This week could see far-reaching beneficial consequences for health care in India. But we need to ensure that the emerging paradigm shift does not miss out on what medical education can and should do to overcome the inadequacies.
Recent events in our country have been full of sound and fury, which have disillusioned the public with their futility. But this week has the potential for promising developments in Indian medical education which, in turn, could have far-reaching beneficial consequences for health care in India. The Board of Governors of the Medical Council of India (MCI) has been continuously refining its proposals for major reforms in undergraduate medical education. These are to be discussed today with the State Directors of Medical Education and the Vice-Chancellors of universities, who together are the CEOs in this field of education.
The Board has been hard at work on these proposals for some months, with the aid of a designated Working Group for Undergraduate Medical Education. This Working Group, in turn, has been holding wide and sustained consultations with scores of expert groups, which have resulted in a general consensus that major changes are overdue and must occur expeditiously. Thus this week could be a rare, opportune and pregnant moment in the troubled history of regulation of medical education in India. The nation has a vital stake in ensuring that the emerging paradigm shift does not miss out on what medical education can and should do to overcome the inadequacies and inequities in our health care system. And to take our country to the happy consummation of quality assured and universal health care. There should not be a slip between the cup and the lip.
It is important to recognise the special potential and limitations of the present Board of Governors of the MCI, inherent in its origins. The long simmering discontent with the inefficiency and improprieties of the MCI finally erupted when, in April last year, its president was arrested on charges of corruption. The government moved quickly, in May 2011, to issue an ordinance entrusting the considerable powers of the elephantine Council to a small group of six nominated Governors. They were chosen with commendable care, both for their eminence in the profession and their reputation for integrity. In August, Parliament gave its assent to the provisions of the ordinance, but only for a one-year term ending in May 2011.
Thus, on the one hand, for the first time, a small body of reputed experts has the power and, indeed, the mandate to rectify the perceived wrongs of the MCI. They have recognised the need to move quickly on many other fronts as well such as shortage of medical manpower, quality of medical education, shortage of faculty in medical colleges, deficiencies in postgraduate training and so on. The issue of the short period of their trusteeship has now been resolved by extending their term to May 2012.
New medical graduate
Thus the MCI and the Health Ministry together are in a position to consummate this long process of gestation and produce a new Indian medical graduate. And hence the need and urgency to raise in the public domain one crucial aspect of reform of medical education which may not receive the priority it deserves. In spite of the danger of over simplification, the argument here can be stated briefly.
(1) It is generally agreed that the major challenge in health care is in ensuring sound and competent basic health care to the disadvantaged communities, both rural and urban. Indeed, it is an every day experience that even for those who can afford it, dependable and quality assured basic care is a very rare commodity.
(2) This type of care is non-specialised, has to address all common and urgent medical conditions, with limited laboratory and other facilities. It should ensure continuity of care for all members of the family, of all ages. It is mainly ambulatory. And it must include disease prevention and promotion of health, in the family and the community.
(3) Obviously this is not the kind of care that medical students are now exposed to in the so-called teaching hospitals. It is a different kind of clinical practice, usually referred to as Family Medicine (or family practice, though the former is a better term). This can be taught only through a significant exposure to secondary and primary levels of care, the lack of which is the foremost deficiency in Indian medical education today.
(4) Unless and until this component is introduced as a required part of the undergraduate course, India will never be able to solve the lack of competent, well trained, basic doctors in our primary and secondary level health clinics and hospitals. Without this, the proposed new medical graduate will not be the basic doctor who forms the backbone of a sound health care system all over the world and which India sorely needs.
The logic of this is such that a high powered “Retreat” of the Health Ministry on September 28 and 29, 2010 expressed its approval as follows: “Request the MCI to address the issue of curriculum change to make doctors more sensitive to primary health care. Subjects such as Family Medicine need to be given importance.”
But there are many difficulties in this proposal which might result in its being put aside for the present. Health issues have never been a powerful element in our political discourse. They have never been a decisive factor in the elections, unlike in Britain or the U.S. So there is no great incentive for political parties to reflect on or act decisively on the societal responsibilities of medical education.
Electorate easily pacified
In the public perception, sound medical care is equal to access to particular medical interventions and publicised advances in medical care. The electorate is more easily pacified by the offer of medical insurance of the type instituted recently in the southern States. The move suggested above requires the creation of a speciality which hardly exists now. This discipline has to work in close coordination for the State health care system whereas the MCI works at a national level.
Family Medicine is not a field of medical practice that readily attracts the private sector or professionals who make their career decisions based on socio-economic rewards. And, therefore, at this moment in the formulation of the reforms in medical education, there is a special need for all the custodians of Indian medical education, especially the Ministry of Health, to act on behalf of the public to ensure the following:
About 20 to 25 per cent of clinical training, during the “clinical” phase of MBBS, should occur outside the teaching hospitals, at the primary/secondary levels.
Since this is quite different from tertiary care, new departments of Family Medicine should be established in all medical colleges to implement the above.
Either by arrangement with the State health care system or on their own, medical colleges must have sufficient clinical services at the primary/secondary levels to implement the above two. The outlay required for these, in faculty and infrastructure, is minor compared to the prevailing requirements for medical colleges.
There is a tide in the affairs of men. This week has the possibility of a tide which, taken at the flood, could lead to better health for all of us. “Omitted, all the voyage of their life is bound in shallows and in miseries.”
(Dr. P. Zachariah was formerly a Professor of Physiology and continues to engage in issues in medical education.)
Keywords: family medicine, medical education reform, medical graduation, health issue, Medical Council of India, government healthcare
Please read www.ramkrishnacarehospital.com and open your eyes.Doctors means small time crooks turned butchers by paying money stolen by their parents.Imagine what is happenning to others.No one to see what is happenning inside private hospitals.No grievance redressal method.Traitors all.
This is already a long debate to include and develop family medicine as a core branch of medical health system in India to provide a specialist care at a very primary and secondary level of our population, but now its the time to accept family medicine as a primary subject at UG / PG level.....because we are already lagging behind in our health statistic from our counterparts in the world , who are already setting examples and milestones after adopting this marvellous branch of medical education longback.
so its time for MCI and Health Ministry of India to wake up and do something positively for the people who are still far away from quality medical facilities in distant part of our country....i think setting a new department of FAMILY MEDICINE in each medical college is much-much easier than established a whole chain of medical colleges.....choice is yours, MCI.
Charting a full career path for medical students in community set up is very important to attract more and more young doctors to opt for family medicine and become primary care physicians for life. This requires fully fledged academic family medicine departments at primary and secondary level, so that doctors engaged at this level have opportunity to gain growth as well as respect to the level of professorship. MBBS has always been a very compressive course to be able to produce basic doctors; it's only in recent decades that its quality has detoriated due to PG entrances for limited specialty seats. Using basic doctors in community set up for 2-3 years and drawing a career path towards super specialty courses is not right approach.There is serious conflict of interest as the doctors and faculty engaged at tertiary care have benefitted from lack competent primary care physicians over several decades. According to a recent TOI report 86% of medical tourism is taken by rural Indians. In spite of family medicine being a recognized specialty since 1983 through amendment in MCI act and Family medicine being the focus area of human resource development in the NATIONAL HEALTH POLICY 2002 (STANDING NATIONAL POLICY), Medical Council of India did not have definition as well as curriculum for family medicine both for UG/PG level till 2009 (as confirmed by reply to an RTI application). Its seems that there has been conscious efforts in past to block FAMILY MEDICINE in India by various groups. Leaving family medicine to only basic doctor level and ignoring 'completed academic institutionalization of community health services through post graduate courses as well as availability of faculty at community level' is only work half done. We hope that wisdom prevails these historical changes are allowed to happen, otherwise it's an opportunity lost!
1 year internship is more than enough for competent general practice. The bitter truth is no student does the internship sincerely. and no one bothers about that. That 1 year period is spent solely for PG entrance preparation. This is the situation in majority of North India. South India is better in this aspect. There the interns undergo compulsory and vigorous training in all the major departments. As PG students when we interact with students from all over India, we could easily notice this gross difference in competency. as a Intern in a Govt.medical College in Chennai, I have conducted around 70-80 deliveries. In some Northern States, they dont even know how certain procedures are done or what are the equipments generally needed in a ward. Really very poor.. my suggestion is.. 1. making internship compulsory (not only on papers), 2. in final MBBS case presentation, inspite of concentrating more on MS, AS, AR, complicated respiratory diseases,paraplegia and such speciality cases, more focus should be given to common ailments like malaria, typhoid, diarrheal diseases, asthma and PUO, etc..3. In a north indian state where i am doing PG, the government doctors are never present on duty. they just pay a share of their salary to the CMO of the district and enjoy in their home and do activities such as PG entrance preparation. 4. the situation in medical colleges are much poor. There is no equipment, there are no monitors in elective OT and even in ICUs. sparing one or two, no consultant is present on duty hours. They have their own busy private practice even in their duty hours. even when a maternal death occurs, no one bothers about this, no medical audit, nothing. 5. So first rectify the flaws existing in the present system, rather than focusing on changing the system. 6. If the MCI is not able to enforce a strict system at tertiary level, how can they enforce the new changes at secondary and primary levels(no one will be there to receive the order at all). 7. the proposed new system is unnecessary, immature and is just a routine eyewash measure. Change in attitude is required at all levels.
please read www.ramkrishnacarehospital.com to know how we have arrived in the 21st century.What doctors are doing in hospitals.And how they are getting away.I also understand that Government of India and medical council of india have not created any mechanism to see what is happenning inside private hospitals.Because they are owned by sons of politicians or well connected such kind of people. India cannot change.All these articles are to misguide the people that now all will be well.WHat we need is 100% transparency and a grievance redressal mechanism that is super efficient and punishment for the guilty.
I hear all these comments about medical education, but one major problem which inflicts India is delivery of healthcare and it's lacking because the monetary compensation is not close to lucrative at all. I am myself a medical professional and I realize that MBBS is good enough for providing basic medical care. I think the government has to make compensation better for physicians if they want to deliver quality medical support to the underprivileged population
This article in particular and the general thrust of public discussions on healthcare delivery system in India, do not even broach the subject of totally unregulated nature of India's healthcare system. Privately, I have heard from many practicing doctors in India on what is known as 'commissions' -- which are actually kickbacks and bribes -- that are routinely expected and demanded by healthcare providers from labs where they send their patients for tests -- from blood work to X-rays to CT scans and other diagnostic tests. I also have heard about unethical, and probabaly illegal exchange of moneys between GPs and specialists, between hospitals and surgeons etc. and between pharmaceutical companies and physicians.With patients coughing up 100% of the healthcare expenses, the helpless consumers of healthcare in India are caught under the vice-like grip of the healthcare system in India, with many low-income families facing bankruptcies. Why nobody wants to even broach this subject?
Those are interesting view points from Dr. Zachariah. I completely agree with those views. There are two issues that we need to consider first. On the first hand, we have to see how to improve the health of the community at large and the second is the changes in medical education to better match the public health needs.The best way to address both the issues is the integration of two systems to get a trade-off. First we need to see whether Family Medicine as a specialty has addressed the community needs and fill the gap in community health from various countries that is in place. As per my knowledge, there is quite a good amount of data to suggest that the family doctors have succeeded in meeting the community health through health promotion and health education. Therefore, I seriously see a need to change the medical education policies to better match the community needs. However, by simply creating a family medicine specialty with increased (20-25%) rotations in primary and secondary levels of health care for medical students may not completely address the restructuring of medical education to meet the community needs. Following are my suggestions to achieve a better integration of medical education to appropriately address the community needs. 1.Family Medicine is the best capsule for the ailing Indian health system. It is very important that how we administer that capsule. Family Medicine should be developed as a specialty at the post-graduate level (MD level). First we need to understand the definition and the core objectives of family medicine. The Academy of Family Physicians of India (http://afpionline.com/default.aspx) may be an important resource in this regard. 2. Family physicians should be trained in public health, if possible with a Master of Public Health. Family doctors should be aware of the core disciplines of public health to better address the community health needs. We have the Indian Institutes of Public Health (IIPH) instituted by the Public Health Foundation of India (PHFI) to address the need of training family physicians in public health. If that is not possible at this point, it not a bad idea to initially integrate family medicine into community medicine and get family physicians trained in community medicine. 3.There should be a greater emphasis with regard to research into community health problems by the family doctors. Therefore, training in public health and/or community medicine would serve the purpose. 4.How do we attract medical students in to family medicine specialty and then the family physicians into service for the rural and tribal communities are a big challenge? Family Medicine as specialty, if developed really well, then I don't think it is a problem in attracting medical students into it. There is a huge demand for post graduate medical seats. Therefore, I am very positive in getting medical students in to the family medicine specialty. The government should provide enough incentives for the family physicians to reach the rural/tribal communities to do research and/or medical care. It is not a bad idea to set up medical colleges in the tribal sub-plan areas with coordination of the Integrated Tribal Development Agencies (ITDA) such as a Tribal Medical College. These tribal medical colleges should have an attached Center of Tribal Health Disparities (CTHD) to aid in research in issues related to disparities in tribal health. The students coming out of these medical colleges should be mandated to serve their needs. To conclude, the government should work in coordination with the Medical Council of India (MCI) and all other related agencies to improve the health of the public at the primary level through changes in the medical education. "Prevention is better than Cure"
I am trained in India and worked in primary, secondary and tertiary teaching hospitals in India for more than 12 years. For some time now I am working abroad. It is heartwarming to note the medical council has turned to be one of the rare non corrupt organisations in India, at least for the present. I wonder how long the our corrupt politicians will allow it to work as such.I dont think it is the deficiencies in the medical education primarly which result in doctors not concentrating in primary and family health. There is consierable political interference in the transfers and posting that, if given a choice anybody would leave. Doctors once they have completed the learning curve tend to leave on this accord. The remuneration should also be competitive. I know of many colleagues who earn just over Rs 20,000. in rural areas, while their just graduated kids earn more than treble than amount in software companies in cities. The govt should be ready to spend more money in health. The MCI has made no mention of the fact we spend the lowest GDP% on health among the civilised countries. The care given by the family care medicine doctors should be of high quality and be equivalent to any specialist in the field they practice. If they are ' jack of all fields and master of none' nobody who has a choice will go to them.
Medical education in India today ,like all other education system is hijacked by a section of people whose only objective is to earn money and more money at the cost of the diseased and the dying poor.The training in the teaching hospitals are towards this goal by the example young mind see in their mentors.The proposed All India entrance examination will foster this trends and install a capitalistic mind set on 'feudal' lines. This is a wrong step. Let each university conduct its own entrance examination,design its own courses of study and hospital training ( under the framework set by the MCI) comprising of at least 25% of practical training in a rural setting at the primary health centers run and managed by the university and not by the government.Today the Primary Health Centers,run by the state governments, are plagued with absenteeism, indifference, incompetence and corruption on a mass scale.This can be minimized if these centers were run by the university based on the principle of autonomy in education.This is exactly is the practice in the American medical education.
Improvement of Family Medicine at the grassroot level and to take its benefits to the disadvantaged communities, demands the aforementioned reforms in undergraduate medical education. But considering socio-economic viewpoint, not much of doctors would prefer opting for this stream. So it is still a dilemma for the educated middle class or the intellegentsia of our society, whether to do the right thing and offer our services to the poor and downtrodden or to realise our capitalistic dreams of big house, car and money. And government is also not helping in any way, by offering some incentives to work for the disadvantaged communities. Governement is more concerned in reducing the deficit by cutting on social spendings.
Prof. Zachariah is right in pointing out that even the ordinary average middle class finds it difficult to find good primary healthcare. Though, there has been a proliferation of medical facilities, the good caring ones are rather lacking. A major factor contributing to this i feel is the selection of less than meritorious people for the job. It is very easy to find a doctors son becoming a doctor by virtue of donations/NRI seats etc, and returning back to run the family business. This kills quality and turns the hospitals into money making machines because the money spent on the childs education has to be compensated. Hope the MCI considers this aspect and ban the paid seats.
In government medical college hospitals, for example, in Chennai, the number of out patients is enormous (in Stanley and MMC-more than 5000 patients a day).Of this, 3|4th of the population belongs to secondary and tertiary care category only. So, the under graduates need not separately under go exclusive training in secondary and tertiary care centers where teaching staff are not post graduates and the infrastructure is not up to the required standard. In Tamil Nadu, the medical students and medical officers are coming under 3 different heads viz. Director of Medical Education, Director of Public Health, & Director of Health Services. When I was working as Dean, Government Thoothukudi Medical College and Hospital, I found it very difficult to co-ordinate with DPH & DMS whenever they organized state government's popular health schemes like 'Varumun Kappom'. Unfortunately qualified specialists with post graduate qualification would not be available in their side and I was to be forced to depute my teaching staff to conduct the camps. Unlike Dr. Zachariah's era when so many specialties were not existing and an undergraduate with MBBS was more than a specialist in almost all the specialties, including family medicine; at this juncture, cutting of 25% exposure of the under graduates to clinical medicine in tertiary care centers will definitely jeopardize the quality of outcome.
The views of Prof.Zachariah on primary and secondary level health care and creation of permanent clinical training for medical students at these levels are laudable and worth emulating by the Government. At the same time they should also increase the number of medical colleges on par with engineering colleges. It is a myth that the quality of education will fall if we increase the number of medical colleges. Like in engineering it will contribute to nation's progress, especially in the field of primary and secondary health care. The insurance schemes are just eye wash and they only benefit the insurance companies and the license giver! Instead the money is worth spending on creating facilities for primary heath care. The Medical Council should quickly decide on this and implement the same.
If we want health of our poor people to improve, there is no substitute for improving accessibility of this under-privileged section of our population to medical care at affordable cost. For this purpose focus of our medical education has to change. The poor do not need costly medical care. They need a caring family physician, as pointed out in this article. If those who study medicine in different streams today are reluctant to take enough care of our poor, it is not their fault alone. We as a society have to ensure that the doctors who serve in rural areas are paid decently and their services are regarded as important. Many times it is found that they are victims of local politics. This should not happen.
Medical education is one thing and the delivery of health care is another. To start with, the authorities should consider having senior medical students be a 'part of' the PDS SYSTEM that is already in place. At or near the outlets, these students should provide a target oriented advise and basic screening such as, basic cleanliness, hand washing, disposal of waste, healthy diet, smoking cessation, vaccinations,exercise, maternity care etc. These measures are FREE and go a long way in preventing infectious diseases. This could be done as a mandatory part of Social and Preventive medicine rotation for M.B.BS students and as a requirement for the PDS card holders.
I read this with great interest as I am a health professional trained in India. Whilst I agree with a lot of the sentiments expressed, 2 themes strike me as being the core issue behind any comprehensive review. One is the independence from politics at a macro and micro level and the other is transparency. Both are interlinked in such a way that if one is disengaged, the other cog slows it down to a level that becomes untenable. Political interference is common in any country, and UK, Australia and New Zealand are recent examples of how a good system can be brought close to ruin. MCI has a long history of being run by a community close to politicians and have repeatedly shown no regard for the needs of the community at large. In that regard, my concern is that the review will not go far enough to provide the autonomy that is seen in the countries mentioned above to provide clear direction as to the future of the profession. Dilution of standards and flagrant disregard for humanity is rife in the profession. Imagine this, a student pays a lifetime earnings to go through medical school and he/she comes out with only one aim- to recuperate the money back. I have realised that being a medical professional does not make millions. The ethos of the profession being more than that has been lost with the private provider generation. As a double whammy, private medical institutions have only contributed to dilution of standards and not the other way around. I am hoping against hope that this panel will have a mandate to make brave changes and make the MCI a truly bonafide organisation like the General Medical Council for eg. Then only will we make true steps towards progress. The rest of the regulations can be put in place once the MCI takes the lead role.
the movement to create family medicine as a specialty originated in USA in the in late last century for the same reasons expressed in your editorial.The results of this are very evident in the American health system as of today.We lack primary healthcare professionals. We need to develop a cadre of basic health care professionals like physician's assistants, nurse clinician etc.
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