|Year : 2015 | Volume
| Issue : 2 | Page : 59-63
Whither Medical Education and Healthcare?
Department of Surgery, Chairman Division of Minimal Access Surgery, Head, Clinical Skills Centre, Maulana Azad Medical College (University of Delhi) and Associated Lok Nayak Hospital, New Delhi, India; Editor-in-Chief, MAMCJMS
|Date of Web Publication||1-Jun-2015|
Department of Surgery, Chairman Division of Minimal Access Surgery, Head, Clinical Skills Centre, Maulana Azad Medical College (University of Delhi) and Associated Lok Nayak Hospital, New Delhi, India; Editor-in-Chief, MAMCJMS
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Lal P. Whither Medical Education and Healthcare?. MAMC J Med Sci 2015;1:59-63
Sixty-seven years postindependence and with 398 medical colleges in the country,  medical education still seems to be struggling with respect to the availability of teachers, formulating course content and executing delivery. This eventually affects the quality of medical doctors being produced who may not be equally trained and equipped due to lack of uniform standards across the country and lack of a uniform exit test. The national body, the Medical Council of India (MCI), which is supposed to be the guardian of regulation of standards for medical education and which should be reviewing medical education at both undergraduate and postgraduate levels, is more occupied with the work related to granting of permissions or otherwise to the new medical colleges. The evaluation of course content of subjects has been delegated to its so-called postgraduate committees comprising of handful of teachers often handpicked by their officials, rather than to national body of academics (present and former teachers) in the particular subject area as is usually the case with international councils.
The deficiency in the current medical healthcare has been highlighted in a recent article that India produces 0.7 doctors/1, 000 population as against 2.5/1, 000 by USA and that India is short of 3 million doctors and 6 million nurses as per price waterhouse cooper (PWC) study.  At present, 52, 255 MBBS doctors are created annually in the country from our medical colleges which are clearly not sufficient on their own to provide for the health needs of the country.  To add fuel to fire, another international publication highlighted that "the latest in technological medicine in India, is available to people who can pay, albeit at a high price, but the vast underclass, 800 million people or more, has little or no access to healthcare, and what access it does have is mostly to limited substandard government care or to quacks, who seem to operate with near impunity. There is one leveler, however: Corruption is rife at all levels, from the richest to the poorest." 
In a recent commentary in the British Medical Journal, it was stated that when devising effective solutions, it is important to identify the possible drivers of corruption. India has a lack of external accountability and oversight of both public and private health sectors. Most doctors work in the underfunded and inefficient public sector because it is a secure job with time bound promotions and little supervision. However, those in much better paid private sector jobs are incentivized to generate business for their employers by over investigation and overtreatment of patients who are at their mercy both medically and financially. Private medicine has flourished in India because of a weak regulatory climate with no standards to monitor quality or ethics. 
The disparity in investment in the health sector is to be blamed to all the successive governments who have chosen to invest just about 1% of its gross domestic product on public health, compared with 3% in China and 8.3% in the USA.  Without revenue on salaries, infrastructure, and facilities, one cannot expect to see results.
The overwhelming focus of the government on producing more doctors at both undergraduate and postgraduate levels (and justifiably so due to adverse people to doctor ratio) has unfortunately compromised the quality. The government has tried to augment the number of doctors by increasing the number of seats in the existing medical colleges and by opening of new medical colleges. Often, the number of seats has been increased without an adequate increase in the infrastructure and qualified staff. Such an approach not only compromises the quality of the medical graduates but also gives a wrong signal to the lay public that the production of doctors can be increased overnight. Some of our top doctors as well as the policy makers at the helm of affairs would have to take responsibility for this, no matter what they might feel about it. If it were so easy to produce medical doctors, why the western countries, whom we try to emulate in every other way, could not increase their capacity in the USA or United Kingdom (UK) or Australia or Canada by this formula. These countries still import doctors from other countries to manage their gaps and deficient numbers, and also in the process provide opportunities to medical graduates from other countries to join their system on a short-or long-term basis. Imparting training to the increased number of medical students in the clinics of any one unit (especially in Government Hospitals) poses additional challenges to an already overburdened system.
Similarly, in postgraduate courses, seats have been doubled giving an additional postgraduate to every professor without a corresponding increase in the infrastructure related to that increase. This problem can perhaps be better understood for surgical trainees more than others, where hands-on surgical handicraft has to be taught to the doctors during their training and requires the operation theatres in both the elective and emergency settings. It is painful to see the surgical postgraduates being denied the opportunity to learn surgery. Any capacity enhancement has to think of the increase in hospital beds, increase in operation theaters, increase in intensive care unit beds, related increases in staff requirements and other related factors before simply increasing the admission numbers. Colleges have been entrusted with such numbers when institutions lack the required accommodation for students and doctors and their requirements of grounds, libraries, duty rooms, etc. Can one think of doubling up a dinner invitation without the knowledge of the catering services?
A recent publication commented on the MCI's inspections to authenticate infrastructure and staffing in some of the private medical colleges that collect patients and faculty for the period of inspections, without anything being existent before and after, the so-called "ghost institutions." It was remarked "the impressions these MCI inspections create in the minds of the young medical students are deeply embedded into their subconscience."  Grave injustice is being done to the cause of medical education and quality healthcare and a disservice to the nation when the guardian of standards for medical education itself, the MCI, fails to check private institutions which are deficient in staffing and infrastructure requirements whereas ridiculously following the rule book for minor violations like lecture hall ventilation when it comes to nonprofit making Government Medical Colleges.
The effects of this quality deterioration are evident in the falling standards of the examination results and the resulting quality of medical graduate who has never done the procedures he or she is expected to perform or know as a Primary Health Care physician posted anywhere in the country. In such a scenario, the overall falling standard of patient care by the doctors that the government thinks it has marvelously produced is inevitable. Moreover, most of these doctors while away their opportunity of hands-on training during the internship (1-year) in preparing for the postgraduate entrance examination. Such an approach also reflects the lack of desire by the young graduates to serve the masses, the poor, and the needy at villages.
With limited opportunities available to the students during their postgraduate training in terms of actual hands-on clinical skills due to the foregoing, they fail to get the full taste of the degree that they actually receive at the end of their 3 years of training. In the last year of this training, once again they use a lot of their time in preparing for postdoctoral entrance examinations at the cost of quality training. At no place in their exit examination, is there a credit or assessment for the log book, hands-on experience, paper presentations, publications, performance in routine teaching activities such as journal clubs and seminars and so on.
The fact is that while the population has increased tremendously thus increasing the patient load as well as the student load in schools, commensurate increase in seats for undergraduate and postgraduate education has not taken place. Such an increase requires newer medical colleges with designated infrastructure. Better salaries for the teaching cadre of staff will ensure that many doctors at the end of their requisite training will be willing to take up posts in such medical colleges, rather than being lost to private institutions for private practice or leave for higher training and settling abroad. Teaching jobs at the end of a 10-15 years period of medical undergraduate, postgraduate and postdoctoral training by which time the trainee reaches 30-35 years of age, are not at all lucrative at the present time.
Instead of announcing new All India Institutes of Medical Sciences (AIIMS), for which one needs 5-10 years to build and also struggle to fill the posts for all categories of staff, there is a serious need for the government to think about upgrading the largest Medical College in every state to an AIIMS like premier institution, which would bring the results much faster than when new AIIMS institutions come up over decades, and at the cost of people leaving from medical colleges to fill those positions. If we talk of the AIIMS at Delhi, a recent newspaper quoting government data, reported that 223 posts of doctors, 287 posts of nurses, and 692 posts of paramedical and technical staff are currently vacant in AIIMS at New Delhi itself.  If this is the story of the so-called premier institution in the capital city of New Delhi, one can only imagine the staff positions in the six others already started on a skeleton staff in other states. Announcing such newer institutions, when the government struggles to fill the posts would be counterproductive. Let medical care, teaching, creating doctors to take care of patients, and patient care itself, not be made into a cruel joke!
Teaching faculty is not made overnight, and senior professors are made after 15-20 years of their experience in a Medical College. Medical teachers should be recognized that they do teaching, clinical work and research and take part in both undergraduate and postgraduate teaching and thus need to be uniformly paid equivalent to the so-called "premier" institutions. The several scales of pay at every level, throughout Universities, Central Government Colleges, State Government Colleges and the AIIMS/Postgraduate Institute of Medical Education and Research, need to be urgently reviewed and made uniform. One rank, one pay needs to be implemented in all premier teaching institutions. How can it be that faculty in a college like Maulana Azad Medical College is not being paid like the premier institutions like AIIMS, etc? How is it possible to have four sets of pay scales in a single state of Delhi for doctors doing similar jobs and with similar responsibilities? Moreover, the same can be said for other institutions in other states as well.
The prescription mentioned in an article on reforming medical education and transforming healthcare in India by equating the number of undergraduate and postgraduate seats in all medical colleges including the National Board of Examination Institutions, though realistic on paper, can be disastrous to say the least, in the absence of augmentation of infrastructure required to impart skills and training to the enhanced number of candidates. 
There has been a recent move by the government to redesignate nonteaching staff into teaching designations using a formula. Most regretfully, this approach can only destroy the very concept of teaching and research which is a totally different mindset and training, required to be done from the very beginning and which requires teaching the undergraduate MBBS students as their teachers. This situation can be compared to upgrading a cabin crew of an aircraft to become pilots to fly the aircraft because everyone has been flying inside the aircraft anyways! This is the reason why medical teachers remain a revered community for their hard work, diligence, dedication, and humility to make them continue on this laborious path rather than take easy exit routes. However, harsh working conditions combined with poor pays are making it harder for this community of teachers to survive.
Poor infrastructure in hospitals, poor general sanitation conditions, poor pay scales and, in general, pathetic conditions in some of the Government Hospitals have adversely affected the general public perception about those working in such hospitals. It is felt by the public that these doctors must be really incompetent and worthless, that they continue to work in such difficult and harsh circumstances and that if they were really good or bright, they would have left for the private hospitals. All of us know that this is far from the truth. One can imagine the curse that plagues the system that medical teachers are working in. Having said that it must be understood that poor auditing of results, time bound promotions, absence of incentives to those who work hard and eventually despair among the medical fraternity has also bred to complacency, lethargy, and hopelessness in some of our fraternity. The so-called corruption amongst the medical community possibly stems from poor pay scales leading to frustration and then moral breakdown. It could be a topic for psychological assessment. A handful of us, however, are dedicated and continue to grow and fight the system and take up the challenges, as a mission of patriotism toward the country.
The component of research from medical colleges is lagging far behind that emerging from the developed world. There is no rocket science for this reason. We have the brains and the talent, but research needs huge financial input in terms of advanced equipment and facilities which are severely deficient. It is only when we overcome our basic problems can we think of doing some quality research. Still our medical teachers and the entire doctor community, through their commitment and intelligentsia continue to bring out high-quality research published in top rated medical journals and for which India is respected. One thing that distinguishes hospitals in India and the USA is the enormous amount of donations that the latter receives from top companies and business houses annually. It may be a bit shocking for us to realize that top hospitals/universities like Harvard, Stanford, Johns Hopkins, Mayo, Cleveland, Memorial Sloan Kettering, Mount Sinai, Barnes Jewish and so many more which are epicenters of research and medical training are all privately funded institutions, each working on billions of dollars of annual donations by private individuals and companies! Unfortunately, there are a handful few in our country that can be anywhere near to these. All of us read about thousands of crores of profits by our top 100 companies, but you would never hear that thousands of crores has been donated by them for teaching, research and development of universities and hospitals. Profits emerge from public money, and a certain portion of it can be rightfully reinvested back to where it came from for the upliftment of Indian masses. We need to encourage donations by such individuals or companies in our own country to increase financial resources for both salary and infrastructure upgradation. Some of the private medical colleges run by eminent trusts in India are doing an exceptional job toward both teaching and training.
National Board of Examinations (NBE) was set up on the advice to the Prime Minister by a three academician surgeons (R N Sinha, Ramamurthy, Gupta) in the year 1974 with the purpose of conducting uniform national level examinations on all subjects and making them at par and recognized by international bodies in different countries like the Royal Colleges and the American Board etc.  This function of conduct of the exit examination is one of the best models being done even today and universities and medical colleges need to adopt many aspects of the examination format from the NBE to make their own examinations standardized. For training, it was conceived by the original teacher thinkers that the NBE would accredit the vast number of district hospitals and other nonteaching Government Hospitals in the country. These include those run by Municipal Corporations, Railways, Employee's State Insurance, labor, mines, etc., where all the basic specialties are already there, trained specialists are there and huge patient workload is there. Thus there is a great scope for students to learn and be trained as clinical specialists so that they can be made as good surgeons or good physicians and so on, and thus augment the numbers required for our country.  Unfortunately, the focus of the NBE which conducts the Diplomate of National Board (DNB) courses for both specialty and super specialty subjects, has completely digressed from the original plan and has shifted training into private institutions. As a result, teaching, training, and hands-on skills are all severely compromised in many of the private centers who need these DNB students for running of hospitals as staff working in that particular department and cannot be taught freely on paid private patients of consultants. The hands-on training despite the claims cannot compare to the Government Institutions and a differential class of physicians is thus being created. Unfortunately, this original plan was never enforced, and the whole game shifted to the private players who had the financial power and the political backing to do what is now unfortunately happening.
The responsibility for making teachers is with medical colleges and not the NBE recognized institutions, and this flaw needs to be corrected at the earliest. At best, they can make nonteaching clinicians at those centers whose volume of total work and hands-on work for the student compares equally to a government district hospital. The government not only brought in gazette notification for equivalence of DNB to MS/MD  but also made it equivalent for the purpose of teaching jobs in medical colleges,  which is stretching it a little too far. Serious harm is being done to the public by making such private centers equivalent to medical colleges while their end products are not even comparable!
There is a metaphor used in technology: Garbage in; garbage out! If we as medical teachers fail to convert the young lives of our progeny who want to acquire medical skills and treat the ailing mass of humanity, it is time to think of our roles seriously. If excellence does not become the benchmark of medical fraternity, excellence cannot be exhibited in treating our population. Politicians, government organizations, bureaucrats, medical teachers, doctors, and all the others involved in the entire process of maintaining and upkeep of standards have at times unknowingly and at other times willingly and consciously, degraded medical education to the present nadir.
The sooner we realize this, the better for the sake of our people of this country. Corrective actions need to be taken at the earliest and medical teachers from medical colleges need to be involved by the government and the quality maintaining agencies, in this process. Curriculum needs to be relooked for all subjects from both the undergraduate and postgraduate points of view and to bring it in line with training in developed nations. The increase in the number of doctors for the ever increasing population definitely needs new medical colleges with undergraduate and postgraduate seats rather than overburdening existing institutions, which have the correct norms and do not dilute the stringent requirements of the regulatory body.
Legislation for recognizing postgraduate qualifications from USA, Canada, UK, Australia, and New Zealand to enable enrollment as medical practitioner in the concerned specialty,  has been a positive step in the government's endeavor to bring back our brains working in these countries to our country and rectify the mistake of the past of derecognizing foreign qualification as a knee jerk reaction. The foreign international medical councils followed the decision of General Medical Council of UK to derecognize all Indian degrees (from all medical colleges, good and bad standards) due to the mushrooming growth of low standard medical colleges in the early seventies when some doctors got exposed due to their low level of knowledge in the UK.  While the recent government legislation in 2008 has brought back a handful of our doctors to practice at big private hospitals in India which can pay them similar to what they were earning in those countries from where they came, there has not been any eagerness from such expatriates to join government healthcare for sheer lack of resources, opportunities, facilities, working environment, and extremely poor pay scales. Recently, a renowned surgeon who was successfully working as a top rate surgeon in UK made a challenging move to take up a position in one of the newly announced AIIMS at a senior level, leaving his family and children still in the UK due to sheer love and passion for his own country. Eighteen months of working in extremely disappointing situations has now made him regretful of his decision to serve his country, and the hostile nonprogressive environment has made him take a decision to return back to the UK. Such are the stories of several of our doctors who have made sincere efforts to make a return to their native country "Bharat" but lowly payscales, red tapism, poor working conditions, nonexistent infrastructure, and hurdles at every step have made them return to the foreign lands who welcome them and acknowledge their hard work and commitment. There is a scope for a large amount of introspection here.
We need to study the healthcare systems of the advanced countries and follow their successful model. To supplement the doctors, these countries (USA/UK/Australia) have developed very robust cadre of Nurse Practitioners (NP), Physician Assistants and Certified Registered Nurse Anaesthetists who work independently but under supervision of a qualified doctor designated for the particular job in both hospitals and peripheral outreach clinics. Even in the UK, peripherally located NP provide the care in the community as the first line of approach, such as postoperative care, intravenous medications, terminal care, mental health, and so on. The government needs to think in terms of these more realistic courses for creating an army of thousands of such cadres, which can be trained more easily in the existing medical colleges and district hospitals of the country, thus providing lakhs of job opportunities in addition to augmentation of health infrastructure. This should be the preferred route rather than the rural doctors' scheme that was announced and then fell into a serious debate and controversy.
The original ethos of the NBE to train clinician doctors at Government District Hospitals in the country under trained and experienced clinicians should be revived to augment the number of postgraduate clinical doctors with DNB qualification who are clinicians and not meant to be medical teachers. The task of producing medical teachers for undergraduate and postgraduate courses as teachers should be left alone for the medical colleges. Salaries have to be made at least 75% equivalent to that of private sector doctors to make the jobs lucrative for our young doctors as working in the public sector remains challenging. Brain drain has to be checked by effective and visible steps as stated above. Medical teachers need to be recognized as doing three times the work by other categories of doctors in the form of clinical care, teaching, and research and thus need to be paid at least three times of the existing pay scales. Unless respect and dignity for this community of medical teachers are granted, talented students will shun away from this profession and those who have qualified will seek greener pastures in the private sector or leave for Western countries. Massive input would be required to augment the infrastructure for health care delivery in the existing medical colleges and district general hospitals first, and then target creating new ones. Unless we have a healthy nation, one cannot think of development or progress.
As one of the pioneer teachers has suggested,  it might be prudent for us to organize and call for an urgent All India National Meeting of Teachers to build a consensus on subject wise curriculum, standards, training and for future directions for medical education at undergraduate and postgraduate level for improvement of healthcare delivery and submit a consensus statement for the government to consider. Medical teachers would have to take a lead to initiate this "manthan."
Quality and not quantity has to be the benchmark for medical education and optimum healthcare.
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