The dissolution of the Medical Council of India (MCI) has led to debates on the circumstances involved and the alternatives available. The agency that was set up to regulate medical education and practice had failed on many fronts – despite good intentions. The last straw that led to its demise involved charges of massive corruption. It was an open secret for years. However, this is also a historic opportunity for change and to open a new era in medical education. It provides an opportunity to reappraise the regulatory systems involved.
The MCI was packed with medical professionals, many of them from for-profit medical colleges. This often resulted in narrow perspectives and conflicts of interest. Each specialty represented on the body pushed its own limited agenda, often missing the bigger picture of the health care needs. The woods were missed for the trees.
The new authority should be composed of diverse stakeholders. They should include patient advocacy groups, consumers of health care, social scientists and allied health experts, in addition to distinguished medical professionals from leading medical institutions. This will ensure that overall health and health care needs, rather than narrow professional interests, are the focus.
Lacunae
Over the years, the MBBS course, set in tertiary care institutions which often deal with exotic and rare disorders, has not equipped students to deal with the health needs of local communities. The explosion in medical knowledge has resulted in the introduction of new specialties. But there has been a marked reduction in the time spent for training in each subject and for acquiring practical skills during internship. The focus of undergraduate education has shifted from training basic doctors to manage common diseases to learning medical theory. This pattern has made them less skilled and much less capable of managing basic conditions.
The new regulatory authority should aim to channel education to deliver relevant health care to the vast majority of India's people. Health care needs should be determined based on local and national statistics rather than on western data and priorities. The focus of medical education and the health care delivery system should be on universal coverage of basic health needs. The regulators should periodically monitor the national health scenario and adapt medical education to changing health needs.
The syllabi, curricula and methods of teaching of the undergraduate medical course should focus on competencies and skills to be mastered rather than on knowledge to be acquired. The basic doctor should be a competent generalist who also has the background to specialise.
Trivial factors
The MCI regulations and inspectors were more concerned about the dimensions of classrooms and other such relatively trivial factors than about, say, the quality of teaching. The requirements were so archaic that many good medical colleges found it difficult (and unnecessary) to meet them. For example, every department of physiology is required to have amphibian and mammalian laboratories, despite a government ban on experiments involving such beings. The shortage of teaching faculty and the proliferation of capitation-fee medical colleges meant that many institutions employed teachers whose only mandate was to show up for MCI inspections. The high density of medical colleges in certain areas also means there are fewer patients in the new colleges. This results in inadequate clinical training for students.
The new regulatory authority should provide a basic framework for medical education and should measure the success of medical institutions by their output, namely the quality of the teaching programmes and the doctors produced, rather than on physical infrastructure.
The marked variability among medical colleges and major lacunae and inadequacies in some of them in terms of teaching faculty, clinical exposure, training and evaluation, make for unacceptable variations in the quality of new doctors. The training and evaluation systems for medical courses should be standardised and should focus on skills and competencies to be mastered, rather than on knowledge retained. The new authority should set national competency requirements for basic physician training and establish norms for a streamlined system of quality assurance and certification.
Innovation stifled
The current guidelines include much minutiae and rigid regulations that stifle improvement and innovation. The specification of basic and broad minimum standards for processes will allow for innovation and release good medical colleges from oppressive stipulations. This will allow for the growth of different models of medical education that are best suited for a diverse and vast country like India.
The same office and set of officers of the MCI handled accreditation and regulatory functions; this diluted and weakened both processes. The new authority should consist of two independent divisions. One should accredit medical education and the other should oversee medical practice. Complete lack of self-regulation was evident in its previous avatar. It needs to be replaced by a watchdog with sufficient teeth to ensure and enforce minimal technical and ethical standards in medical practice. The crass commercialisation of medical education and unethical practice should be checked.
The MCI was a law unto itself. While medical professionals and their regulatory authorities have privileges, they should also be held accountable for standards of medical education. The regulatory authority should be answerable for health and health care delivery. The focus should be on equity and inclusiveness which are mandatory for a vast and diverse country like India.
For enlightened regulation
Physicians have always promoted medical education and its reform as a means to increase professional status. Abraham Flexner, an American reformer of medical education at the beginning of the 20th century, promoted educational transformation as a public health measure. He argued that the business ethic that governed for-profit medical colleges was incompatible with the progressive academic values necessary for socially useful medical education. He emphasised that the exploitation of medical education was particularly inconsistent with the social aspects of medical practice. He reasoned that in modern life the medical profession is an organ differentiated by society for its highest purposes, not a business to be exploited. He maintained that the government was the proper instrument for regulating medical education, because social welfare is inextricably linked to the quality of a nation's physicians.
Geographic, cultural, social, and economic diversity characterise India's States. Many regions are economically backward. The new regulatory authority will have to consider the scarcity of medical and health resources, the inequity in their distribution and the inefficiency in their utilisation. The small number of physicians now serving disadvantaged communities result in poor health care delivery and poor health indices. The increased requirements and competition for entry into the medical course and the long years of study required to become a physician have promoted “professional elitism” and have inhibited those who are economically underprivileged from pursuing careers in medicine. The issues related to inequity will need to be addressed as part of long-term planning of human resources.
Tasks
The new regulatory authority should lay down, implement and monitor standards for its diverse functions. It should promote high standards of medical education, maintain up-to-date registers of qualified doctors, foster good medical practices and be a watchdog to deal firmly and fairly with doctors whose fitness to practise is in doubt.
The authority will need the support of all those involved in medical education and in commissioning and delivering health care services. This will be a challenge for India with its large population with largely unmet health needs and variable access to health care. Nevertheless, it is a challenge that must be met. This is a great opportunity to ensure that medical education and training successfully equip doctors with basic skills and competencies to practise and for the life-long learning process that they require to keep up with advances in medical science and health care delivery.
( Professors George Mathew, M.S. Seshadri and K.S. Jacob are on the faculty of the Christian Medical College, Vellore. Many other faculty members contributed to a debate on this subject from which points emerged. )
