Basic medical education and training should be tailored to (i) develop appropriate manpower to meet common health needs, (ii) recognise and manage common health problems, (iii) teach critical appraisal of new information to keep abreast of advances, and (iv) ensure ethical practice. The current system falls far short of these objectives. The lack of relevance of medical education in India has been highlighted in medical literature. The World Health Organisation published its recommendations of “Reorienting medical education” (ROME) in 1991, arguing for major shifts in the educational model. Yet, two decades after the proposal, the changes made have been minimal and superficial; training continues to be inappropriate and inadequate for meeting the health needs of the country.
The standards and setting: The pyramid of health-seeking has its base in informal household remedies, traditional medicine and primary care, and moves through secondary hospitals with tertiary care facilities at its apex. The vast majority of patients seek outpatient services in clinics and small hospitals. A small proportion visits — and an even smaller fraction is admitted to — tertiary care centres. The referral patterns of tertiary hospitals make uncommon conditions presenting at these centres appear common with the exotic seeming standard. Since medical colleges in India operate at the level of tertiary care centres, such uncommon conditions are used for educating India’s basic physicians. The medical colleges, modelled on European-American institutions, retain their colonial inappropriateness. A model, with its focus on local reality (for example, as used in Cuba), is probably more suitable.
The curriculum: In India, the medical college setting, with its different specialities, drives the medical curriculum. Systems and areas of expertise are organised into separate departments, each with a narrow focus and circumscribed field. The demands of the specialty, the teachers and the settings are the factors that tailor medical education rather than the needs of the population they are meant to serve. The failure to develop simple and relevant guidelines for the management of common local medical problems implies a reliance on strategies meant for developed countries. While the need for clinically relevant basic science education is often discussed, in reality, the curriculum continues to be loaded with inconsequential detail.
The examination system: In practice, the systems of examinations have a greater impact on the approach of students to education than the curriculum. The tertiary care focus results in the use of uncommon conditions for assessment during clinical examinations. For example, mitral valve stenosis, an uncommon condition, is a standard case for the final clinical examination, while common conditions (diabetes mellitus, hypertension) are never used for assessment. A medical graduate can pass this examination without ever having been assessed on the diagnosis and management of malaria, endemic in many parts of the country.
Knowledge, skill and confidence: Most medical colleges focus on the transmission of information to students. Many new subjects have been added to the curriculum at the cost of basic clinical medicine and surgery. The acquisition of skills and the confidence to apply them are limited. The emphasis is on arriving at a clinical diagnosis, while a hands-on approach to the management of patients is not stressed. Clerkships during the course and exposure to secondary hospital settings are the exception than the rule and, even when present, occur for short periods. Internship is fragmented with brief periods spent in many specialties. The superficial and theoretical approach to patient care makes students less competent doctors. The general population realises this lack of skill and shops for specialist care. Young graduates also quickly appreciate this deficiency and seek postgraduate qualifications in order to acquire clinical expertise. Seeking a postgraduate qualification is a survival strategy for most doctors, rather than a choice based on aptitude or one based on need. The long periods of training, investment and specialisation in urban-based tertiary centres make doctors reluctant and less suited to work in rural primary and secondary health facilities.
Role models and mentors: Young medical students see their seniors as role models and their teachers as mentors. However, even good medical teachers, while emphasising clinical skills and focussing on common conditions that affect the health of the majority of the general population, are seen to pay lip service to these goals by actually practising in tertiary care facilities. Their actions speak louder than their words and their message of clinical care and service to the underprivileged sounds hollow. In fact, the resistance of the majority of the faculty to change the status quo was one of the major reasons for the failure of the “ROME” effort to get off the ground.
Knowledge, data and official policy: Medical professionals in India tend to quote knowledge acquired from the West. Research is often considered a luxury we cannot afford. The lack of involvement of teachers in clinical research on common problems contributes to the lack of local information. Official statistics constantly underestimate the problems on the ground. For example, 3 million cases of malaria per year are reported officially while unofficial estimates put the figure many fold higher. The use of chloroquine prophylaxis for pregnant women in areas endemic for malaria is opposed by the official policy, citing medication resistance based on research data from other countries and from small pockets in India, whereas doctors working in remote areas find such prophylaxis helpful. The official tuberculosis policy recommends anti-tuberculosis medication without nutrition supplementation, when local evidence suggests better recovery rates with the addition of food to the medication regime.
The significant differences between official perception and reality make teaching medicine difficult. Teachers are caught between quoting official statistics and policy and preparing students for examinations rather than preparing them for the ground reality.
The way forward
With capitalistic thought gaining ground, the Alma Ata Declaration “Health For All by 2000” was abandoned, primary health care initiatives were diluted and the ROME programme was not just stalled but also forgotten. The solutions pursued are “add-ons” without evaluation of the current system and its major shortcomings.
Solutions for the absence of skill-based training during undergraduate medical education are postgraduate courses, including family medicine and the master’s course in medicine and surgery. These belatedly correct the lack of skill among undergraduate doctors. The scarcity of doctors to man hospitals in rural India has prompted the recently conceived course, bachelor of rural health care. This option will improve essential services in rural areas but will divide practitioners on the basis of quality and quantity of training. Neither approach will correct the fundamental problem of the absence of the required skill and confidence among new physicians.
The compulsory posting of new physicians to rural health centres will also have a limited impact on health care delivery. The insufficient skill and confidence of these doctors will result in the continuation of second class health care for the rural poor, the underprivileged and the marginalised.
There is a need to revamp basic medical education. Tinkering and cosmetic changes, as attempted over the past few decades, will not have any impact on the quality of basic doctors. Focus on clinical medicine and the transfer of the necessary skill and confidence are essential. There is a need for patient and community-centred medicine and for the dismantling of disciplinary and specialist boundaries during undergraduate medical education.
Training should be set in primary care and secondary hospital facilities, which is crucial to learn about common health problems in the community and to manage them without expensive technological input. Testing of skills required for working in primary care and in secondary hospitals, rather than the practice of assessing theoretical knowledge of uncommon disorders, is mandatory for success. Physicians with skills to manage common problems in the community will make good general practitioners, be ideal gatekeepers for referral to specialists and follow up patients with the help of advice from tertiary care, consequently becoming the mainstay of the system.
The current approaches to undergraduate medical education do not meet the challenge of managing the basic health needs. Unless fundamental course corrections are made, undergraduate medical education in India is bound to flounder and produce doctors who lack the skill and confidence to manage common diseases and illnesses in the population. The imperative is to re-work medical education and to re-orient training to make it relevant to meet the health needs of the country. The system needs to struggle and transform itself with better and appropriate science and more humanity to make it responsive to societal needs.
(Professors Seshadri and Jacob are on the faculty of the Christian Medical College, Vellore.)