Medical professional education in India: In “flux”

MEDICAL PROFESSIONAL EDUCATION (MPE) IN INDIA: IN “FLUX”

Medical profession is an occupation aimed at protecting, promoting and restoring good health, by identifying, diagnosing and treating the diseases with acquired specialized scientific knowledge.^[1] Medical professional is a qualified doctor, who abides and is fully committed to the ethical principles and values of medical profession.^[1]

Medical profession was, is and will always be considered a “noble” profession. Only a few years ago, it used to be a coveted dream of the youth, to be a doctor. The starry-eyed parents would be desperately looking forward to make sure that, their ward, achieved this goal, no matter whatever it takes and would feel immensely proud about it. The things have changed to a certain extent. Although with lesser amount of sheen, the aura still persists.

MPE IN INDIA, IN BYGONE ERA

For almost 150 years, India was a slave country and under the dominion of “British Raj.” Logically, the medical education was by rote, lock, stock and barrel, the copy of the British System. It is to be clearly understood that the genetic makeup of the Indian education as such, inclusive of medical, was deeply influenced by the British. Their infrastructure, the curricula, principles and practices of professionalism were inherited by the earlier generation of Indian doctors, literally verbatim. Entire culture was seeped in British mannerisms, ethos and attitudes. Just to give an example, the author still recollects, the early morning lectures of Anatomy by Prof. Ramlingaswami in my Alma Mater (MGIMS, Sewagram). With pin drop silence only interrupted by his narration about the “embryology” in clipped, British accented English, augmented by the screeching sound of the chalk on the green glass board. Only variation would be his “explosive expletive” – “Who is that anti-social element? Get out!” for the unfortunate student, who could not control his bout of cough! I am sure, many of us have our own store of such anecdotes and myths. There were no PowerPoint presentations (ppt), no electronic media and no distractions. However, the “monotony” was rather enjoyable. So, was Prof. Ramlingaswami, an autocrat and not a “facilitator?” I have never forgotten the embryology and histology taught by him. After completion of your MBBS, after passing the final MBBS examination, (by far the toughest of the examinations, in the author’s opinion), came the “glorious” period of 1 year of internship with its euphoria of successfully achieving the dream, the look of pride in the eyes of parents, that out of worldly sense of pleasure at being addressed as “Doctor so and so.” Those ward rounds, doing first intravenous injections (intravenous cannulae, central venous lines were unheard of, only in higher centers like PGIMER there used to be “butterflies”). One year ended, as if it were a dream, then the straight forward process of applying, getting selected for Post-Graduation (PG). Only few nationally eminent institutions such as PGIMER, JIPMER, conducted their own entrance examinations. You complete your PG by simply slogging day in and day out, but in the process gaining, knowledge, skill and attitudes of the highest degree. It is neither the contention nor an argument of the author that period was better than the present. Whatever might be the shortcomings, it would be pertinent to ask, did majority of us, medical professionals from that era, do “badly?” Not really! That was the point in time, when multitudes of Indian Medical Graduates (IMGs), became Foreign Medical Graduates (FMGs). Those who did not join such programs, became the overseas contracts specialists/consultants (like yours truly!), were sought after, persuaded and welcome by many foreign shores. Those who remained in the dear old motherland, landed a fruitful job or opened up their own private clinics and prospered. In short, the medical profession was flourishing!

MPE IN “TUMULTUOUS” RECENT PAST AND PRESENT!

So, what went wrong? Where did the voyage of MPE go astray? How and why did the outcomes of MPE get smudged, fudged and almost completely lost? Lot of retrospection and a lot more introspection are needed. There are myriads of factors. Mentioning all would be beyond the scope of the present discussion, but to mention a few:

First of all, there has been an unprecedented explosion of information brought forth by the electronic media, internet, Google, Wikipedia…. so on and so forth! The prospective medical undergraduate (MUG) is convinced in his/her mind, the information, which is going to be disseminated by the teacher, in today’s class, is readily available “online.” In fact, the teacher more than likely, has “copy-pasted” the same in his/her ppt, which though abhorrent, is sadly true. With the advent of smartphones, the MUG can verify or refute a point and “win” the battle of wits, right then and there, in the classroom, while demoralizing the teacher. The hunger of gaining more and more information by attending lectures, seminars, tutorials, continuing medical education programs (CMEs), or even conferences is no longer a necessity because MUGs are convinced in their minds that everything is available by a simple press of a few keys on the electronic device.

Second, the attitudinal change in the minds of the end product, the IMG. At the outset, on completion of their MBBS, during their internship, they are not looking forward to honing their skills, utilizing their knowledge and becoming more proficient in their chosen profession. Rather they are desperately trying to go through external coaching classes, mugging up and doing online practice tests for cracking the National Entrance cum Eligibility Test (NEET). Gone is the charm of being a novice doctor, with a thirst for “hands-on training,” proficiency in communication skills and gathering the pearls of wisdom from seniors. It is purely mechanical, robotized and a monotonous period of 1 year which could be longer in case of those poor souls, who could not get an appropriate score and crack NEET!

Finally, the sheer, naked and gross materialism pervading the entire society. No occupation is anymore an honorable profession, but a simple and pure business, a commercial enterprise (medical profession included). A doctor is a part of the same social fabric. When the young IMG sees, the money-making process happening at every nook and corner of the community, society and even nation, in all the walks of life, including the judiciary and political system, how can he/she be expected to be honorably practicing his/her profession altruistically? Altruism is becoming more of elusive concept. Simply a word you find only in the dictionary. For making the “Fast buck,” any and all corners may be cut by everyone, inclusive of a medical professional.

WHAT NEXT? THE “FUTURE” IN “FLUX!”

Taking into consideration, the conflicts that seem to be encroaching upon the Medical Profession, the Medical Council of India (MCI) has prepared “revised Graduate Medical Education Regulations 2017” (GMR, 2017). Many luminaries, scholars, experts and pathfinders have come together under the governance of MCI, deliberated and conceived a major revision in the basic medical undergraduate curriculum (MBBS curriculum), naming it as “Attitude, Ethics and Communication (AETCOM) Competencies for IMG 2018.”^[2] This is proposed to be implemented to the August 2019 entrants of the MBBS course. Accordingly, all the higher education institutes, involved in providing the MPE, have to adopt themselves, train their faculty to be qualified to deliver Competency- Based Medical Education. For this purpose, Curriculum Implementation Support Programme has been laid down in place and as a chain reaction, a small number of faculty were trained at specified nodal centers, who, after returning are expected to train their own institutional faculty colleagues. So the process shall go on perpetually!!

While all this is absolutely fine, it is certainly going to be a protracted and tedious process. The major hurdle would be to train the faculty to come out of their comfort zone and get attuned to this major philosophical change in the deliverance of MPE on day-to-day basis. All of this process at present is only covering the MUGs. The next logical step would be the changes in the training of Medical Post Graduates. One also cannot forget the whole social structural and attitudinal changes the MUGs have undergone, even before they became MUGs. So to bring them in a proper perspective will be another task.

With all these changes taking place inclusive of bringing in elective courses as a part of the syllabi, continuous assessments to mention a few, one stops and wonders could the MPE be heading toward, choice-based credit system (CBCS), in a highly modified form?

Another important thing to be taken into consideration is, why, only IMGs? Why is it being impressed on only the medical profession by the medical professionals themselves that they have to change dramatically, while the other professions are going about their business of training, practicing, and enjoying their existence in their own sweet comfort zone? To make the entire society a “utopia,” changing only the MPE in isolation may not be very fruitful!

Only the time will tell us, how successful all these changes shall be? But one fact remains, the MPE in India is in “flux” at present and going to remain in same state for more time to come!