. However, a student taking up physiology as a speciality will need an in-depth study of physiology. In the present system, the amount of time and effort spent on gynaecology and obstetrics is a waste for an ophthalmologist. Four years is enough time to get adequate training in a speciality. The rest of the training is by experience. By having a focused training in a speciality, lengthy courses become redundant. Instead of a rigid curriculum, this scheme will bring in flexibility as envisioned in the NEP.
The concept of internship under an established practitioner is nothing new. It is already a practice in chartered accountancy to do article-ship under a chartered accountant. Thus the new system will remove the agony associated with the entrance exam at each PG level. It will encourage family practice, which is the need of the hour. It will stress more on training and experience rather than degrees. This system will be dynamic. Evolving specialities will automatically be brought entry-level once the speciality is developed. For example, now we can have urology as an entry-level course but this can evolve to prostrate surgery and renal surgery once the knowledge base of these specialities reaches a substantial level.
The above discussion is just an outline of the reforms required. These reforms can be implemented in two stages. In the first stage sub-specialities like cardiology, neurology, urology etc can be introduced immediately after the MBBS course. In the second stage, the above recommendations can be implemented. The specifics can be worked out by competent agencies like the National Medical Commission and the Universities. The implementation of these reforms will go a long way in streamlining the health system in India.
Also read: Why India's medical education and health sector are suffering