Articles

CHANGING TRENDS IN MEDICAL EDUCATION

Prof .B. RAMAMURTHI

Neurosurgeon

Ex.President

National Board of Examinations

WHY CHANGE MEDICAL EDUCATION

            The question often posed by some midical teachers is “why do we want to change the pattern of medical education in India ? has the system not produced excellent doctors who have served the country?” many of them are internationally well known in their fields. Our doctors who have gone abroad have established an excellent reputation for themselves. Over the decade many good hospitals have been estabilshed in India and modern techniques made available to the public. Then what is the need for modifying the system?

THERE IS A REAL NEED

            The critics remark that though the above achievements are laudable, a closer examination will show that the present system has not served the country well in many respects. While it is true that there are many good doctors, the general standard of the medical graduates who pass out of our medical colleges is low compared to international standards, both in skill and in knowledge. The doctors who pass out are not equipped to deal with the problems that would face them in society. The type education they get quips them with knowledge about rare and complicated illnesses but has given them no skill or knowledge to deal with problems peculiar to our country. The medical students are not aware of ethics and also unaware of how to take a leading part in improving the health of the nation.

            Are these criticisms justified ?

WHAT SORT OF A DOCTOR DOES THE PATIENT WANT ?

            It is obvious that there is no unanimity among medical educationists about the aims of medical education and as to what sort of end product they want to produce at the end of 5 years of training. The latest equirements for the Medical Council of India enumerates more than 16 items in mindbogging officialese.

            Why not look at the view point of a person who is ill ? What sort of doctor would he like ? He would like a doctor who can understand his problem, diagnose his disease and give him the proper treatment. He would like the doctor to be kind and efficient. He would like the doctor to be kind and efficient. He would prefer, nowadays, that if the disease is outside the competence of the doctor he would refer the patient will also prefer that the doctor advises him about how to prevent his falling ill again. ( In a lighter vein, the patient will definitely prefer that the doctor charges no fees at all for services rendered.)

            From the above to present it in simple terms, it is obvious that the doctors we produce should know about the human body and the mind and their diseases, about diagnosing them with or without diagnositc aids and start treatment if within his field of competence, or otherwise refer the patient to a specialist. The doctor must have compassion for his patient and respect ethical values.

            Do we provide  such doctors ? The whole clinical training is concentrated on serious deseases that require hospital treatment and rare diseases which require a professor’s guidance. The expousre of the student to ordinary illnesses and to emergencies is minimal. Ethics and compassion are rerely talked about and if the medical student learns about this at all, it is by the example of few of his teachers. He has no opportunity to talking to anxious relative or has no knowledge of how to comfort them or the patient in times of distress.

            When the medical graduate comes out of the college with these disadvantages, he finds that life outside the hospital is entirely different and his teachers have not equipped him to take up practice in the community.

BETTER OCRRECT IN THE BEGINNING

            Hence, it is essential that medical teachers have a clear conception of the ned product and train them accordingly. This has been  suggested for some years with little effect. If the teachers do not change their approach, it will become necessary for the intelligentia in the society to poing out that the end products of medical education are not good enough and the teachers should change their techniques. When the public feels it can criticise the end product of any factory or consumed goods, why is society not interested in the end product of medical education, a product that is going to influence their life and well being.

            It is  a waste of energy to suffer from the ill effects of the end product and later talk about “Consumer Forums”. It is better to question and corect the source of production. It is apparent that many years of discussion have not improved the and product, and it the medical teachers are not inclined to change their rechniques, should not society be intersted ?

MENDS THE BONE OR REPAIRS THE WELL ?

            It is clear that an ill person needs a competent doctor. In this miliew has entered the medical politicians and the midical sociologists who want the mdical student to be a jack of all trades and a paragon of all accomplishments. They want the fresh graduates to be competent on all  health matters. Life prevention fo diseases, eradication of effects of poverty and unhygiene and malnutrition  and in correcting all the health ills of the nation diluting considerably the necessity for clinical competence.

            Here we can quote

            “Doctor bell fell down the well and broke his collar bone

             Doctor should attend the sick and leave the well alone “

            A man with a broken collar bone would prefer a doctor who knows how to mend the broken bone, than one who is competent in repairing wells. The medical politicians and sociologists joining the band wagon of some “Experts”  have downgraded clinical competence, expecting the doctor to be more interested in mending wells than in mending bones.

“Mending the fence around the well surely must be done

             By persons who own the well and by other public men”

            Prevention of disease is outside competence of a physician. Polluted water, adulterated food, obnoxious fumes in the air, unhygienic habits are tobe corrected by an intelligent and well informed public and by its representatives, the politicians and the bureaucrats. The doctor can only be an informed adviser. He should treat the sick and not clean the streets.

            Instead of taking this problem of ill health in dirty county, as their own responsibility, to expect the physicaian to prevent disease is a classic example of passing the buck. On top of this, to blame medical education for the prevent diseases in soicety is a supreme example of escapism, both on part of the Government and the public.

            It must be made clear to politicians in general and also to the medical politicians who sing the tune that prevention of illness is the duty of society and has to  be done by improving the environment and by changing individual habits. The physician can act only as an adviser of catalyst. To talk of changing medical education to cure ills of society is like suggesting changes in the training of pilot, when society does not care about providing safe aeroplanes or safe runways. Medical education needs to be modified for amny reasons stated earlier but not as a means to provide better environment and better health.

TEACHING AND TRAINING

            The technical details of medical teaching and training leave enormous scope for improvement and may not interest our readers. However, they should know whether the doctor who graduates has acquired all the skills necessary for his profession and knows about compassion and kindness.

ONLY THEORY – NO SKILLS

            The teaching provided to these udergraduates Is almost entirely theoretical with class lectures and bedside clinics, with very little attention being paid to clinical skills. A class of 120-200 students, drowsy in the afternoon, has to listen to the monotonous drone of a lecturer who almost never uses audiovisual aids. Beside or OP clinics have 35 to 50 students standing round the bed and listerning to haranguing from the clinical teachers with few opportunites for personal observation and examination. At the end of the final year, the student has memorised innumerable facts propounded by his teachers and but has acqured no clinical skill whatsoever. He cannot diagnose an emergency, he cannot give an intervenous injection, nor do a lumbar puncture, nor use the opthamoscope nor apply a bandage after four and a half years in a medical college These things are reserved to be learnt all within a nine months period of inership! But this was not always so. Many of us remenber the days when we erer taught clinical skills in our III, IV, of final years.

MEDICAL TEACHERS AND PRIVATE PRACTICE

            One aspect of topical interest is whether medical teachers spend enough time teaching or neglected this due to their involvement in private practice ? clinical teachers at all levels do not stay in the wards long enough except on their admission days. By lunch time few clinical teachers can be seen in the teaching hospitals (there are exception) and almost all except those with specific duties have disappeared to their clinics for private practice. A different picture prevails in a few medical institutions in the country where the teachers are full time with no practice allowed.

            Does this mean, that to have good teaching, all teachers must be full time all have no private consultations ? If they have to serve full time, their remuneration must be attractive can states or institutions afford this big hike in the salry of medical teachers ? If they cannot, should medical teaching get worse, with no remedy in sight ?

            Cannot good teaching and private practice go together?

            Years ago, when we have the system of Honorary Medical Teaches, we as students, could see no difference between our paid professors and honorary professors. Both took the responsibility of teaching seriously an devoted time to their students. Many of them made evening rounds and took the students with them. This was true of assistant professors also. They all had good private pracitce and had a good name in society as efficient doctors. If privare practice did not interfere with student teaching then, why should it now ? Have values changed or has money become improtant ?

            To get out of the vicious cycle of spiralling costs and the inability of the state to make all medical teachers full time, it is obvious that, instead of repeating that teachers should not have private practice, steps should be taken to Restablish the old values among medical teachers and to resssure them that good teaching and private practice can and should coexist.  The Indian Medical Associations, the society for  Advancement of Medical Education and Associations of Civil surgeons and Assistant Surgeons etc and the public at large – all have a part to play in recreating this atmosphere of dedicated teaching while still having a good practice.