Medical Education in India: The ravages of MCI

Introduction

Soon after his arrest in April 2010, a television channel referred to Dr. Ketan Desai, the then-president of the medical council of India (MCI), as ‘the man who destroyed medical education in India’. Nothing can be farther from truth than that. Medical education was in a disarray well before Dr. Desai shot into limelight for the wrong reasons (1), and is likely to remain so even after his departure so long as it remains the exclusive preserve of doctors. Medical students grow up in the cloistered environment of medical colleges, dissociated from the larger academic world – which explains why the core strategy of medical education in India has remained virtually unchanged over the past seventy-five years despite tell-tale signs of its inadequacy and irrelevance, and is likely to remain so in future as portended by the NCHRH (National Council for Human Resource in Health) bill and the Vision-2015 of MCI. Given below is a brief account and analysis of the underlying problems of medical education in India. The main focus of this essay is on how centrally-dictated warped policies can cripple education and not on the willful neglect of teaching that plagues all branches of education in India. It also steers clear of issues related to malpractices in medical education and medical practice.

Medical Council of India

Centralized curriculum The MCI is a statutory body charged with the responsibility of establishing and main-taining uniform ‘standards’ of medical education and not uniform ‘infrastructure’ or uniform ‘curriculum’ (2). Yet, this ‘God of small things’ grossly oversteps its jurisdic-tion as it takes upon itself to tell medical colleges about the minimum floor space that a department must have, the minimum number of faculty members that a depart-ment must have, the size of the table that a professor must have, the minimum teaching experience that a fac-ulty must have before he can be allowed to teach in the college, the minimum number of publications the teacher must have before he is promoted, the laboratory equip-ments that the department must have, the sequence in which all the medical subjects must be taught, the mini-mum number of hours that must be devoted to each sub-ject, the number of papers that each examination must have and the maximum marks for each, the type of ques-tions that must be asked in the examinations, the number of days that must be devoted to the practical examina-tions, the way the marks in theory and practicals must be totalled to compute the results, and even gives a few tips on how to teach (3-5)! The only thing the MCI does not

Abstract

The ‘Vision 2015’ recently enunciated by MCI betrays a complete lack of understanding of the core challenges posed by medical education, particularly in India. In contrast to the other streams of professional education, viz., engineering and law, where the faculty has to apportion their work hours only between teaching and research, the bulk of the time of medical professors is consumed by patient care, which is a sensitive job. The massive patient load in government hospitals in India, which is routinely extolled as a great repository of clinical material for medical students, actually ends up leaving the professors with little time or energy to teach undergraduate students, much as inquisitive students are unable to contact the busy professors to get their doubts cleared. The insistence of MCI on research publications for career advancement of faculty has only aggravated the neglect of undergraduate teaching. Over the past decades, this core problem, abetted by an abject lack of accountability, has culminated in the near-total absence of undergraduate

clinical teaching. In essence, therefore, the problem of medical education is one that requires an innovative management more than an innovative curriculum - a problem of implementation than of theorization. The last thing required in this situation is the imposition of a curriculum that is touted to be ‘innovative’ on the 330-odd medical colleges of the country. The MCI-nominated experts who prepared the ‘innovative curriculum’ should have known that academics is all about freedom - that ‘innovation’ is not something to be imposed by a regulatory body on academics; rather, every academic, institution and university should be free to experiment and innovate continuously without being hamstrung by the diktats of a regulatory body, so long as they produce excellent graduates. It is not without reason that a centralized curriculum, as insisted upon by MCI, does not exist in India for other professional courses like law and engineering. In USA and UK, there is no centralized curriculum for medicine either.

Sabyasachi Sircar (sircarss@gmail.com)

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tell us at length is what to teach to the students. Unfortu-nately, this legitimate freedom of teachers to decide what is to be taught does not come with the right to decide the number of course hours or the method of assessment or to modify the curricular superstructure. This anomaly, to-gether with the politicization of the medical curriculum, is the root problem facing medical education in India: Ours is probably the only country where a proposed medical curriculum finds a place on a government website – of the Ministry of Health & Family Welfare (6)!

In USA and UK, deciding on the medical curriculum is the prerogative of the universities with their respective accreditation agencies – the Liaison Committee on Medi-cal Education (LCME) and the General Medical Council (GMC) – ensuring quality control (7,8): As for infrastruc-ture, the ‘LCME guidelines on Functions and Structure of a Medical School’ do not go into microdetails (9). While the US medical colleges enjoy total freedom in curricu-lar design, a modicum of uniformity in the curriculum is ensured through a centralized exit examination – the US Medical Licensing Examination (US-MLE). In UK, even the exit examination is opposed on the grounds that it is an indirect way of influencing the curriculum. The re-sponsibilities of the GMC versus its medical colleges are clearly delineated: The GMC is responsible for ‘Setting the standard of expertise that students need to achieve at qualifying examinations or assessments’ while medi-cal colleges are responsible for ‘providing a curriculum and associated assessments that meet … the GMC standards and outcomes’ (10,11). Even the GMC guide-lines on ‘Design and delivery of the curriculum, includ-ing assessment’ (12) and ‘Standards for the delivery of teaching, learning and assessment’ (13) do not impinge on the autonomy of medical colleges in these domains. In India too, the AICTE, BCI and UGC do not dictate the curriculum for engineering, law and general courses, respectively.

It is ludicrous that the MCI conducts (and medical teachers undergo) ‘faculty development programmes’ (14) with the goal of training the medical faculty in ‘curriculum develop-ment’ even as it denies teachers the right to experiment with curriculum. In USA and UK, deciding on the subjects to be included in the curriculum is the prerogative of the medical college and the course instructors decide on the number of theory / practical / demonstration in each subject.

Profligate regulations As argued below, the MCI rec-ommendations on infrastructure (3) are far in excess of the actual requirement, which is a major deterrent to the opening of private medical colleges, and more so in the suburban areas. For example, in the department of Physiology alone, the MCI mandates four undergraduate

laboratories, one each for amphibian, mammalian, he-matology and human experiments – and specifies the floor area for each. This, despite the fact that with a little juggling, the same laboratory space can be utilized for all the four categories of experiments. In fact, it is possible to cater to the laboratory space requirements of 5 depart-ments (Physiology, Biochemistry, Pharmacology, Micro-biology, and Pathology) with one large central laboratory, but that would be unacceptable to the MCI. Even the MCI regulations on essential equipments are seriously flawed. Many of these instruments mentioned in the MCI booklets are not only unnecessary but even obsolete, of-ten to the point of being unintelligible.

As with space and equipments, so it is for staff strength. As mandated by MCI, the average number of faculty members in the departments of Anatomy, Physiology, Biochemistry and Pharmacology in the government med-ical colleges of Delhi is 9, and the only work each fac-ulty member in a nonclinical department is obligated to do is to deliver, on an average, 15 – 20 lectures a year. Private medical colleges cannot afford such profli-gacy and therefore have invented ways of circumventing the problem by engaging the faculty members in numer-ous other courses like dentistry, physiotherapy, nursing, and so on.

Undergraduate Medical Education

Classification of medical subjects The MCI regu-lations mandate a sequential study of the preclinical, para-clinical and clinical subjects. Thus during the first year in a medical college in India, the student learns about the gross structure of the body and its parts (anatomy), the embryonic development of those parts (embryology), the microscopic structure of the organs (histology), the way the organs function (physiology), and the chemical reac-tions underlying those functions (biochemistry). These subjects are called the preclinical subject as it is argued, debatably, that the clinical subjects cannot be learnt with-out first mastering these subjects.

In the second year, the student learns about structural abnormalities in various organs (pathology), the disease-causing microbes (microbiology), the details of various drugs used in therapy (pharmacology) and community medicine (earlier called Preventive & Social Medicine), which deals with health, hygiene and strategies of dis-ease prevention. They are also taught about medical ju-risprudence and forensic medicine. These subjects are called the paraclinical subjects as they are supposed go hand-in-hand with the clinical subjects. In the next two-and-half years, the student learns the clinical subjects

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that include medicine, surgery, obstetrics and gynecol-ogy, ophthalmology, ENT, pediatrics, dermatology, psy-chiatry, orthopedics, anesthesiology and radiology.

In the present context, however, it will be more meaning-ful to classify the subjects taught to undergraduate medi-cal students as (a) the non-clinical subjects that do not deal with patients, like Anatomy, Physiology, Biochemis-try, Pharmacology and Microbiology, and (b) the clinical subjects that include all the other subjects mentioned above.

Curricular strategies The sequential system, espe-cially, the way it is implimented in the medical colleges of India, is flawed on several counts: For one, it entails the teaching of vast amount of medically-irrelevant facts since each of these subjects is allocated course-hours far in excess of what is required. Moreover, the structure, function, dysfunction and therapy of organ-systems form a continuum, and any attempt to segregate them is con-ceptually incongruous. Any discourse on an organ dys-function is usually rooted in the normal function (physi-ology) of the organ, which in turn requires reference to the microscopic structure (histology) and the chemical processes in the organ (biochemistry). It also requires a reference to the ultrastructural abnormalities (histopathol-ogy). This continuum is typically embodied in a lecture in Medicine, which begins with the anatomy, physiology and biochemistry of an organ, the relevant pathology and pathophysiology, and the infecting microbes (microbiol-ogy) and then goes on to the signs and symptoms of the disease and its management with the relevant details of the drugs used (pharmacology). The entire lecture is typi-cally completed in an hour and provides adequate theo-retical knowledge for clinical practice.

Segregation of the teaching of medical topics along departmental lines results in massive repetitions (of-ten with contradictions) of facts and concepts, caus-ing confusion among the students. A case in point is the thyroid gland, which is taught under anatomy, histol-ogy, physiology, biochemistry, pathology, pharmacology, community medicine, medicine, surgery, pediatrics and gynecology. Thus, a topic that should take 1 hour for a thorough coverage consumes 11 hours in order to sat-isfy departmental egos. The large number of lectures on immunology are repeated in Physiology, Biochemistry, Microbiology, Pathology and Medicine. Similarly, the he-matology practicals (estimation of hemoglobin, red and white cells counts, etc.) are done separately by both Physiology and Pathology department out of a despera-tion to consume the practical hours allocated by MCI. The central diktat of the MCI makes it impossible for the

medical colleges to experiment with newer and more efficient pedagogic strategies like the problem-based learning (PBL) wherein the discourse begins with a clini-cal case and proceeds backwards to the relevant basic sciences. The problem-based curriculum – the extension of PBL to the entire curriculum – has been adopted by more than 300 medical colleges across the globe.

Undergraduate training in nonclinical subjects It is important to note that practical classes in Anatomy, Physiology, Biochemistry and Pharmacology have been largely discontinued in the West several decades ago since it is only the ‘theory’ of these subjects that is consid-ered relevant to medical practice. The MCI has mandated medical colleges to devote nearly 1480 course hours to the practicals in these subjects without stipulating how to spend so many hours – a stark example of putting the cart before the horse. The wastage of time in these practical classes is most strikingly borne out by the pharmacology practicals wherein the students are taught to prepare a mixture using the archaic mortar and pestle, and dis-pense elixir in a bottle taking care to attach the label and tie the thread on the cap properly. In biochemistry, they are still taught to estimate reducing sugar levels us-ing Benedict’s solution and a host of other estimations that even technicians do not need to know.

Undergraduate training in clinical subjects In striking contrast to the overbearing approach in pre- and paraclinical teaching, the story of clinical training – the one that truly matters in medical practice – is one of abject ne-glect, attributable in large measure to the preoccupation of clinicians with patient care. In government hospitals, the OPDs are choc-o-bloc with patients and the students hardly have the place to stand there, let alone speak to the Professor, who too does not have the time to talk to the students. (In the US, a consultant would see about 8 – 10 patients with prior appointment during the OPD hours).The ambience in the wards is more congenial to teaching. However, during this time, the Professor is busy with the work-up of the newly-admitted patients, some of whom are critical. It is also the time when he turns to his administrative work and research pursuits (for whatever they are worth) and therefore the teaching is relegated to postgraduate students and senior residents who are nei-ther competent enough to teach, nor take the teaching se-riously. The students are rarely posted in the Emergency Ward and therefore, do not learn to deal with emergencies. Even the few clinical classes held are of little help due to the abject lack of coordination with the theory classes. In the lesser medical colleges in smaller cities, the faculty is simply not around to teach the students – they are busy with their private practice during office hours.

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A quick calculation, based on the MCI-recommended 300 hours of Medicine classes (with a 1:2 apportioning be-tween theory and clinics) would show that at best, a total of 70 cases can be discussed during the clinical post-ing in Medicine, which is a grossly inadequate quan-tum of clinical teaching. The actual numbers are far less. The number of bedside classes that can be held during the clinical postings in some of the other subjects, based on the MCI recommendations are 5 classes in Radiology, 5 classes in Psychiatry and 7 classes in dermatology! In view of the grossly inadequate time allocated to the clini-cal disciplines, it is not difficult to see how profligate it is to devote 1480 hours to the practicals in pre- and paraclini-cal subjects. At the end of the day, the students are not taught even the elementary skills like applying bandages, giving injections or resuscitating a patient – let alone the skills of delivering a baby or performing surgeries that an MBBS doctor used to possess earlier. Even the cogni-tive skills like the interpretation of ECG and radio-graphs (X-rays) are rarely taught: At best, a couple of ECG and X-ray findings are discussed in the wards by an obliging physician who holds aloft an X-ray plate or an ECG strip as the students crowd around him in large numbers to get a glimpse of the plate/strip – a testimony to how archaic medical teaching has remained in India. The bottom-line is that no practicable mechanism has been evolved for imparting the clinical skills to a large number of students in the chaos of a busy hospital – the students just loiter around in the hospital premises not knowing what to do or whom to ask.

For a layman to appreciate the solution to the above-noted problems, it needs to be understood that clinical acumen has two components – one that requires contact with the patient, and the other that is best acquired in the classroom environment, away from the commotion of the hospital. In our present system of medical education, no distinction is made between the two categories of clinical skills: Both are taught by the bedside while the classroom is used only for didactic lectures on the description of var-ious diseases. To achieve effective clinical teaching in an overcrowded hospital, it is necessary to shift a substan-tial part of the clinical teaching to the classrooms.

1. Contact with the patient is required for engaging in a dialogue with the patient to elicit the history of his present and past illness, examining him, and carrying out diag-nostic and therapeutic interventions on him. Most of the clinical ‘psychomotor’ skills are non-interventional (e.g., palpating the liver to see if its enlarged or testing the strength of a muscle to see if it is paralyzed) and are fairly easy to learn. However, those that are interventional (e.g., inserting a venous or a urethral catheter, a nasogastric tube or an endotracheal tube, the removal of a foreign

body from the eye or the nose, and of course, minor and major surgeries) are difficult and require considerable practice under supervision. The psychomotor skills have never been listed comprehensively but a crude estimate would put the number of essential non-interventional psy-chomotor skills at 150 and the interventional skills at 75.

2. The classroom is the best place for learning diagnos-tic and therapeutic decision-making: These are essen-tially theoretical exercises that involves sifting through the vast maze of diagnostic possibilities and short-listing a few of them (the differential diagnosis) and the feasible therapeutic options. The classroom set-up is also ideal for teaching the interpretation of ECGs (electrocardiograms) and X-rays (radiographs) which can be projected on a large screen. Even history-taking skills can be taught in the classroom by having a medically-qualified person to pose as a patient i.e., role playing, a common pedagogic technique used abroad (15).

The teaching of psychomotor skills to 100 to 250 medi-cal students is extremely challenging – it requires a 1:1 teacher-student ratio besides tremendous patience and perseverance. While there can be no substitute for hands-on experience, a video-tutorial demonstrating the essen-tial skills to the beginners would act as a primer to boost the confidence of the students, reducing considerably the time required for acquiring the necessary skills. Even then, these skills need to be learnt under supervision. At pres-ent, students either practice the skills under the su-pervision of a senior friend or worse, in the absence of any supervision altogether. At the end of the day, most of the students do not acquire the necessary clinical skills since the entire exercise of skill-learning is self-motivated – there is no compulsion to learn them, nor are the skills tested adequately in the examinations.

Ironically, students sometimes learn the clinical skills bet-ter in medical colleges where the education system has collapsed completely and the senior doctors are nowhere to be found in the hospital premises. In such situations, the MBBS students are taught entirely by their senior friends, resulting in a 1:1 teacher-student ratio. Of course, the learning occurs at the cost of rampant experimentation on the patients, often resulting in fatalities. With proper supervision, however, ‘peer-assisted learning’ provides an eminent solution to the problem of teaching clini-cal skills to a very large group of students: Indeed, it is the norm worldwide (16). It worked quite well even in India till about 30-40 years ago. However this seem-ingly self-sustaining cycle of teaching-learning, wherein senior medical students teach their juniors, requires regu-lar surveillance by the consultants. Absence of the same over the past several decades has brought the cycle to a

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grinding halt, resulting in a situation wherein senior medi-cal students themselves do not possess the clinical skills, let alone teach to their juniors. The cycle had started in an era more than a hundred years ago when medical colleg-es had much fewer students. To kick-start the same cycle today, when medical colleges admit 100 to 250 students annually, would be a stupendous task.

For teaching the cognitive skills, it is necessary to intro-duce clinical problem-solving exercises into classroom teaching in a big way (17, 18). Problem solving ex-ercises form the bedrock of clinical education and examinations (like the US-MLE) in the West but are given a short shrift in India. Examples of good prob-lem-solving exercises are given in the Box-I. Unfortunate-ly, even if medical colleges in India resolve to introduce

clinical problem-solving exercises, it will be several months if not years before the same would be possible since its prerequisite is a sufficiently large bank of clinical problems in the Indian context. In India, we haven’t even begun developing such a question bank, and the bulk of the questions asked in the examinations for entrance to postgraduate courses or recruitment of medical officers are too bookish (see examples given in the Appendix-I) . It is also the main reason why our doctors are ill-trained, since the questions asked in examinations shape, in large measure, how the student studies. The knowledge of the signs and symptoms of a vast array of diseas-es does not guarantee that the doctor would be able to diagnose a patient – much as rote memorization of the theory in any discipline does not ensure deft solving of the corollaries.

BOX-I

US-MLE type questions based on clinical problems

Example-1

A 50-year old female is evaluated for hypertension. Her blood pressure is 130/98. She complains of polyuria and of mild muscle weakness. She is on no diuretics or other blood pressure medication. On physical exam, the PMI is displaced to the sixth intercostal space. There is no sign of congestive heart failure and no edema. Laboratory values are as follows:

Na+: 147 meq/dLK+: 2.3 meq/dLCl-: 112 meq/dLHCO3-: 27 meq/dL

The patient is on no other medication. She does not eat licorice. The first step in the diagnosis is

a. 24-h urine in cortisolb. Urinary metanephrinec. Plasma renin and aldosteroned. Renal angiogram

Example-2

A 19-year old with insulin-dependent diabetes mellitus is taking 30 units of NPH insulin each morning and 15 units at night. Because of persistent morning glycosuria with some ketonuria, the evening does is increased to 20 units. This worsens the morning glycosuria, and now moderate ketones are noted in urine. The patient complains of sweats and headaches at night. The next step in management is

a. Increase the evening dose of insulinb. Increase the morning dose of insulinc. Switch from human NPH to pork insulind. Obtain blood sugar levels between 2:00 and 5:00 a.m.

Multiple-choice questions in clinical subjects in India

Example-1 (AIIMS 1986, 1997, 1999 and 2005)

The usual incubation period for pertussis is:a. 7 – 14 daysb. 3 – 5 daysc. 21 – 25 daysd. Less than 3 days.

Example-2 (AIIMS 2004)

All of the following statements about mosquito are true except:a. It is a definitive host in malariab. It is a definitive host in filariac. Its life cycle is completed in 3 weeksd. The female can travel upto 3 kilometers.

Example-3 (AIIMS 1988)

Diabetic coma is caused by:a. Ketosisb. Hyperglycemia with hyperosmolar ketosisc. Simple hyperglycemiad. hyperkalemia

Example-4 (PGI 2003)

Diabetes mellitus is associated with all of the following except:a. Encephalopathyb. Myopathyc. Myelopathyd. Myelitise. Neuropathy.

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The undergraduate examinations are a travesty of ex-aminations and the MBBS degrees are awarded in much the same way as the BA / BSc degrees are doled out throughout the country. However, the comparison must end there since unlike their counterparts in the general stream, the poorly-trained medical graduates, who are licensed to wield the scalpel and prescribe potentially lethal drugs, wreak havoc on the populace: When an ill-trained MBBS doctor begins his independent private practice, he poses a greater hazard to the patient than the ailment he purports to alleviate. It is notewor-thy here that it is only in the medical profession that graduate-level training - or rather, its inadequacy - has a direct impact on the society. Contrast this with an ill-trained graduate in the general stream who has to first qualify for a school job before (s)he can adversely impact primary education.

Postgraduate Medical Education

The full import of the above account of undergraduate medical education cannot be appreciated unless it is considered together with postgraduate medical educa-tion. Here again, it is necessary to separately discuss the teaching in the clinical and nonclinical departments.

Postgraduation in clinical subjects During the 3 years of postgraduation in clinical subjects, absolutely nothing new is taught: If the students feel that they are learning anything new, it is because they never learnt during MBBS what they were required to. There are no syllabuses for these MD courses and none are required either: These departments render hospital services and the MD students are expected to be totally involved in pa-tient management – the students gain experience simply by being among the patients and helping out in patient care. The MCI recommends that the training program of each of the 6 semesters be clearly defined and writ-ten out. It also recommends that the postgraduates maintain a log book of the daily work they do (19). Unfortunately, almost all medical colleges ignore these recommendations, which could ensure a semblance of quality in postgraduate training – and get away with it !

The postgraduate student is also required to submit a thesis, which mostly requires a fair amount of biostatis-tics. However, there are no appropriate courses on bio-statistics to go with this ‘research training’. More about this is discussed below under MEDICAL RESEARCH.

The examinations held at the end of the three-years are entirely stage-managed – the results are preordained. The examinations comprise 4 theory papers in which

almost anything can be asked – there being no syllabus. Even the demarcations between the papers are fuzzy: if there are 4 theory papers, it is only because the MCI mandates so. The MCI turns a blind eye to the non-implementation of clause 14(4)b(iii) in its postgraduate medical education regulations, 2000, which states that “…Provided that after five years from the commence-ment of these regulations, there shall be one theory paper of ‘multiple choice questions’ unless any insti-tution wants to have such paper earlier” (19). In the practicals, there is a MCI-mandated system of external examiners but the latter never argues against the wish of the internal examiners because they are carefully hand-picked by the internals and are assured of a quid-pro-quo when their own candidates appear in the examinations. As a rule, most of the candidates pass except those who offend their teachers: Knowledge is no criterion.

The paradox of postgraduate (MD/MS) courses with-out any syllabus or any new learning can be resolved if one realizes that these MD/MS courses are essentially residency programs (as they are called the world over) that need to be done after graduation. It is during resi-dency that the medical graduate acquires the confi-dence to manage patients. Justifiably, there is no syl-labus for residency, which draws upon the knowledge and skills acquired during medical graduation. In the West, once the medical graduate completes residency and acquires the necessary level of confidence in patient management, he takes the examinations for member-ship of learned societies like the Royal Society (or the American College) of Physicians/Surgeons/Gynecolo-gists (20,21). For further specialization, one has to apply for fellowships. In the US and UK, there are no ‘higher’ medical degrees.

The global norm of a ‘single degree’ in medical sciences is a veritable attestation of the fact that a medical gradu-ate must have a reasonably complete knowledge of all branches of medical science. Residency builds confi-dence in practice, and specialization enables a sharper focus. Thereafter, the long years of clinical practice by-and-large adds to the ‘interpolation’ of knowledge pertain-ing to the innumerable variants of diseases – there is little increase in the depth of knowledge because the corpus of clinical knowledge is essentially ‘uniplanar’ – a vast, seamless expanse of wafer-thin knowledge. In physics or economics, for example, it is impossible for a student to grasp a Master’s-level concept without first going through the Bachelor’s level. The same is not true in medical or surgical specialization where the doctor merely ‘restricts’ his practice to a smaller domain to increase the ‘den-sity and thoroughness’ of his knowledge – and not its ‘depth’. The case of a teenaged boy in Tiruchirappalli who

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performed a Caesarean section at a hospital run by his doctor-parents at Manapparai in July 2007 is pertinent here (22). To do a Caesarian, the boy did not need to know (and probably did not know) how to conduct a nor-mal delivery (or for that matter, anything else about medi-cal practice) – which bears testimony to the lack of depth and sequence in clinical practice: One can just start from anywhere – a premise that is somewhat corroborated by the success of problem-based curricula in medical edu-cation. It also perhaps explains why, more than in any other profession, quacks and imposters are easily able to masquerade as qualified physicians and surgeons.

The consequences of the MD course in India can be ap-preciated against this backdrop. Half a century ago, when few medical graduates went for postgradua-tion, the MBBS doctor could handle a vast array of cases – they could deliver a baby, perform a Cesarean, remove a gall bladder or an appendix, set a fractured bone and operate on a cataract. Such a doctor could ca-ter to a broad array of the health needs of the community. As postgraduation replaced residency and the MD degree came to be viewed as a ‘higher degree’, the incentive of the faculty to teach anything during MBBS vanished be-cause the syllabus for every subject is identical in MBBS and MD. ‘Learning begins with postgraduation’ became the unwritten dictum, undergraduate education became grossly neglected, and the medical graduates became nincompoops who knew nothing. The rhetoric of health administrators –‘doctors must go to the villages’ – does not take cognizance of this reality: The medical services that could be rendered to the rural population by a single MBBS doctor five decades ago would now re-quire a team of specialists from Medicine, Pediatrics, Surgery, Obstetrics and Gynecology, Ophthalmology and ENT although the health needs of the masses remain largely unchanged.

It also begs an explanation why the MD program should require a thesis submission, considering how few of them will ever take up an academic assignment. During MD program (read residency program), junior doctors are expected to gain in confidence in medical practice, and any obligation to work on a thesis is a distraction. The vast majority of doctors with MD/MS go for clinical prac-tice and will never do any kind of research whatsoever. On the other hand, the research training during MD is so shoddy that those wanting to do serious clinical research will find themselves wanting in the necessary skills. If still there is so much of fuss about research in medical col-leges, it is because MCI mandates a certain number of research publications at every step in career advance-ment, which further eats into the time available to busy clinicians for undergraduate teaching.

The existing DNB (Diplomate of National Board) exami-nations, leading to the membership and fellowship of the National Academy of Medical Sciences (MNAMS, FNAMS) also has the requirement of thesis writing - this, despite the fact that a DNB-qualified candidate is not eligible for teaching positions (23) and it is unlikely that they would ever do any kind of research.

It may be noted here that in UK, there is no prerequi-site of thesis-writing for taking the MRCP/MRCS ex-ams which are conducted by the relevant Royal Colleges (24). There are certain diplomas and degree courses (e.g. MSc, MD, MS, MCh or PhD in different subjects) which are run by a few individual Deaneries, which may require thesis (25, 26). The GMC of UK however only recognizes Royal Colleges examinations for post gradu-ate qualifications, and these extra degree obtained from Deaneries can some time adds to better job prospect when applying for Registrar or consultant posts. In In-dia, As per Clause 13.6 (Training Programme) of the MCI regulations on postgraduate medical education, the MD program is a 3-in-1 course that requires the postgraduate student to be involved in ‘management and treatment of patients entrusted to their care’, to ‘carry out work on an assigned research project’ and ‘to participate in teach-ing and training program of undergraduate students and interns’ (19). These rules, together with the bond that PG students have to sign, provide medical professors with bonded laborers to whom he can legitimately relegate all his responsibilities of teaching, research and patient-care.

Postgraduation in nonclinical subjects As ex-plained above, the core premise of residency program is that postgraduate students learn best through routine involvement in patient management and that the syllabus is best defined by the constellation of patients that throng a busy hospital. Surely, there can be no residency program without patients and yet, the precepts of residency program – including the maintenance of a log book of work done – have been daftly extended to the nonclinical subjects. Since there are no patients in nonclinical departments, the postgraduate students spend their time helping out undergraduate students in the practical classes and attending the undergraduate lectures of faculty members. There is no syllabus (course content) and the one published by MCI in 2006 (27) would be considered as mere guidelines by any worthy educa-tionist. Not a single postgraduate class is held during the entire 3-year period of the postgraduate course. The tran-script of the log book maintained by a postgraduate stu-dent (see Box-II) proves that postgraduation in a nonclini-cal subject like Physiology is absolutely sham, as every student will testify on conditions of anonymity.

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The stated purpose of introducing these MD courses in nonclinical subjects was to produce teachers who would be able to teach their subject to the MBBS students. This is as nonsensical as saying that the purpose of MSc course is to produce teachers who would be able to teach the BSc students, and that the purpose of the BSc course is to produce teachers who would be able to teach the 12th graders in school. It is because of such an asinine objective that the MD syllabus (none exists) in a nonclini-cal subject must of necessity be identical to the MBBS syl-labus in the same subject. Such an objective obviates the necessity of imparting any research training and yet, the postgraduate thesis is mandatory in these subjects too. A parallel drawn between medical and legal education will lend some insight into the paradox of MD in nonclinical subjects: One has only to imagine the consequences if the Bar Council of India mandates law colleges to offer a 3-year LLM degree course in legal history to LLB lawyers so that they can teach the subject to the first year law students. What should be the ‘postgraduate syllabus’ for

such a course and what would be the professional stand-ing of the lawyer qualified with LLM (legal history) as a legal practitioner or as a historian?

As for the research thesis, the postgraduates in these subjects are in a no-man’s land: they neither have the wherewithal to do clinical research (which is best left to the clinicians), nor have the depth of knowledge to do credible basic research (which is best left to academ-ics with MSc, PhD). As discussed under MEDICAL RE-SEARCH (see below), the inspiration for clinical research springs from the dilemmas faced in patient management. Not having any patient-care commitments, these depart-ments lack ideas in clinical research, not to mention that clinical research is anyway not their domain. As for basic research in their own subject, it is way beyond their ability since the teachers themselves were never trained in the same during their postgraduation. Thus, the vicious spi-raling of ignorance continues. Needless to say, the thesis in any of the nonclinical subjects is not worth the paper it is written on.

In nonclinical subjects, the examinations are a joke and the pass percentage is routinely 100% unless a candi-date has offended a professor. If the examinations are spread over two days, it is only because the MCI wants it so – The examiners are mostly clueless how to spend the two days. In India, two types of MBBS graduates stray into these nonclinical departments for postgraduation. Most of them see these courses as the easy way to acquiring an MD degree. Thereafter, many go for private practice displaying their MD degree and mas-querade as specialists in Medicine (concealing the fact that it is an MD in a nonclinical subject) to hoodwink the populace. Others find a faculty position with great ease since few MBBS graduates want to do postgraduation in basic sciences. Those with an MD in Pharmacology are sometimes picked up by the pharmaceutical industry and those with an MD in Microbiology have the option of opening a diagnostic laboratory. The few MBBS gradu-ates who opt for MD in a nonclinical subject to learn basic research are soon disappointed. However, they are unable to leave the course since at the time of admis-sion, most universities require them to sign a bond of a huge some of money (3 to 6 lakhs) pledging that they will not leave the course till its completion and retain their original certificates as security! Even if they leave the course paying the bond money, some universities (like Delhi University) do not allow them to join another post-graduate course over the next four years! While signing bonds pledging service to the institution after completion of a course may make some sense, the practice of coerc-ing students into signing bonds forbidding non-comple-tion of the course certainly needs legal scrutiny.

BOX-II

Log book of a 2nd year Postgraduate Student in a Pre-Clinical Department. (The original, which is countersigned by the HOD, is available.)

8-5-09 Fri 9-10 am Self study 10-11 am Self study 11-1 pm Practical1 attended 2-4 pm Self study 9-5-09 Sat Holiday (Budhh Purnima) 11-5-09 Mon 9-10 am Attended Lecture2

10-11 am Discussion3

11-1 pm Self study 2-4 pm Self study 12-5-09 Tue 9-10 am Attended Lecture2

10-11 am Meeting4

11-1 pm Attended Seminar5

2-4 pm Self study 13-5-09 Wed 10-11 am Self study 11-1 pm Self study 2-4 pm Self study 14-5-09 Thu 9-11 am Self study 11-1 pm Meeting 2-4 pm Assessment Viva6

1 Undergraduate practicals2 Undergraduate Lecture3 Discussion on the undergraduate lecture topic4 Meeting to discuss undergraduate teaching program5 Postgraduate seminar, delivered by a 3rd-year postgraduate student.6 Assessment viva of undergraduate students

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The farcical MD courses in nonclinical subjects and the high demand for MD-qualified teachers in the nonclinical subjects have entirely to do with the preposterous diktats of the MCI. In a medical college admitting 150 students per year, the MCI recommends 8 faculty member and 6 tutors in the nonclinical depart-ments like Anatomy and Physiology. However, there are very few who do postgraduation in the nonclinical sub-jects and there are fewer still who are willing to join the faculty of nonclinical departments even when paid hefty salary since private practice is by far more lucrative. MCI insists on the requisite number of faculty members be-fore it grants recognition to a college. On the other hand, suitably qualified faculty members refuse to join a medi-cal college till it is MCI-recognized. This chick-and-egg situation was allegedly exploited by MCI for extortion (See Box III: My experience as an MCI inspector). The MCI remains adamant on its recommendation on faculty strength despite sufficient proof of its redundancy. Of late, it has vastly increased the number of PG seats in medi-cal colleges, including those in the nonclinical subjects – a move that has the potential to treble the number of postgraduates in nonclinical subjects in the coming years. These postgraduates will suddenly find themselves out in the cold if and when the regulations for setting up medical colleges are liberalized or rationalized.

It is important to note that in US and UK, the nonclini-cal subjects are taught either by clinicians or by scientists with a PhD. In several medical colleges, only a single faculty member, with the help of one or more teaching assistants, teaches the nonclinical subjects to the en-tire class. Also, medical colleges in US or UK do not offer postgraduation in any of the nonclinical subjects. How-ever, there are 6-12 month courses for medical graduates in a wide range of subjects of medical relevance. These include nonclinical subjects like neurophysioloy, labora-tory biochemistry, microbiology, clinical pharmacology etc and lead to an M.Sc degree. They are listed under ‘post-graduate courses in Medicine’ by the British Council (28). Thus, to the global medical community, an MD degree (meant for medical practitioners) in basic sciences (like Anatomy, Physiology, Biochemistry, Pharmacol-ogy and Microbiology) is conceptually absurd. Sev-eral medical colleges around the world do not even have the nonclinical departments – they are considered irrel-evant in medical colleges (29-33). The ones that do exist are populated mostly by biomedical scientists and focus intensely on research. Medical graduates in the West who want to switch to basic research do a PhD after completing the relevant courses to catch up.

It is likely that these weird MD courses in non-clinical sub-jects, which have no parallel worldwide, were introduced

Box III

Court verdict on Courseless Courses

In the years 2007-2008, I sought information under the Right to Information Act (RTI) 2005 from the best universi-ties in each state regarding the postgraduate syllabus for MD (Physiology), MD (Pathology) and MD (Medicine). The re-plies obtained confirmed my suspicion that there is no post-graduate syllabus in any of the medical colleges of India.

In mid-2008, armed with the information obtained under RTI, I took the matter to the Delhi High Court as a Public Interest Litigation (PIL). The judge admitted the case with the remarks “It is time we have more such petitions”. When the respondents failed to reply on successive hearings, they were reprimanded by the judge, forcing them to file a half-baked reply. Surprisingly, however, the case was dismissed soon after.

What really changed the judge’s mind? It was not induce-ments for sure, since the judge had an impeccable reputation for probity. Perhaps, he had consulted some doctors - could be his personal physician - to make sense of the shocking evidence of 3-year courseless medical courses throughout India. The doctor must have explained to him that postgradu-ate medical courses do not require syllabuses. The informa-tion probably determined the judge’s verdict.

The information received by the judge was only partly true. While clinical subjects like Medicine and Pathology do not (or rather, cannot) have a syllabus, basic subjects like Physiolo-gy, Biochemistry, Pharmacology, Microbiology and Anatomy must have a syllabus. The incident convinced me that there are no short-cuts to the understanding of the problems of medical education in India and that one has to understand the entire gammut of issues related to medical education globally if he is to understand what is wrong with Medical Education in India.

There is another, small twist to the tale. At the time when the case seemed headed for a watershed verdict, I received a phone call from one of the recruitment agencies that help medical colleges find suitably qualified faculty members. I had received calls from them earlier, asking if I were inter-ested in working for one-or-the-other medical college. This time on, they had an interesting offer for me: “Sir, are you interested in the post of a permanent MCI inspector?”. I politely refused.

On whose behalf was the recruitment agency calling me? For those who know the tricks of the trade, the post of per-manent MCI inspector promises huge bounty. Was the offer supposed to be an inducement?

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BOX-IV

My experience as an MCI inspector

It was exactly at four-o-clock on a summer evening a few of years ago. I received a phone call from the office of the MCI: “Sir, are you interested in going for an MCI inspection? It is a medical college down south about two-hour’s drive away from the city.”

-“When?” I asked.

- “At eight pm tonight. Your ticket is booked.”

- “Okay”, I confirmed.

“What’s the mad hurry about?” my wife asked, “You should have refused. They would have found someone else.”

“I have always wanted to know what MCI inspectors do and I do not want to miss this chance” I insisted.

The flight was on time. Seated next to me were the two other inspectors. One of them was the permanent inspec-tor of MCI: She was a lady who was a lecturer when I was an undergraduate student. I remembered her for the wrong reason: she had shouted at a boy who was restless in her class saying, “If you do not behave, we know how to get back at you”, a veiled threat that she had the powers to detain him in the examinations. I was not surprised. Perma-nent inspectors of MCI are required to be very strict.

When we landed at the airport at around 10:00 pm, we were welcomed with shawls and bouquets and driven down to Radisson hotel where we were lodged for the night. Our team leader, the permanent inspector, fiercely opposed the idea – she wanted to reach the medical college the same night and it took us a lot of persuasion to make her relent. If she had her way, we would have reached the college past midnight and started the inspection at 8:00 am sharp. However, she did ensure that we started very early the next morning and reached the medical college by 9:00 am.

It was a new medical college and it needed the permis-sion of the MCI to start regular undergraduate classes from August. When the inspection started, I was given the task of physically inspecting the Anatomy, Physiology and Biochemistry departments – the so called preclinical depart-

ments. The Head of the Anatomy department introduced herself and her entire faculty to me and took me around through the departments, showing me the lecture halls, demonstration rooms, the museum and the mortuary. I had with me a list that mentioned everything that a new anatomy department was to have and I was supposed to verify them all. We began by counting the number of chairs in the anato-my lecture hall. There were five chairs short of the stipulated hundred and the Head pleaded to me in supplication that the five chairs must be somewhere nearby. The consterna-tion created by the presence of the MCI team was palpable and it was painful to see a senior professor of Anatomy thus humbled. I smiled and moved on. It was an ordeal for me to do what I did not believe in. The infrastructure that was deemed mandatory by the MCI was to me a colossal waste of money: I knew there was a much less expensive and more efficient way of imparting a far superior education in anatomy. I felt the same as I was taken around through the Physiology and Biochemistry departments.

When I was through, I was escorted to the Principal’s office where my madam had created a mayhem – shrieking and throwing everyone into a tizzy. She was going through the papers of the faculty members, who were standing by her table, to verify if they had adequate teaching experience. She did not consider it necessary even to ask them to be seated even though most of them were grey-haired profes-sors who had retired from other colleges. After completing the verification of the preclinical department, she called the faculty of the paraclinical departments of Pathology, Microbi-ology, Pharmacology and Forensic Medicine. As the Head of the Pathology department walked in, our eyes met and I saw her face flush. To spare her embarrassment, I quickly looked the other way. She was none other than the same lady who had taken me around in the anatomy department posing as the Head of the Anatomy department!

The verification of papers continued rather uneventfully till madam stumbled upon the papers of a young lecturer-to-be in Forensic Medicine. She looked up to see the person – a young, sly-looking guy with a mischievous smile on his face. His very sight seemed to infuriate her. “You have done your MD? What do you know of Forensic Medicine? What are the differences between a male and a female pelvis?

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Between a male and a female jaw bone? How do you tell a homicide from a suicide?...”, she hurled a flurry of questions at the hapless guy who continued to smile impishly. Peeved by his do-what-you-like smile, she flew into a fit of rage. “Show me your MD degree … it must be fake…I will get it cancelled right away…” she yelled. I knew she couldn’t be more wrong and decided to intervene. “Madam, it is of your own making”, I said firmly, “Do not probe it deeper or it will boomerang on the MCI. Rest assured, the certificate is genuine” Even at the peak of her tantrum, she could see reason and relented. She knew – and we all know – how easy it is to get a genuine MD/MS degree under the watch-ful eyes of the MCI.

In the afternoon, madam took me along for the outdoor inspection: possibly, my firm intervention in the morning, which arguably saved her from the embarrassment her forg-ery theory would have inevitably caused her, elevated her opinion about me a couple of notches. When madam was shown the animal house, she wanted to see the animals too but quickly retracted her statement realizing its absurdity: animals are brought in only weeks before some experi-ments are to be performed on them. She did however take a serious note of the fact that there were no mattresses on the hostel beds. She was also extremely fastidious about the boundary wall. “These people also have an engineering college”, she explained to me, “and it is quite possible that they are trying to deceive us by showing us the boundary wall of the engineering college… these people are very clever…you know?” I gave an appreciative nod that seemed to please her though I couldn’t help wondering how it mat-tered if the engineering and medical colleges shared a vast, common campus with shared facilities – medical students barely get enough time for extracurricular activities anyway. In the evening, she sat on the computer in the Principal’s room to write her report on the inspection. Finding her to be very slow on the keyboard, I volunteered to type it out for her. She wanted perfect secrecy and I showed her how to lock an MS-Word document. As I typed out the detailed report, I knew it was a negative report: She hadn’t twisted the facts but had highlighted the negatives. She had also in-cluded that the hospital did not have adequate equipments and adequate number of patients. I couldn’t see how these were immediately relevant because it would be a full year before students would visit the hospital. I felt sad to see the officials of the college tense and loitering nearby nervously: They wanted to know the results. I had a mischievous idea: madam would never know if I saved a copy of the docu-

ment on the desktop with a different name for the benefit of the officials. I decided against it. When the report was complete, madam copied it to her pen drive and asked me to delete the file from the computer and empty its recycle bin. She then made me search the entire computer twice over through the “search command” to ensure the file was really gone. She was paranoid: “You know, these people are very clever”, she told me, “They would do some tricks in the computer so that it retains a copy of the report in it”. I wished I had gone ahead with my little mischief.

Late in the evening, the owner of the college – a smart young surgeon with an FRCS, the son of a state minister – came to meet me in the hotel room. He wanted to know the verdict. My whole-hearted sympathies were with him and I gave him the hint. He was crest-fallen but he opened out to me. The story he told me made me sit up. They had filed the application for MCI inspection of their college about 3 days before March-end – the stipulated deadline. Due to postal delay, MCI received the application on the first of April and refused to come down for inspection. The college appealed to the High Court and won. MCI appealed to the Supreme Court and lost. The court directed the MCI to inspect the college. The verdict was delivered in the court at 3:45pm. MCI had called me at 4:00pm: the plan was to rush down to the college at the shortest possible notice and catch them unawares. His story explained, among others, madam’s urgency to rush to the college at night straight from the airport. “Sir, I have spent 300 crores of rupees on this college”, he said, “Can I afford to wait for another year for the college to start? I am willing to pay any amount for hiring the best faculty for my college, but anyone I invite to join this college asks me if it is MCI-recognized, while the MCI wants me to have only MCI-recognized faculty.” His entreaty still rings in my ear.

I came back to Delhi with a heavy heart. It was insulting to do such a menial job and I wondered why doctors han-ker for a chance to go on an MCI inspection. Money, it is widely believed, is the motivation but that is true only of the permanent inspectors. For temporary inspectors like me, the lure of staying in a 5-star hotel, the food, the drinks, the gifts and the overall VIP treatment seem to be adequate inducements. As for myself, I have never accepted another offer for going on an MCI inspection though I keep receiving them, like all other senior professors, with routine regularity. I had seen what I wanted to see. A few years later, I was also offered the ultimate reward – the post of a permanent MCI inspector – but that is another story (See Box-III).

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with the covert agenda of purging biomedical scientists from teaching positions in medical colleges. In the initial years, medically-qualified teachers were not available in sufficient numbers since postgraduation in a nonclini-cal subject is almost always the last choice of medical graduates. To cope with the shortfall, MCI continued the provisions for inducting biomedical scientists into medical colleges as faculty members. As the availability of medi-cally-qualified teachers eased up, the MCI imposed stricter restrictions on non-medical candidates, the most vicious clause being that a non-medical faculty member cannot head the department if a medically-qualified per-son with the necessary experience is around (5) (vide Schedule-I, Clause-2). Over the years, most of the self-respecting nonmedical professors have either left the medical colleges in protest of this apartheid or are simply counting their days to retirement. Those who now seek a job in a medical college are mostly the dregs of the nonmedical academics.

Postdoctoral degrees As if the postgraduate de-grees were not unwarranted enough, there is an ever-increasing number of postdoctoral DM degrees being offered in medical specialities like cardiology, neurol-ogy, gastroenterology, endocrinology, nephrology and MCh degrees in surgical specialities like cardiothoracic surgery, neurosurgery, urosurgery etc. Surely, more are in the offing (Delhi University proposed DM in Transfu-sion Medicine) and in the coming years, we might even see DM (Assisted Reproduction), MCh (cochlear trans-plantation), MCh (retinal surgery) and so on. Of late, a few nonclinical departments too, like Physiology and Pharmacology, have joined the chorus for DM degrees which, hopefully, would be dismissed with the derision it deserves.

It is not that superspecialization is not necessary – the world over, it is the order of the day – but what is coun-terproductive is its veneration as a ‘higher degree’ which undermines the importance of the basic medical degree. Indeed, an MBBS doctor who has dutifully performed abdominal surgeries like gall-bladder or appendix-re-moval several times can directly switch to urosurgery (the preserve of superspecialists) without much of a problem. In the same way, if an MBBS doctor decides to restrict his practice to cases of hypertension only, he will acquire over a period of time a vast experience of the idiosyn-crasies of hypertensive cases and can legitimately call himself a specialist who is every bit as competent as a cardiologist with DM degree in treating hypertension. It was only on the strength of their experience that the MBBS doctors of yesteryears called themselves as cardiologist, neurologist, nephrologists or gas-troenterologist. As I have argued earlier in this essay,

medical/surgical practice is vast but lacks in depth and therefore, it needs to be compartmented into ‘domains’, not graded in ‘degrees’. In the West, the basic medical degree of MBBS (UK) or MD (US) remains, by and large, the only medical degree, and superspecialization is rec-ognized with a certification or a diploma. In India, the obsession of medical educators with multitier degrees has led to the recent suggestion for a rural MBBS course called Bachelor of Rural Medicine and Surgery (BRMS) that will be implicitly lower than MBBS (34). Surely, medi-cal education in India can do without more confusion.

Medical Research

There is a lot of popular misconception about medical research. Unlike the general streams like science, arts, commerce and even fine-arts where research comprises the core-competence, research competence is not a re-quirement for doctors. Even in professional courses like engineering and law, an exposure to research forms an integral part of the training and helps in the practice of the respective professions with insight and finesse. How-ever, in medical education worldwide, research neither forms an integral part of the training, nor holds out sig-nificant benefits to the medical practitioners who have the mandate to practise only what is well-established and are prohibited from straying beyond the clinical protocol – indeed, they can be pulled up in the court of law for doing so. Doctors understand little about the founda-tions of medical science, let alone medical research, but know what all can be fixed in the human body. Doctors are trained, out of necessity, like mechanics because the corpus of medical knowledge required to be internal-ized by doctors is so massive – almost boundless – that the knowledge must necessarily be spread out thin so as to keep its volume manageable. A doctor is to a bioscientist what a mechanic is to a mechanical engi-neer. Charles Leblond (1910–2007), a doctor by training and a pioneer of cell biology and stem cell research, ex-plained why he decided to concentrate on basic research than on medicine: “That type of work just did not appeal to me as much as research did. You see one patient, then another, and then another, and at the end of a good day of hard work you have seen 25 patients. And the next day you see 25 other patients. Many doctors like the variety. Myself, I’d like to work with one patient for several days.”

Types of medical research To understand what sets apart medical research from the rest, the differ-ent types of medical publications that often pass as re-search papers must first be understood. The common-est, and by far the most useful medical publications are the case reports. These reports, which may pertain to

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some unusual clinical features of the patient or an un-usual response to therapy, find a permanent place in the corpus of medical knowledge and rarely become ir-relevant. Even a private practitioner who stumbles upon a rare case can publish it in a reputed journal, provided he has adequate writing skills and provides the relevant proofs. No research training is required to publish case reports. The second category of medical publications pertains to clinical research, which is typically statisti-cal and helps to rejig the clinical protocol: It may be a comparison of the available therapeutic regimes for their efficacy, of diagnostic tools for their reliability, or simply a description of the prevalence or incidence of diseases. These require a moderate knowledge of biostatistics that few doctors possess: In almost all medical colleges of the country and even abroad, doctors do the work in collabo-ration with statisticians – the reason why some medical colleges have a statistical cell. Doctors themselves have little knowledge of experimental design and biostatistics unless they do a course on it. No such courses exist in India (except those offered by a few private organiza-tions) and therefore the clinical research here is much like a collaboration between the lame and the blind, mak-ing them error-prone. Unlike case reports, publications on clinical research lose their relevance very quickly as newer drugs and diagnostic tools emerge from the labo-ratories and replace the existing ones. Clinical research is mostly done by medical academics for professional enhancement – those in practice could not care less about it. The third type of publications pertain to basic research in life processes which have the potential to revolutionize medical practice. Such research emanates from the laboratories of the basic sciences and doctors hardly have any knowledge about them. The clinician only provides logistical support to basic researchers - from providing clinical materials to clinically evalu-ating the research outcome - and yet, hogs the media glare ever-so-often.

Research in clinical and nonclinical departments It should be clear from the above account that clinical re-search does not require critical thinking – it only requires (a) access to a large number of patients, (b) commu-nication skills, and (c) some common sense about ex-perimental design (the statistician does the rest). It is the reason why publishing papers is so easy in the medical field and one need not be awe-struck by the number of publications of clinicians which typically run into several hundreds. On the other hand, faculty members in the departments of Anatomy, Physiology, Biochemistry and Pharmacology neither have a guaranteed access to patients (unless a clinician obliges) nor have the neces-sary cues that emanate from patient care about what to research on. For the same reason, they hardly have any

clinical research papers, as a quick internet (PubMed) search will reveal. Nor do they have any papers in basic research because not only have they not been trained for the same but they do not even have the temperament of a basic researcher: For years together, doctors are trained to focus strictly on areas with clinical relevance, to increase the breadth of their knowledge rather than its depth, and to shun lateral thinking. In fact, such training begins in the high school as soon as they decide to take up medicine as a career whereupon their motto becomes: ‘anything that is not likely to be asked in the medical entrance ex-aminations is not be studied’. A mind programmed strictly for applications cannot do basic research.

Although, as explained above, few doctors have the abil-ity or inclination to do research, those working in medical colleges are desperate to publish papers because MCI mandates a certain number of research publications for every step in career advancement. The result of such recommendations have been two-fold: first, certain indexed medical journals have allegedly started publish-ing papers in exchange of money, and second, the re-search obligations are further eating into the time avail-able to busy clinicians for undergraduate teaching.

The medical psyche

It will not be possible to figure out in its entirety the rea-sons for the dismal state of medical education portrayed above without a peek into the doctor’s mind. The medical psyche described below is far more prevalent than one would venture to believe.

Medical students get accustomed to getting social re-spect from an early age – almost immediately on joining the college. Even as first year medical students, they are addressed as doctor-sa’ab whenever they don the white coat. Their seniors keep reminding them over the first several weeks that they have joined ‘the noble profes-sion’ and constitute the creme-de-la creme of the soci-ety, inflating their ego even before they have begun their higher education. At the same time and on the same pre-text, their faculty subjects them to a vicious discipline that is unimaginable in any other stream of higher education including the professional ones: the threat of detention in the examinations – which are atrociously subjective – is brandished as the deterrent against insubordina-tion. Medical science is an empirical science where exceptions ever-so-often outnumber the norms and where age and experience counts far more than intel-ligence or reasoning ability. Therefore an awe of se-niority gets etched into the medical psyche and the mind gets steeped in the motto: “There’s not to make reply, there’s not to reason why”.

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Through much of his mid-level career, the doctor experi-ences two conflicting emotions that spring from the ven-eration by his patients on the one hand, and the humilia-tion by his seniors on the other. In the long run, this toxic cocktail of emotions has the potential to turn him into a bully. Medical schools are known to teach with humili-ation and disrespect: Heidi Lempp, senior qualitative researcher at Guy’s, King’s College said “I have noticed a clear and observable alteration in the attitudes and be-haviours of medical students during the period of medical studies...But reform will not be easy: it will mean con-fronting the culture of medical education and the medical profession” (35).

Unlike other professionals like engineers (who at some stage or other are exposed to labor management or fi-nance management) or lawyers (who learn about legal management), the only management medical profes-sionals know of is the management of patients on an individual basis. While lateral thinking is generally the main mantra of management, it is prohibited in pa-tient management. Doctors, who are trained to obey and tread the beaten track, simply do not have the manage-rial insight that is required for managing the clinical train-ing of the large number of students admitted to medical colleges annually: Medical training went on reasonably well so long as the number of admissions weren’t many and posed no management problem but it went haywire once admissions started increasing. The current prob-lems of medical education is basically a manage-ment problem that doctors can never measure up to, and therefore need the involvement of educationists, professional managers and social activists. This might be one of the reasons why the GMC (General Medical Council) of UK, of which the MCI is but a legacy, has on its board 10 doctors and 10 lay people.

Alternative strategies in medical educationNone of the problems discussed above are insuperable provided the medical colleges are given a free hand in designing and redesigning the curriculum to ensure quality medical education in the Indian context. Ensur-ing good clinical teaching is difficult, given that the clini-cians in government hospitals are weighed down by their massive clinical commitments and the clinics in private medical colleges with paid medical services do not attract enough patients to serve as clinical materials for medical education. The only way to tackle these contrasting problems – of ‘too many’ and ‘too few’ patients – is to allow innovative ideas on medical education to flour-ish free from the encumbrances of regulatory diktats. Private medical colleges that do not attract many patients can rely heavily on videography, computer simulations

and ‘skill-laboratories’ as done in several medical colleg-es in the West (36). In crowded government medical col-leges, a case can surely be made for hiring reputed pri-vate practitioners as ‘non-faculty instructors’ (allowed by LCME of USA) to teach undergraduate medical students on part-time basis during the 9:00 am to 12:00 pm time slot – given that much of this training is currently imparted to undergraduates by junior residents with the tacit ap-proval of the MCI.

Effort should also be directed towards reducing the pa-tient load in tertiary hospitals by making available medical facilities of credible standards in the primary health cen-ters (PHC). There is no reason why thousands of normal deliveries – which even the village dai’s can do – should be conducted in tertiary hospitals or why the PHCs cannot be refurbished for the same and be used for training un-dergraduates students in conducting deliveries and even surgical and orthopedic skills. This will serve the twin ob-jectives of reducing the rush in tertiary hospitals to make them congenial to teaching, and exposing the undergrad-uate students in a major way (and not in a cursory way as done at present) to the challenges of working in a rural setup. A friend of mine, a brilliant dermatologist, not only agreed with me but went a step farther saying “You can teach the practice of medicine sitting under a tree”.

In fact, the MCI recommendations on hospital infra-structure run at cross-purposes to the necessity of tak-ing health care to the rural hinterland – If we want our doctors to practise in villages, their training in highly-equipped hospitals is not only irrelevant but actually counterproductive. Consider this example: Most lung disorders can be diagnosed on the basis of physical signs. However, there is little incentive for using clinical skills in a hospital equipped with an X-ray machine. More-over, if the doctor fails to detect a lung disorder through physical examination, he can be pulled up for negligence in not recommending an X-ray chest. The urban doctor therefore gradually loses his clinical skills and will find it difficult to practice in villages. On the other hand, a doctor trained in a rural setup with no X-ray facility will always rely on clinical signs and yet will not be accused of negli-gence if he misses a difficult diagnosis.

The ROME scheme If the laudable launch of the ‘Re-Orientation of Medical Education’ (ROME) scheme (37) by the Government of India in 1977 to impart ‘communi-ty-oriented training to medical undergraduates in primary health care’ fell through, it was because the ROME pro-gram could not be dovetailed to the strait-jacketed MCI recommendations on medical education. ROME needs to be revisited – in a bigger and better way – with the regulatory bodies staying clear of the nitty-gritty’s of

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medical education. The recommendations in the ROME scheme signified a half-hearted policy towards its vision-ary objective. ROME needs to realize its ultimate vision wherein the bulk of medical training (and not merely a few visits to the PHCs) is imparted in the rural setup. This is eminently possible in the villages of today where technology has vastly narrowed the gap with the cities and would provide the most optimum patient load that is required for medical training. Even private medical colleges might find the idea appealing provided the regulatory body desists from making needless rec-ommendations on grandiose infrastructure. Finally, the shifting of medical training to villages will see the rein-vigoration of the hitherto neglected PHCs with positive spin-offs in rural health care.

A major argument against substantially shifting under-graduate medical education to the villages is the canard that medical teachers would refuse to go to the villages. Two things need to be noted here: First, while senior doc-tors might be reluctant to go to villages, it can be made mandatory for resident doctors, both junior residents and senior residents, to spend their last six months in villages, serving in the PHCs, if they are to obtain their residency completion certificates. Senior resi-dents and even 3rd year junior residents have more than adequate knowledge, skills and confidence to handle most of the routine and emergency cases. Somehow, this option has never been probed. Second, even senior doctors may be willing to go to villages if given the right incentives. Here, the ‘Dharan experience’ is illu-minating (38): Over the past several years, the Govern-ment of India has deputed medical teachers from premier medical colleges in India to the BP Koirala Institute of Medical Sciences in Dharan, Nepal. This bucolic place nestled in the foothills of Himalayas has little to offer to urban elites and the life there is dull and at times, difficult. Yet, medical teachers made a bee-line to join Dharan, mostly on its short-service scheme. The incentive was money,– a par diem tax-free allowance of Rs. 1500. The doctors would not leave Dharan even for a day lest they forfeited the par-diem allowance. The lesson to be learnt is that many doctors will be willing to go to villages for a decent extra remuneration provided it is a short posting that does not disrupt their family obligations while provid-ing a welcome break from the urban commotion.

The NCHRH Bill

That the medical community is stuck in a time-warp is evident even in its latest proposal on revamping medical education – the NCHRH draft bill (39). Section 13 (c) and (d) in the Bill is a case in point:

13. Recognition and approval of courses – (1) The Council shall recognize and approve courses, period of study, includ-ing duration of practical training to be undertaken for such courses, including graduate and postgraduate programs, and in this regards may prescribe: (c) subject of examinations for recognized qualifications, methods of assessment and evaluation, qualifications of ex-aminers, the conditions of admissions to such examinations and the standards therein to be attained. (d) types, numbers and standards of staff, equipment, ac-commodation, training and other facilities to be provided for the students undertaking an approved course.

It should be obvious that the NCHRH proposal is laced with the same preconception that I have argued against in the preceding pages. Thus, the diktat on the numbers of staff and equipment (!) and even the methods of as-sessment (which needs to be standardized only at the exit examination level) are back on the agenda. Consider especially the proposal on prescribing the ‘subjects’ of examinations which makes little sense: In problem-based curriculum (40), the demarcation between ‘subjects’ get obfuscated. Moreover, there are also different ways of demarcating the subjects, e.g., in-stead of having subjects like Anatomy, Physiology, Bio-chemistry, Pathology, Medicine, Surgery etc., one may opt for the alternative option of Hematology, Cardiology, Pulmonology, Nephrology, Neurology etc. Thus instead of teaching the structure of the brain in anatomy, its func-tions in physiology and its disorders in pathology and medicine, they can all be taught as ‘neurology’. Even in the present system, there are subjects based on organ-systems, e.g., Ophthalmology (the eye), ENT (ear, nose, throat) and Gynecology (female reproductive organs) which cater to the medical, surgical and pediatric aspects of therapy. It goes to show how the current array of medi-cal subjects is a hotchpotch of conflicting approaches. Surely, the medical colleges should be free to experiment with different approaches. The same holds true for the methods of assessment and evaluation that must be con-tinuously innovated.

As for prescribing the qualifications of teachers and exam-iners, it is reiterated again that in medical practice, higher professional degrees do not guarantee better teaching skills, and there is no reason why a brilliant general prac-titioner with only an MBBS degree should not be allowed to teach medicine to the undergraduate students if it ben-efits all parties concerned. Similarly, there is no reason why the duration of the MBBS course needs to be uniform throughout India. In the US, the duration of the MD varies from 4 to 6 years. In the UK, the MBBS is usu-ally for 5 years but can be more or less than that. Foren-sic Medicine is not taught at the undergraduate level in

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almost any college in the UK, and in most colleges in the US (41). It surely makes sense to consider these issues and record them during accreditation but to set precondi-tions on the inputs would be to stifle innovation, jeopar-dize the output and breed inefficiency. With technology ever on the move, the input of human resources required is likely to reduce over the years, and private players must be allowed to use such technology and employ fewer and better faculty if it makes better business sense without compromising on quality.

As for quality control, it should be made binding on medi-cal colleges to make available on the internet the details of their curriculum, infrastructure, faculty strength, while the MCI should only ensure that such declarations are true. Like the GMC inspection teams, the MCI (or accred-itation bodies) should talk to all sections of the workforce – faculty, students and technicians – and examine course materials and examination papers, giving suggestions wherever relevant and recording their observations on the net (8). Moreover, a National Exit Examination on the pattern of the US-MLE can be a great leveler and the statistics available through it can pinpoint substandard colleges that indulge in grade-inflation.

National exit examinations

The NCHRH bill, while proposing an ‘exit’ examination for postgraduates, proposes a ‘standardization’ exami-nation for MBBS. Subsequent utterances of some of the MCI bigwigs (42) betrays the reason why two different terms - exit and standardization - have been used: It is nothing but a ploy to avoid an exit examination for MBBS graduates, which would lay bare the absymal standards of undergraduate medical education. Ensuring quality control is far more challenging in undergraduate than in postgraduate medical education and it is possible that the newly constituted MCI has tried to wash its hands off the former. Way back in 2003, the National Workshop on Need-based Curriculum for undergraduate medical cur-riculum held at Ashoka Hotel in New Delhi observed: “The workshop feels the dire need for a standardized National Examination to be administered across the country which will serve as both Final MBBS examination and Entrance Examination to various postgraduate courses and eligi-bility condition for various Government jobs and other purposes. Medical Council of India may prepare detailed guidelines for organizing such an examination, by an ap-propriate body constituted by the Central Government in consultation with the Medical Council of India. This body may be entrusted to hold the examination in accordance with the curriculum framework recommended by the MCI” (43). The suggestion remains unimplemented. What we

are likely to have in its place - courtesy MCI - is a National Exit Test that will be ‘voluntary’ and will be taken, for ex-ample, by a meritorious students from ‘Muzaffarnagar’ who wants to prove that he is every bit as good as an AIIMS graduate (42)! Clearly, the MCI’s recipe for the National Exit Examination is a desperate cover-up operation. The MCI bigwigs may not be aware that it is a gross human-rights violation to let loose an army of untrained doctors - licensed to wield the scalpel and prescribe potentially lethal drugs - on the largely illiterate and unsuspecting populace of India.

Even a mandatory national exit examination is not without its pitfalls: A lot however depends on the type and quality of questions in the national exit examinations for MBBS, to appreciate which the readers need only to compare the type of questions asked in the US-MLE and the ones asked in the PG entrance tests in India (Box-I). The first prerequisite for conducting a national level objective test would be to create a massive question bank - a formi-dable task if the experiences of the developed countries is anything to go by (44). For one, medical science is an empirical science and the questions have to be con-structed far more carefully than those of the physical sci-ences in order to be unambiguous. Second, the shelf-life of the questions is short since medical knowledge meta-morphoses quite rapidly. There are two more reasons, which are peculiar to India: First, most of the MCQs in Western books are useless to us - plagiarizing MCQs is a routine practice in the physical sciences - because they are alien to the Indian context. Second, medical teachers in India are incapable of writing good, problem-based MCQs since the teaching itself is not problem-based: It is only during problem-based teaching that ideas for good problem-based questions originate, following which they need to be tried and tested with the students since, ever-so-often, they turn out to be erroneous or ambiguous and need modifications. Thus, the cornucopia of problem-based MCQs - without which a national bank cannot be sustained - has to be found within a countrywide arena of hectic prob-lem-based teaching. What we are likely to see instead are daft questions that the better students would find hard to answer - as currently witnessed in several postgradu-ate medical examinations. The scientific surveillance for maintaining the standard of the question bank - working out the difficulty and discrimination indices of each ques-tion - is not practised in India, at least for the medical question banks. If only the difficulty and discrimination indices of the questions had been worked out, it would have revealed how most of the questions put the brighter students at a heavy disadvantage. Till such time that a massive national bank of good, problem-based questions

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is created with a mechanism for updating it regularly - or arguably, even thereafter - it is necessary to institute a system of accreditation by an independent external body. Indeed, it will be expeditious if these accreditation agen-cies are under the aegis of the NCHER bill of the HRD ministry that focusses mainly on accreditation (45).

The NCHRH bill also proposes a dual route to postgradu-ation: Some would complete a 3-year MD course (simi-lar to the one existing now) while others, including those who fail to clear the MD/MS examinations, would take the National Exit examinations for postgraduates. Thus there will be mutual recriminations betwen the two factions of postgraduate doctors with each claiming superiority over the other: The MD/MS degrees will be disparaged as lacking national-level standardization, while the board certification will be lampooned as the last resort of those who flunk the MD/MS examinations – this, despite both undergoing identical training.

A similar situation exists even today – with the Diplo-mate of National Board (DNB) examinations, which are identical to the MD examinations and yet, ‘the holders of Board’s qualification awarded after an examination (DNB Final) are eligible to be considered for specialists post in any Hospital other than a training/teaching insti-tution.’(22). Seemingly, the continued espousal of the MD/MS degrees by MCI is a ploy to provide medical graduates with a back-door route to postgraduation, thereby defeating the very purpose of a national exit ex-amination or a DNB examination.

Finally, the following clauses in the draft bill of NCHRH-2009 are in sharp conflict with MCI’s policy of curricular centralization:

III-15(1) The Council shall recognise courses and qualifications in-cluding graduate and post graduate programmes offered at any uni-versity or medical or health and other academic or non-academic or training institutions, in a foreign country.

III-15(2) The qualifications granted by any university or medical or health institutions outside India which are included in the Schedule shall be recognized qualifications for the purposes of this Act.

IV-23(2) The examination (national level exit examination) shall also be open for … … … individuals holding a foreign post graduate degree in medicine or health, where such a degree has been ob-tained from an institution not recognised by the Council.

IV-23(4) The Council may conduct a national standardisation exami-nation for undergraduate programmes and mandatory screening test for candidates having successfully completed undergraduate pro-gram from a foreign institution that is not recognised by the Council.

Thus, while students in India have to adhere to a centralized curriculum with all its limitations, the stu-dents with foreign postgraduate degrees are exempt from it. Such dichotomy is not there in the policies of US and UK on foreign medical graduates since there is no centralization of curriculum in these countries. Argu-ably, the discrepancy also opens up a legal loop-hole: An Indian or NRI student postgraduating from a medical college in India that is derecognized by the MCI but rec-ognized by the GMC should be eligible for the National Exit Examinations and thereby make the MCI’s mandate against his college irrelevant!

Common Entrance Examination

In January 2011, it was reported that medical colleges in the southern states had rejected the MCI proposal for a common medical entrance test on the grounds that it dis-criminated against those who were not at ease with the English language (46). The rejection of common entrance test immediately attributed, sotto-voce, to the lobby of private medical colleges who are bent upon extracting capitation fees from undeserving students. Private medi-cal colleges are routinely denounced for ignoring ‘merit’. What is rarely appreciated is the lack of validation of the presumption that an entrance examination assesses ‘merit’ and that ‘meritorious’ candidates make good doc-tors, not to mention that the meaning and relevance of the term ‘merit’ has never been questioned. There is neither logic, nor proof, in the assumption that those who can an-swer a large number of MCQs in Physics, Chemistry and Biology - mostly through rote memory - would necessarily make good doctors. The common entrance test, which totally ignores the candidates’ power of comprehension, communication skills, aptitude, temperament and motiva-tion, is a poor substitute for a common exit examination that tests if the medical graduate can be expected to treat patients properly. If the latter is in place, few undeserving aspirants would pay astronomical sums for admission to a medical college knowing that the transaction would not signify a guaranteed deed for an MBBS degree five years later. At the same time, where both the stakes and the confidence (of clearing the exit exam) are high, for example, with scions of doctors with well-established nursing homes, the capitation fee is beneficial to all concerned and need not be grudged. Surely, while government medical colleges may have to adhere to a common entrance test, private medical colleges must be allowed to make their own assessment of MBBS aspi-rants - through tests and interview - as it is done in USA (47) and UK (48). For their part, private colleges should root for a national exit examination: These colleges badly need an image-makeover to attract bright students and set off a self-sustaining cycle of excellence. This can be

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achieved only if they put up good performances in suc-cessive exit examinations.

MCI Vision 2015

On 28th of December, 2010, MCI released Vision 2015 - a road map for medical education in India (49). As for the broad policies, the document adds little to what is already given in the first few pages of the 1997 Graduate Medi-cal Regulations and, if this essay on medical education is anything to go by, Vision 2015 fails to take cognizance of the core problems afflicting undergraduate medical edu-cation, viz., (1) the paucity of time available to clinicians for undergraduate teaching, (2) the total absence of case-based problem-solving exercises in undergraduate cur-riculum - both in teaching and evaluation; (3) the logistical and ethical issues associated with the imparting a wide array of psychomotor skills that need to be practiced on patients to 100 - 250 medical students in each medical college; (4) the logistical problems of effecting integrated teaching so long as medical disciplines and departments remain split along ‘preclinical’, ‘paraclinical’ and ‘clinical’ lines, (5) the mind-set that Anatomy, Physiology, Bio-chemistry, Pharmacology, Microbiology and Community Medicine cannot be entrusted on a team of clinicians and non-medics, (6) the logistical problem of having a uniform curriculum for 330 colleges spread across a large country of diverse languages, cultures, climates and health prob-lems, in rural and urban areas, for government and private colleges with disparate resources and patient load, (7) the reciprocality of technology dependance and manpower requirement, and the need to leave it to the colleges to strike a balance betweeen the two; (8) the dampener posed by a centralized curriculum on the creativity and motivation of teachers in designing better ways of teach-ing and evaluation; (9) the inherent risks in allowing a small group of self-appointed educationists to experiment with a centralized curriculum on a nation-wide scale; (10) the necessity of establishing a modicum of quality control, either through a common exit examination or through ac-creditation by external agencies.

Hackneyed call for integration What is most ironi-cal in Vision-2015 of MCI is that, having engendered the separation of pre-, para- and clinical disciplines and de-partments over the past decades, the MCI today laments the lack of integration: It does not recognize the difficulty in integration so long as each discipline ‘belongs’ to a de-partment that claims its pound of flesh from the student. There is no reason why medical colleges cannot do away entirely with the pre- and para-clinical departments and instead, allow the Department of Surgery to accommo-date anatomists, and the Department of Medicine to ac-commodate physiologists, biochemists, pharmacologists

and community medicine professors: The laboratories and professors of microbiology and pathology can be present in both Medicine and Surgery departments. There is nothing demeaning about a physiologist declar-ing himself as “Professor of Physiology, Department of Medicine”. A fully fledged ‘Department of Physiology’ is necessary only for promoting hard-core research and not for lodging idle physiology teachers: A PubMed search shows that in India, Medical Physiology departments (in-cluding AIIMS) have contributed only 406 papers during 2001 - 2010, which translates to 1 paper per professor in 20 years (assuming 4 professors in each department).

Budding researchers Another shocker in Vision-2015 (for undergraduates) is the statement that “There should be a workshop on learning the nuances of research in terms of principles, collection, organization and analysis of data to prepare a budding faculty member for guid-ing the thesis/research profile in their subsequent work profile. The minimum duration of the exposure to these techniques should be at least 3 days.” The suggestion assumes that the majority of undergraduate medical stu-dents are ‘budding faculty members’ who would eventu-ally join academics!

The authors of Vision-2015 are probably unaware that medical research is nowhere on the radar of GMC or its US counterparts: The GMC only sets out ‘the good prac-tice principles that doctors are expected to understand and follow if they are involved in research’ (50). The MCI, instead of limiting itself to clinical training, exhorts medi-cal graduates into patient care, research and undergrad-uate teaching in the same breath. In the process, it has messed up postgraduate training. The ghost of medical research has now returned to haunt the visionaries of un-dergraduate medical education!

It is not just Vision 2015 but even the periodic utterances of the members of the board of governers are worrisome. In particular, MCI’s tentative plan of creating more special-ists without first ensuring quality undergraduate training betrays a sense of its resignation in improving the latter. Postgraduate training is essentially built on the foundations laid by undergraduate training. Without a strong founda-tion, postgraduate training would, in due course of time, reduce to the same degenerate state in which we find undergraduate medical education today.

Limited Decentralization and Damage Control

The vast majority of medical graduates and educators in India concede that our medical education is in shambles but, having grown with the system, see nothing wrong

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with the all-pervading diktats of MCI and the intellectual slavery it entails: They see the tough MCI regulations as essential for keeping private medical colleges – which are generally loathed as crass profiteers – on a tight leash. On the contrary, the regulations have only made it im-possible for private colleges to function cost-effectively, forcing them into double-dealing. The situation is remi-niscent of the India before its economic liberaliza-tion when private enterprises were viewed with deep mistrust and government rules were meant to police them. All that changed in the summer of 1991. Twenty years later, it is time to liberate medical education too.

As the first, cautious step towards a limited decontrol, the MCI should invite all universities (which have affiliated medical colleges) to prepare their own integrated curricu-lum (including teaching and examination schedules) for a 4½ years’ MBBS course. The MCI can also stipulate the minimum campus size and the minimum outlay so that private entrepreneurs do not ‘start medical colleges in two rooms’ (as feared by a senior official in the Health Ministry). A go-ahead should be given on a case-by-case basis after ensuring that the proposed syllabus includes all that is currently taught but is free from gross repetition of topics, and MCI inspectors should periodically report on its implementation.

At the same time, MCI must disallow any immediate dis-mantling of the existing departments or dilution of faculty strength as these would jeopardize countless careers. It must first discontinue MD courses in the basic sciences and wait till MD-qualified ‘teacher-researchers’ dwindle in number, for reasons explained below.

As a medically-qualified physiologist in a secure govern-ment job, I am deeply concerned about the fate of medi-cal graduates (many of them very bright) who do post-graduation in Physiology believing that it offers an excit-ing yet secure career in research and teaching only to be disillusioned soon and yet, are compelled to complete it due to Draconian rules. After completion, those who go to work in research laboratories abroad have a tough time explaining to (or rather, concealing from) their supervi-sor what training they underwent in the three years of the course. Many of the supervisors are flabbergasted by the MD degree in Physiology. As and when private colleges are given the freedom to employ only as many instructors as required (1 or at the most 2 in each col-lege), these MD-qualified physiologists will suddenly find themselves jobless and will be forced to enter into the increasingly competitive arena of general medical prac-tice with very little clinical knowledge. In such a scenario, which I see as looming large (there were around 90 ap-plicants for the 9 posts of Assistant Professor of Physi-

ology in the Central Health Service for which interviews were held in Delhi in the last week of February 2011), government medical colleges must continue to employ them (and those in other pre- and para-clinical subjects) in large numbers – as atonement for its past flawed poli-cies – till the backlog is cleared. The MCI on its part must immediately discontinue these bogus courses instead of increasing their seats many-fold, as ‘blindly’ proposed in ‘Vision’-2015.

Conclusion

The centralization of medical curriculum in India has prevented medical colleges from functioning efficiently. The uniform curricular and infrastructural formula – laid out in microdetails – that is foisted on medical colleges throughout the country has no parallel anywhere in the world or for that matter, in any other stream of academ-ics in India. It has not only stifled innovations in medi-cal education but the flawed diktats have crippled medi-cal education countrywide and spawned ludicrous MD courses in the pre-clinical (basic) sciences that do not have any course content whatsoever. The plethora of postgraduate and postdoctoral degrees has undermined the importance and quality of undergraduate medical (MBBS) training. Internationally accepted methods of quality control like accreditation of medical colleges and national exit examinations for medical graduates have been avoided for the wrong reasons, allowing poorly-trained doctors to register as medical practitioners.

The NCHRH bill and Vision-2015 are ridden with the same flaws that undermined medical education in the past. The myopia in Vision-2015 is exposed in its fol-lowing statement: “A detailed document regarding the training programs, minimum activities, infrastructure and equipment requirement at each level, minimum faculty and staff with budget is attached as Annexure IV”. Read-ers who still do not see anything wrong with the state-ment might yet have second thoughts on going through the suggestions given below, which would align medical education in India with global trends:

1. The regulatory body for medical education should be reconstituted to include equal numbers of medical and non-medical members, as it is for the General Medical Council of UK

2. The curricular design should be completely decentral-ized and there should be no prerequisites of infrastructure or staff-strength for starting a new medical college since the adequacy of infrastructure and staff cannot be as-sessed without considering the proposed curricular

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strategy. It is the ‘totality’ of infrastructure, curriculum, delivery and evaluation that should be assessed by the regulatory body and reported on its website. Alternatively, the MCI can stipulate the broad parameters of the du-ration of training for MBBS and its goals, the minimum space of the campus and the minimum outlay of money, and then invite proposals from the colleges on infrastruc-ture and curriculum. The MCI can have an Infrastructure and Curriculum Review Committee to ensure that the medical colleges conform to the endorsed specifications before granting permission to start admissions so that fly-by-night operators do not start classes ‘in two rooms’.

3. There should be a national medical licentiate examina-tion for MBBS graduates that would serve both as the final MBBS examination, and the basis for admission to a 3-year junior residency program (proposed in 2003). The examination should be on the pattern of the US-MLE. 4. There should be no junior residency program or post-graduation course in the nonclinical subjects of Anatomy,

Physiology, Biochemistry, Pharmacology and Microbiol-ogy. At the same time, there should be a comittment to absorb doctors who have already obtained MD in these subjects in government service.

5. At the end of the 3-years junior residency program, the medical graduates should be considered as ‘board eligible’ to take the National Exit Examinations for ‘board certification’ (Proposed in the NCHRH draft 2009). The clinical skills should be objectively assessed (through OSCE) and video-recorded to ensure fairness of evalu-ation by allowing candidates to challenge the results, as it is done for the US-MLE and MRCP/MRCS examina-tions. There should be no requirement for thesis writing for board certification, as it is in UK or USA.

6. Just as the GMC of UK recognizes only the Royal Col-leges examinations for post graduate qualifications, the MCI should only recognize board certification for post-graduation, and not the MD/MS/DM/MCh degrees that may be floated by various institutions.

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