Prof M S Valiathan, a reputed cardiac surgeon, and a pioneer to establish the concept of merging medical education and technology, shares his views and proposes recommendations on the current structure of medical education in India.
The present system of medical education dates back to the establishment of the medical colleges in the later part of 19th century. To meet the current challenges, discussions are in progress to set up a National Body by an Act of Parliament, with the twin objectives of promoting and regulating medical education at all levels.
The past of medical education in India fades into the mists of antiquity.Buddhist literature has numerous references to the famous school in Taxila, where Jivaka -Buddha’s illustrious physician – received his training for seven years. As a teenager in Rajagriha, he learnt of his doubtful parentage and decided to study the art of medicine in Taxila “after considering the character of eighteen sciences and sixty four arts” as he wished to be “called a physician, and be respected, and attain to eminence”.
While the Universities of Taxila and Nalanda offered training in all branches of knowledge including Ayurveda, then Gurukula system flourished side by side all over India to impart training in traditional medicine. The many discussions which characterise Caraka Samhita, where less than ten students took part in vigorous debates, with Acharya Atreya presiding, give us a window on the teaching of medicine in the Gurukula system of ancient India.
Medical Education from the West: Medical Council of India
The present system of medical education dates back to the establishment of the medical colleges in Kolkata, Mumbai and Chennai in the later part of 19th century by the Government of India. Their syllabi and training were modeled on those of the Universities of London and Edinburgh, and Indian degrees were automatically accepted for registration by the General Medical Council (GMC) of Britain. The Medical Council of India came into existence in 1934 to uphold uniform standards for medical colleges in all provinces and accord recognition to medical qualifications from institutions in India and abroad.
The Challenges in Medical Education
A major challenge for medical education is what confronts in India is that in several top universities in the US, aspirants for medical admission are encouraged to spend a year in humanities, archeology, anthropology etc., before embarking on their hard years in the Medical School so that they join the medical course with “a liberal intellectual base”. As our students join the MBBS course after 10+2 and lack the liberal intellectual base of the average American student.
Every effort should therefore be made to ensure that the physician trainee knows that he is part of a big picture.
Besides, in medical education in India. The challenges ahead are many, but they are different at the undergraduate and postgraduate levels.
The various reports of distinguished Committees say that, medical education at the undergraduate level failed to produce community physicians or their equivalents. There is no evidence that the initiatives of the Government or those of Medical Colleges such as the ROME programme (Rural Orientation of Medical Education) had the slightest effect on the status and practice of public health which remained one of the lowest priorities of medical students. The authorities fail to provide decent living conditions or security to youngmedical appointees in rural areas. It is also doubtful whether the excellent report of the joint Committee of ICMR and ICSSR on strengthening the social aspects of medicine had even been seriously considered by the MCI. While the neglect of public health in medical education and health care delivery set us back in comparison with several other countries in the developing world such as Sri Lanka and Bangladesh, we should be making another grievous mistake today if we shape our agenda for medical education as if time had stood still from the time of various Reports which were written thirty years ago. During the last three decades, medicine has been convulsed by two kinds of revolution- biological and technological. The unraveling of the Human Genome has given an enormous push to genetic engineering, which impinges on diagnostics, therapeutics, and vaccine development with the result that Departments of Molecular Medicine are being established in developed countries and even in India.
During the last three decades, medical science and medicine have been convulsed by two kinds of revolution – biological and technological .
The General Medical Council (GMC) of Britain, which was the model for setting up the Medical Council of India, is responsible for the maintenance of standards of medical education leading to the MB, ChB (MBBS) degree. In its long history, GMC neither sought nor claimed jurisdiction over postgraduate training in specialties, which was regulated by the Royal Colleges. The Royal Colleges were autonomous bodies set up hundreds of years ago by professional guilds, which enjoyed enormous prestige at the Post-graduate level which made sure that their tests for proficiency met high standards and attracted trainees from all over the world. Post graduate training in the US in all specialties is organised and regulated by Speciality Boards which are autonomous bodies set up by respective professional groups. The Governments in UK and US play no role whatsoever in postgraduate medical education, which enjoys high prestige all over the world. India chose neither the British nor the American model in postgraduate medical education, and placed both undergraduate and postgraduate education under MCI which was subject to Government control.
To meet the current challenges now at the Government level, discussions are in progress to set up a National Body by an Act of Parliament, which would preside over the promotive and regulatory aspects of medical education. For convenience, we shall call the proposed body National Commission on Medical Education (NCME) in this paper. The NCME should be an autonomous body set up by Act of Parliament with the twin objectives of promoting and regulating medical education at all levels. Its powers should be similar to those of the National Commission on Higher Education as proposed in a Bill being considered by the Parliament. Headed by an eminent medical educationist whose contributions as an academician, investigator, and administrator enjoy national recognition, NCME should have 8-10 active members who represent biological sciences, pre/para/ and clinical sciences of medicine,public health, sociology and technology. For making the best possible nominations, the Government should ask for panels of experts in these disciplines from the National Academies of Science, Medicine, Engineering and ICSSR, who should be taken into confidence on the importance of NCME, its role in shaping medical education, and in due course, standards of health care and quality of medical research in India. The members of NCME should have a term of five years. NCME should have its performance uated by an Independent Committee appointed by the Parliament every ten years. As mentioned earlier, NCME’s two objectives relate to the promotion and regulation of medical education, which should be accomplished through two committees, which would be independent of each other. (Figure 1)
Committee for Promotion of Medical Education (A)
This Committee should have three subcommittees to deal with education at undergraduate (A1) and postgraduate (A2) levels and for postgraduate training in clinical specialities (A3).
Committee for Promotion of Undergraduate Studies (A1)
This Committee of seven to nine members should have medical teachers, medical scientists, practicing physicians, scientists, sociologists, and public health experts whose responsibility would be to develop and update the curriculum for MBBS. The Committee should set up a Think Tank who should have a core group and guest members representing all topics of interest. The Think Tank should play the role of a consultant to the Committee on a regular basis and produce draft curricula and updates for the consideration of the Committee who may decide to publish it on their website to seek the opinion of stake holders before seeking the approval of NCME for the proposed curriculum. It is important to ensure that some space – not less than 20% of the curriculum – is left blank for theUniversities/Medical Colleges to fill with innovative schemes and courses.The Committee should assist the Universities – especially smaller Universities or their consortia – in this task.
Committee for Promotion of Postgraduate Studies (A2)
The present system has prescribed postgraduate qualifications MD/MS for pre, para clinical and clinical subjects and DM/MCh for super specialities.
Therefore, a programme of incentives should be introduced to encourage talented students to opt for MD/PhD in pre and para clinical subjects so that at least 50% of teachers in these subjects in the next 15 years will be holders of the joint degree. This would energise high quality research in Medical Colleges. Similarly, MD/Ph.D should be carefully planned in other subjects such as public health, in collaboration with sociology and so on.
This Committee of seven to nine members should consist of medical teachers, scientists doing research in these disciplines and,academicians. It is vital that this Committee frames its guidelines/rules etc., in close consultation with the Universities who may already be offering PhD in some of these or allied subjects.
Committee for Postgraduate Training in Clinical Subjects (A3)
Given the large number of specialities, their growth in numbers, high obsolescence and constant induction of new technologies, and rapid growth of the speciality hospitals especially in the private sector, it would seem appropriate that A3 sponsors the time tested Speciality Boards system of the US which are autonomous bodies set up by the respective professional associations. Each Board should set up Task Forces to develop contents and procedures of training, requirements of training institutions, certification requirements and procedures etc. These responsibilities are handled by experienced professionals who volunteer to serve on the Task force and Boards and ensure that Board Certification remains the gold standard for training in specialities.
Committee A3 should have seven to nine members representing clinical disciplines and superspecialities, with provision to co-opt other specialists when necessary. They should be drawn from the public and private sector, and should have large clinical experience and high degree of peer recognition, which would be no less important than research papers.
NCME’s two objectives relate to the promotion and regulation of medical education, which should be accomplished through two committees, which would be independent of each other.
The Committee should take the initiative for setting up the Boards, ensuring their autonomy, and legitimacy in terms of the equivalence of Board certification with the degrees awarded by Universities in these subjects. Committee A3 should enlist the help of professional associations, National Academy of Medical Sciences, Universities, major hospital chains in the private sector etc., for creating a data base of appropriate experts in each speciality and set the ball rolling for creating Speciality Boards, which would then operate on their own and establish their rules and procedures.
The considerable experience of NBE should also be accessed by Committee A3 in setting up Speciality Boards.
Committee for Regulation in Medical Education (B)
This committee set up by NCME with seven to nine members should be responsible for carrying out the regulatory functions of the Council. Its other responsibilities should include maintenance of a National Register of registered physicians, liaison with State Medical Councils, determination of the registrability of foreign medical qualifications, and disciplinary action against physicians for infamous conduct.
Committee B should consist of senior medical teachers, Deans, experts in the legal and financial aspects of higher education, experts with specialised knowledge in quality assessment/accreditations process, Vice-Chancellors etc. This Committee’s responsibilities should include recommending approval/rejection of new medical college projects to NCME, and accreditation of Medical Colleges. Committee B should prescribe standard requirements in terms of physical assets for Medical Colleges, and of knowledge, skills, and attitudes in UG education according to the standards suggested by Committee A1. It should also develop a model protocol for testing compliance with the standards, and call for tenders from accreditation agencies in India and abroad to accredit Medical Colleges according to the model protocol. The protocols need not be identical in details, but they should broadly conform to the model protocol. Committee B should recommend the selected agencies to NCME for registration for a period of five years, and monitor the performance of accreditation agencies on a regular basis for quality,efficiency, and professional integrity.
Licensure to Practise
Given the existing situation in India where standards of medical education vary among the States and some states even plan to introduce novel schemes for physician’s training which are opposed by others, the time has arrived for the State Councils and NCME (Committee B) to consider introducing a Licensure examinations for all MBBS degree holders to obtain a licence to practise.
No candidate who has gone through the MBBS course properly would have any difficulty in passing the licensure examination which should be conducted by State Councils for each State and by the NCME (Committee B) for the entire country. Licensure by one state need not be automatically accepted by another state. The State Councils should also be authorised to run CME programmes on-line and otherwise, and conduct re-licensure examinations as mandated by Parliamentary legislation. Currently the organisation of CME programmes for re-licensure is left to IMA, universities and others; and this vagueness is a sure recipe for wide-spread misuse of this provision and commercialisation in the years ahead.
Charles Dickens drew a vivid picture of a period in European history when “it was the best of times, it was the worst of times; it was the age of wisdom, it was the age of foolishness; it was the spring of hope, it was the winter of despair; we had everything before us, we had nothing before us”. What he described was like the present period in the history of medical education in India. The question is whether we can make a decisive break with a sorry past and take the sunlit highway to excellence in a physician’s training in India.(The lecture was delivered at IGNOU during 15th Prof G Ram Reddy Memorial Lecture).