Without some quite feasible changes in medical education, we are never likely to achieve affordable, accessible and universal health coverage.
Perhaps the most coveted professional education in India is in the field of Medicine. It is also the most expensive and of the longest in duration. The chances of an Indian becoming a doctor is less than one in a thousand. But the availability and the dependability of this one person could make life and death differences to the remaining 999. They are entitled to expect that this privileged medical graduate is well equipped to meet their health needs.
Importance of practice venue
A distinctive feature of medical education is that a very large part of it occurs in practice situations. Rightly so, since the attitudes and the capabilities of physicians are greatly influenced by the practical training they receive and by their professional mentors. Thus there is an inescapable link between the texture of health care in a country and the milieu in which its physicians are trained. When there are grievous deficiencies in the health care system, it is legitimate to enquire whether these may be related to the practice settings in which its doctors are trained.
It is a curious fact that the medical care system is like an iceberg. The part that gets the most recognition is the relatively small tertiary care segment with advanced technology and highly specialized medical personnel. But in truth this narrow apex of the profession makes little difference to whether every pregnant mother will deliver safely, whether every child will grow into a healthy adult or how long that adult will live without morbidity. Admittedly the achievement of these goals depends not only on medical care. But to the extent that physicians mediate these desired outcomes, the foremost prerequisite is the availability of multicompetent physicians within easy reach of one's home and one's purse, and capable of resolving most of the common medical needs and emergencies. This combination of skills and attitudes does exist; it is referred to, in India, as Family Medicine (FM). These physicians are the backbone of the primary and secondary levels of health care, the vast submerged part of the medical iceberg. When this segment functions well, fewer demands need to be made on the scarce and costly tertiary care centres, thus enabling the whole health care system to function more effectively, efficiently and economically. Obviously, in such an optimal health care system the bulk of the medical professionals will need to be stationed in its primary and secondary levels. But this sector is the Cinderella (the neglected princess) of Medicine in India. FM is the last choice of aspiring young physicians. And many of those who do end up in it are ill equipped to fulfil their vital role. To understand this anomaly, we have to go back to the question of the clinical settings where our doctors are trained.
Our present medical education is the exact opposite of the medical iceberg described above. The major part of every medical college is the so called teaching hospital which by definition is dedicated to tertiary care. All the faculty in it are required to be specialists. The colleges are not required to have departments of Family Medicine. As against the arduous specifications for the tertiary level teaching hospitals, there are no stringent stipulations for primary and secondary level health facilities dedicated to student teaching. Our budding doctors never see the challenge and the potential of competent family medicine at its best. Instead, they are brought up to think that FM is like manual labour, what any one can do but no respectable person wants to do.
We are in the midst of a long overdue effort to revamp the oversight of medical education in our country. But whatever the final shape of the regulatory mechanism, it owes it to our ordinary citizens to bring about some basic but quite feasible changes in medical education. Every medical college must be required to have a large and well developed department of Family Medicine. Its faculty must have the academic competence to develop this discipline on par with the other medical specialities. They must also be sound clinicians capable of handling by themselves 90% of the common medical ailments and emergencies and also deciding when patients need specialist care. Every medical college must have sufficient primary and secondary level health care services where these faculty can demonstrate this kind of optimal delivery of FM. And the curriculum must be restructured to ensure that at least 25 per cent of the clinical experience of students and interns occur in these settings.
Will these changes make undue demands on the running costs and man power of medical colleges? Compared to the high cost of present medical education and its tertiary care centres, these additions will be very affordable in costs and man power. Will these changes result in professionally inferior graduates? There are a few institutions in different countries which have implemented these changes. Their experience shows that, in national examinations and in selection for postgraduate training in specialities, their graduates rank equally with those from the traditional colleges.
We will also need to upgrade and update the skills and competence of the tens of thousands of physicians who are already engaged in primary/secondary care in the government and private sectors, often with inadequate or outdated skills in family medicine. This would require continuing medical education programmes on a vast scale, tailored to their circumstances. For this as well as for the academic development of the neglected discipline of FM and the training of faculty for the new FM departments, it would be good to establish a network of Institutes of Family Medicine across the country based in innovative medical colleges. And since this field is so vast and so different from other medical specialities, and so neglected, we will do well to create a separate National Board of Family Medicine (like the Royal Colleges of General Practice in U.K., Canada and Australia) to develop and accredit these postgraduate programmes in FM.
The beckoning vista
We need to believe in the possibility of a healthier society where every one will receive appropriate health care according to need. The proposed changes in medical education alone cannot take us to that day. But without these changes, we are never likely to achieve affordable, accessible and universal health coverage. Cost, feasibility or possible lowering of quality are not the impediments to these long overdue changes in medical education. What is required is a clear understanding of these issues by the general public, sustained political will and a willingness on the part of the medical profession to embrace this social responsibility. We can no longer leave it to the medical profession by itself to address this issue. Civic society and the media need to add their voice to those of concerned medical activists to bring about these quite practicable changes.
(Dr. Zachariah was formerly professor in the Christian Medical College, Vellore.)