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EDITORIAL
Year : 2017  |  Volume : 3  |  Issue : 1  |  Page : 3-5

Controversies in Medical Education: National Medical Commission (A Draft Bill for Replacing Medical Council of India)


Former Professor and Head, Department of Surgery, University College of Medical Sciences (University of Delhi) and GTB Hospital, New Delhi, India

Date of Web Publication1-Mar-2017

Correspondence Address:
V R Minocha
Former Professor and Head, Department of Surgery, University College of Medical Sciences (University of Delhi) and GTB Hospital, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2394-7438.201230

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How to cite this article:
Minocha V R. Controversies in Medical Education: National Medical Commission (A Draft Bill for Replacing Medical Council of India). MAMC J Med Sci 2017;3:3-5

How to cite this URL:
Minocha V R. Controversies in Medical Education: National Medical Commission (A Draft Bill for Replacing Medical Council of India). MAMC J Med Sci [serial online] 2017 [cited 2017 Jun 27];3:3-5. Available from: http://www.mamcjms.in/text.asp?2017/3/1/3/201230

The medical education is under the supervisory control of the Medical Council of India (MCI) initially established in 1933, subsequently replaced by Indian Medical Council Act in 1956 followed by amendments from time to time. The MCI has been in the eye of storm lately seeking changes in its functioning. Niti Aayog has put a report on the reform of medical council act along with a draft bill in the public domain.[1] Some of the issues raised and the position taken therein require review. Some comments are placed below.

The health-care scenario in the country depicted in the report is saddening and puts those connected with health care to shame. However, temptation to ascribe the dismal care conditions to faulty medical education exclusively must be avoided, notwithstanding need for reforms in the medical education on its own merits. Part of the sad story of health situation, significantly if not substantially, is arising from lack of full and proper utilization of workforce and resources due to ill-planning of services which merit creation of network and smooth referral system.[2] Health parameters are also reflective of general infrastructure such as roads and transport; nutrition and availability of food; safe drinking water; sanitation; and pollution.[3] It is necessary to identify separately medical from nonmedical interventions in health care [4] and to avoid confusion should be financed from separate budget head.[5] Unfortunately, the issue of segregating nonmedical and medical interventions in the organization health-care services has not been addressed.

It is immaterial by what name the 'regulatory body' is called, Medical Commission or Medical Council. It is important if not absolutely essential to understand and clearly define the role the Body has to discharge. Stated in a simple manner, the regulatory body has to ensure that medical education is conducted properly. For this purpose, Commission/Council has to define objectives of medical education in all the domains of learning, namely, cognitive, affective, psychomotor; emphasizing interdisciplinary and integrated approach; formulate requirements for a medical college in terms of infrastructure comprising space, equipment, teaching staff - their number, qualifications, their service conditions, etc.; planning of curriculum and syllabi including teaching/learning methodology; assessment and evaluation strategy; and supporting staff. It is equally essential of the regulatory body to ensure compliance of these requirements before a medical college is allowed to be opened and continued with a view to ensure a reasonably acceptable standard is maintained. Uniformity across the country may not be the desired goal: Medical colleges should be encouraged to aim higher than the minimum acceptable standards, Monitoring is essential to elicit the required information on all aspects including quality of education. I am avoiding using the term 'inspection' because of its unfair negative connotation in the report.

It is surprising to note that infrastructural issues are considered “noncore area” in the document. While laying down the standard requirements, it is expected to give due cognizance to modern newer technologies such as e-class room, live telecast from operation theatres, skill learning laboratory using mannequins, models, virtual reality, and others. These items may be categorized as desirable and recommended. It is also essential to ensure the requirements are based on consideration of pedagogy and is not unduly influenced by extraneous considerations particularly to accommodate wish list/demands of private medical colleges.

It is a nonissue whether regulators are recruited by an electoral process or any other as long as people of high standards of professional integrity and excellence are assigned the job. Assertion that “regulated appoint the regulators is a flawed principle” does not appear convincing. The 'open and transparent' being opted is also liable for favoritism and nepotism. It is hoped that the regulating body does not become mouth piece of the authorities. It is most desirable, actually essential, to retain independence of the regulators. Emphasis ought to be on checks and balances and efficient vigilance.

The debate of “input” versus “output” is completely out of place; both are essential. Deviation from standards must attract deterrent action(s) including derecognition. The responsibility of corrective measures should not be relegated to the accreditation process and publication of ratings of medical institutions. Expecting students to make informed choice based on the ratings as corrective measure is in effect shifting the onus of regulation to students unfairly. In any case, Medical Commission/Council should not indulge in accreditation activity which ought to be carried out by other independent authorized agencies as is the current practice.

A suggestion has been made to conduct licensing examination. There is no place for a separate additional examination for the purpose of granting license to practice and inclusion of name in the medical register. A degree awarded by authorized university/institution must remain sufficient for the purpose. In this context, we may note that the General Medical Council (GMC) (UK) document says “It is our (GMC) job to decide if a university should be allowed to issue medical degree.”[6] A common examination for postgraduate (PG) admission is a different issue and some comments are made later.

The draft bill envisages establishing four boards with assigned functions, namely, undergraduate (UG) medical education; PG medical education; assessment and accreditation; and practice of the profession. This division is not reasonable. We must appreciate desirability of continuity of UG and PG education. Accordingly, it is suggested to combine these boards. Assessment and accreditation of institutions are desired to be carried out by independent external body and the medical commission should not disturb the arrangement. The accreditation may be made mandatory, if so desired. Function of regulating professional practice may be assigned to a separate body so as to enable the commission to devote undivided attention to medical education. The commission may thus be named as “National Medical Education Commission.”

One issue which has escaped attention of the draft bill while formulating reforms is relatively low status to basic degree (MBBS) holders in health system and there is over-emphasis on the PG degrees leading to everyone wanting to join any whatsoever PG course without regard to aptitude or interest. General Practice or Family Medicine is required to be put on more sound footing and accorded due status. It is also desirable to examine rationality of putting specialization in certain areas higher than others using nomenclature “super-specialization” whereas training in all disciplines is of similar duration irrespective whether a degree is awarded at the end of training. It is worth examining, and the Medical Education Commission is the right forum to do so, whether wide disparities in terms of financial compensation and social status accorded to family physician and the specialists/subspecialists can be reduced.

A common entrance examination for admission to PG courses may help the candidates to avoid the stress of multiple examinations and avoid hassle of travel. However, it must be ensured that holding of this examination should not interfere with the internship program. The experience of admission to PG courses on the basis of entrance examination has shown clearly that the internship is neglected as a result of preparation for examination undermining the core objective of internship.[7] One suggestion which may be worthy of consideration is to hold the examination before starting the internship. It will require coordination of examination schedule by different universities. Hopefully, system of continuous assessment instead of end of course assessment is more widely used reducing the stress of entrance examination shortly after the Final Examination.

Further, it may be emphasized that PG entrance examination should be devised for the purpose of scatter of candidates and not for qualifying (pass/fail) format. Obviously, there ought to be less emphasis on the 'must know' components of the learning objectives. As a corollary, there is no minimum pass marks and no one 'fails' by virtue of this examination. Inclusion of assessment of skills is redundant as it is part of the UG curriculum of institutions which is part of qualifying condition for the entrance examination. If needed, skill learning and evaluation may be reinforced. Philosophy of admissions to PG courses by entrance examination probably requires to be revisited. It is hoped that restructured Medical (Education) Commission will address the issue and explore other objective methods of admission including aptitude testing.

It is welcome to note that due recognition to the National Board of Examinations (NBEs) is given to their contribution to the PG education. However, it is not appropriate to merge NBE with PG board or combined UG and PG board. Instead, it is suggested that NBE may be accorded a status of a Medical University mandated with functions of affiliation of the institutions, organizing teaching/learning program and examination. Medical Commission may exercise regulatory role as for other institutions/universities/medical universities.

One of the major ills facing the medical establishment is commercializing arising from privatization of medical education. I will quickly add that there are a number of medical colleges in private sector which are providing excellent education. The problem faced by private institutions is that infrastructure requirements incur high costs. It is mentioned land alone probably needs Rs. 500 crores thereby expecting capitation by whatever means and hefty fees from the students. This has cascading effect; the students who have paid heavy amount will try to recover the investment by fair/unfair means. The students on higher merit are denied admission or rather do not seek admission because of prohibitive financial constraints. The Government and the Medical Commission cannot be mere spectators. Unfortunately, the current Report has sought regularization by suggesting to remove restriction 'only not-for-profit' organizations are permitted to establish medical colleges and thus giving a free hand and legitimizing profit making. This must stop.

As an alternate, we may explore a different strategy. The government may acquire the land in public interest and allot it to intending suitable organization after due careful scrutiny on lease on a nominal charge; provide grant- in -aid for building and equipment; permitting donations/foreign aid/investment; utilizing funds available under corporate social responsibility; etc. Admission to privately administered colleges will be made on the basis of merit. Students with high merit and financial constraints should be provided with scholarships.

The Medical Education is a 'public good' activity and the government must remain committed to provide facilities and financial support for medical education. Demand of more doctors to cater to increasing population needs more new medical colleges, but it is essential to avoid temptation of overwhelming the existing institution.[8] Teaching-learning in the medical college promotes sound patient care,[9] and therefore, location of medical college may be decided as per consideration of patient care. The facilities in a hospital other than that of a medical college can be used with supplementation importantly of appointment of teaching faculty. A system of awarding teaching designations to the existing nonteaching staff in lieu of appointments must discontinue. A paradigm shift is required from “rote to reasoning in the learning process and corresponding changes in examinations and the medical teachers have to play leading role.”[10]

The present exercise on reforms of the medical education is initiated on account of largely negative image of MCI. Anti-MCI sentiments are reflected in many of the observations in the report, which is unfortunate and compromises the credibility of the report. It is hoped that the Niti Aayog while revising will take necessary remedial actions.

Medical educationists and teachers have a big responsibility for the reforms in the medical education and must seize the opportunity.

 
  References Top

1.
A Preliminary Report of the Committee on the Reform of the Indian Medical Council Act; 7 August, 2016. Available from: http://www.nitiayog.gov.in. [Last accessed on 2016 Aug 20].  Back to cited text no. 1
    
2.
Minocha AA. Health services and their utilization: A sociological case study. A report submitted to the Indian Council of Social Science Research (unpublished). Department of Sociology, University of Delhi. p. 132.  Back to cited text no. 2
    
3.
Minocha AA. Health services and their utilization: A sociological case study. A report submitted to the Indian Council of Social Science Research (unpublished). Department of Sociology, University of Delhi. p. 134.  Back to cited text no. 3
    
4.
Minocha AA. Medical pluralism and health services in India. Soc Sci Med Med Anthropol 1980;14B: 217-23.  Back to cited text no. 4
    
5.
Minocha AA, Minocha VR. Investing in health: A review of South Asian regional group. World Development Report Occasional Papers. 1993:19;7-16.  Back to cited text no. 5
    
6.
Available from: http://www.gmc-uk.org/education/27007.asp. [Last accessed on 2016 Oct 20].  Back to cited text no. 6
    
7.
Minocha VR. Reform for examinations for Delhi University's Faculty of Medical Sciences – A paper for discussion. J High Educ (Univ Grants Comm) 1996;19:579-84.  Back to cited text no. 7
    
8.
Lal P. From rote to reasoning: The paradigm shift required in medical entrance examination and beyond! MAMC J Med Sci 2016;2:1-5.  Back to cited text no. 8
    
9.
Lal P. Whither medical education and healthcare? MAMC J Med Sci 2015;1:59-63.  Back to cited text no. 9
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10.
Jain AK. Teaching-learning: An integral component of sound patient care. Indian J Orthop 2008;42:239-40.  Back to cited text no. 10
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