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Year : 2019  |  Volume : 7  |  Issue : 3  |  Page : 69-73

Medical education in India: Past, present, and future


1 Department of Community Medicine, JSS Medical College, JSS Academy of Higher Education and Research, Mysuru, Karnataka, India
2 Department of Anatomy, JSS Medical College, JSS Academy of Higher Education and Research, Mysuru, Karnataka, India

Date of Submission29-Aug-2018
Date of Acceptance01-Apr-2019
Date of Web Publication15-Jul-2019

Correspondence Address:
Dr. Praveen Kulkarni
Department of Community Medicine, JSS Medical College, JSS Academy of Higher Education and Research, Mysuru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AJIM.AJIM_13_19

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  Abstract 

Medical education in global context has evolved over a period of time and so in India. With changing community needs, educational advancements and technological revolutions, we need to update the method of imparting knowledge and skills to the students. Major components of hidden curriculum like communication skills, attitude, empathy, altruism, professionalism, humanities etc need to be uncovered and delivered in a more systematic way. Ever increasing demand of doctors in the country has forced to establish new medical colleges across the country but the quality of Indian Medical Graduates produced out of them needs a lot to think and work upon. Reforms in curriculum Medical Council of India is planning to bring should be taken seriously and all efforts should be made to bring them to reality. In order to bring a competent Indian Medical Graduate in par with global standards should be the MANTRA of every medical education institution.

Keywords: Competent, future, Indian medical graduate, medical education, past, present


How to cite this article:
Kulkarni P, Pushpalatha K, Bhat D. Medical education in India: Past, present, and future. APIK J Int Med 2019;7:69-73

How to cite this URL:
Kulkarni P, Pushpalatha K, Bhat D. Medical education in India: Past, present, and future. APIK J Int Med [serial online] 2019 [cited 2019 Oct 19];7:69-73. Available from: http://www.ajim.in/text.asp?2019/7/3/69/262739



An year ago, while, I was addressing a scientific conference, a nursing faculty got up and asked “Sir, nowadays, I am seeing the medical interns in my hospital who struggle to record blood pressure, insert a Foley's catheter, put an Intravenous line, etc., which even a final year nursing student can perform without hesitancy. Why so?” Surely, I felt embarrassed being a teacher in the medical school, on the other hand, felt this question is much pertinent and a mirror to the current system of medical education in our country. In the era of internationalization of medical education, quality certification/accreditation of medical schools, ranking of medical institutions on preset criteria, are we really missing out something which we and the society cannot afford for? I think and many do think that the answer is Yes. Then, let us introspect on where did we go wrong? Can we do something to control the damage? Whose responsibility is to bring reforms in medical education? In order to answer these questions, we need to study, the past, present, and future of medical education in India.


  Past of Medical Education Top


The medical education in India can be traced back to the era of Charaka and Sushrutha who had their own doctrines in treating and teaching indigenous system of Medicine in ancient India.[1] The formal training of Indians in Medical Science has started at the time of British rule in India where initial emphasis was given to establish the medical schools that provide instructions to students in native languages. Medical Colleges in Madras, Bombay, and Calcutta were established with the objective to afford better means of instruction in Medicine and Surgery to the Indo-British and native youths, entering the medical branch of the service in the presidency. Later on, several institutions to train Indian youths in indigenous system of medicine such as Ayurveda, Unani, Homeopathy, and Siddha were established throughout the country.[2] Keeping in mind, the potential readers of this article, I would henceforth concentrate on medical education pertaining to allopathic medicine.

Even after the independence, the medical education in India did not come out of colonial yoke. Most of our medical schools still felt comfortable with western mode of instruction rather than tailoring the curriculum to the local needs. In the mid-1970s, the Shrivastav Committee advocated reorientation of medical education by national priorities and needs.[3] In 1986, the Bajaj Committee called for the establishment of an educational commission for health sciences. It also noted that medical school faculty, though efficient in their clinical specialties, were deficient as educators. In order to meet the societal need of doctors, larger number of government and private medical colleges were established across the country.[4] These medical colleges have been successful in creating the doctors who could cure the diseases but failed to provide comprehensive health care which includes, preventive, promotive, curative, and rehabilitative services to the people who are in need of the health-care services. Over a period of time, medical education in India has turned out to be a business sector, with competitive pricing for the providing basic and specialized certification.[5],[6] Establishment of Medical Council of India (MCI) as a statutory body to the maintenance of uniform standards of medical education, both undergraduate and postgraduate were one of the welcome steps to ensure check on basic minimum requirements for the establishment and running of undergraduate and postgraduate programs in Medicine.[7] There is also a strong criticism that the statutory body itself hinders the flexibility of offering medical education in the country through its stringent rules and regulations.[8]


  Medical Education at Present Top


The state of medical education in India is at crossroads. It represents a scenario marked by rhetoric wishful thinking rather than concrete steps in right direction.[9] Sticking on to the age-old curricula, which was developed more than 100 years ago, which compartmentalizes the medical disciplines rather than giving holistic understanding of the subject is the root cause for these problems.[10] Every academician and governing authorities in all possible academic forums advocate the need for bringing rampant curriculum reforms in medical education by tailoring it to the current day needs and demands, but when it comes to action, we are still at ground zero.

Apart from curriculum, we still believe that the role of medical teacher is like a “sage on the stage rather than guide by the side.”[11] We often want our students to sit in the class like the rat which is a passive and motivation-free recipient of stimuli and listen to the lectures of an elated faculty member for hours together and feel scared to interact with him.[12] There is a need that this scene is classrooms should change in such a way that the teacher should act as a facilitator and allow students to learn by themselves through active involvement based on the principle of cooperative learning. Thus, the classrooms should become the platforms for two-way sharing of ideas and thoughts between teachers and students with larger scope for healthy debate and dialogues. I can imagine this setting like a lively, noisy, bubbly, energetic classroom rather than an asylum of pin drop silence.

The serious concern about the current day syllabus is that it is stuffed with a lot of knowledge component, in medical education terms, cognitive domain with little of psychomotor domain (clinical skills) with almost no emphasis on affective domain (attitude).[13] The most essential elements of affective domain such as empathy, professionalism, altruism, communication skills, ethics, and humanities are not covered in anyways in the syllabus.[14] Some people argue that these are the behavioral attributes which cannot be formally taught in the medical schools thus the student needs to be adapting them by observing their teachers – this was called as “hidden curriculum.”[15] Considering the current day's incidences such as assault on doctors, professional negligence, violence in clinical setting force us to somehow inculcate them in the current system of medical education. Coming to the psychomotor domain, are we confident enough to say that any student graduated from our institution can independently perform any clinical task in any health-care setting (primary, secondary, and tertiary)? The students who are taught in the tertiary care hospital feel less competent to work in the resource-limited primary care settings.[13] Thus, we need to ensure the graduate should be equipped with some basic competencies to practice his clinical skills in a proficient manner in a given setting in an independent way, these are called entrustable professional activities (EPA).[16]

The current day system of assessment is a mockery of assessment in the real sense. The learning of student for the whole academic year is judged based on his/her performance in single summative theory examination and a viva voce of 3 min!!! On the other hand, I can recollect, two of my students talking informally in a party, “Dude, what is the deal in studying for the whole year? Better to enjoy the life. read the books/question banks/solved answer manuals for last 3 months, vomit it out in exams and proceed to the next level…!!” Can't we have a formative assessment of the student on his performance on day-to-day basis and certify him based on his level of achievement of desired competencies at the end of academic year? The assessment techniques for practical examinations we use are quite subjective and lack reliability. The marks awarded by the examiner are most commonly based on his/her subjective interpretation of the concepts.[17] Thus, there is a need to make assessment more objective by introducing the concepts of objective structured practical and clinical examinations.[18] The student who performs extremely well in controlled examination setting may not do the same way in real-world scenario and vice versa. Thus, we need to take the assessment at workplace and certify the competency of the student based on his performance in the actual clinical setting, this is called workplace-based assessment.[19]

The loop of education gets completed with the mechanism of giving and receiving feedback.[20] How many of us as medical teachers give proper and timely feedback to the students? And receive the feedback from them on the mode of teaching and curriculum? How many of our institutions get feedback from the community on the ultimate product we have produced (doctors) for their benefit? Thus, we need to establish an efficient feedback circuit which addresses the concern of each of the stakeholder in education system.

After a series of consultations and deliberations, MCI has come up with a set of core competencies for an Indian Medical Graduate.[21],[22]

  1. Clinician
  2. Life-long learner
  3. Communicator
  4. Leader
  5. Professionalism.


Under these core competencies, several subcompetencies are defined to bring out a quality product – Indian Medical Graduate. There is a due emphasis given on introducing a module on attitudinal, ethics, and communications Skills for the medical students from the day they enter into medical school.[23] Currently, MCI Regional Centers across the country are training the faculty members on the implementation of this module.[24],[25] Another major reform taken up by MCI is the introduction of basic course workshops on educational technologies for all the teachers in the medical colleges and advanced course in medical education for the selected faculty. These courses empower the medical teachers with adequate knowledge and skills toward designing the curriculum; bring innovations in teaching–learning methods and assessment techniques.


  Medical Education for Future Top


The experiments in the west have proved that student-centered, outcome-based mode of medical education is more effective than the current method we follow, which is teacher-centered and content based. This method of medical education which keeps student as a basic unit and his learning outcomes or competencies as the endpoints is popularly known as competency-based medical education (CBME).[26] CBME is a paradigm shift where the curriculum is designed based on the community/societal needs. The learning outcomes or competencies are tailored to these needs. The teaching–learning methods and assessment are integrated by dividing the boundaries between specialties.[27] For example, if the student has to learn about hypertension as a topic - he will have to learn, anatomy of heart and blood vessels (anatomy), physiology of circulation (physiology), pathogenesis of hypertension (pathology), epidemiology of the condition (community medicine), antihypertensive medications (pharmacology), and management of the condition (general medicine). In the current system of medical education, all these components of hypertension are compartmentalized, and student learns them separately across different years of MBBS program and undergoes assessment accordingly. However, in case of CBME, the teaching and assessment will get integrated across all these specialties, and the student learns hypertension as a whole in a comprehensive manner. The assessment will also take place accordingly.[28]

In CBME, the teacher will be very clear about what has to be taught, and the student is also aware of what is expected out of him/her after undergoing the learning exercise. The curriculum will set the goal of a learning program, defines different roles to the stakeholders involved, designs a set of competencies, divides the competencies into several subcompetencies, specifies the learning objectives to fulfill them, tailors teaching–learning methods accordingly and also plans assessment tools to know whether the student has achieved the outcomes or not. Let us take one example to understand how an ideal curriculum framework of CBME looks like [Table 1].[29]
Table 1: A sample framework of competency-based medical education

Click here to view



  A Sample Framework of Competency-Based Medical Education Top


The role of the teacher in CBME is more of facilitating the learning of students by being guide by the side.[30] More of small group teaching methods, self-directed learning, cooperative learning methods, and communities of practice are encouraged than didactic lectures and notes taking. The teachers have to plan their sessions to be more interactive and encourage student to clear their concepts as and when required. Giving feedback on the learning of students is a very important aspect of CBME. The teachers should acquire essential knowledge and skills pertaining to various methods of providing, timely, formative, constructive, balanced, specific, and goal-oriented feedback to the students.[31]

Assessment in CBME is a very interesting business. The knowledge, attitude, and skills of the student are assessed on regular basis (formative assessment), and specific feedback is given in order to improvise further. The student undergoes several such assessments before he takes certification examination. In the final (summative) assessment, due weightage is given to the performance of student in the formative assessments. The techniques of assessment of student are more objective, structured, reliable, and valid compared to the traditional tools which are more subjective in nature. These tools include objective-structured practical examination, objective-structured clinical examination, objective-structured clinical examination and record, multisource feedback, mini-clinical evaluation exercise (Mini-CEX), and mini-peer assessment tool.[31] Most of these tools are task oriented and can be performed at the workplace itself. Thus, they are also known as workplace-based assessment tools. Most of these tools are available in open source, but when any institution chooses to use them for their students; they need to be benchmarked and standardized based on the local needs.[32]

At the end of educational experience, the student should be able to carry out any clinical task independently with adequate accuracy, confidence, and efficiency without any assistance from the facilitators/teachers at a given point of health care. These set of professional activities which the graduated student is entrusted to perform at the end of the program are called EPA (e.g., conducting a normal vaginal delivery). Now, most of the medical schools in the west are providing medical education to the students keeping these EPAs as the basic endpoints.[33]

The CBME also faces several challenges. These include:[13],[34]

  • Lack of training among medical faculty on designing and implementing the CBME curriculum
  • Higher student to teacher ratio in medical colleges
  • Lack of time
  • The absence of adequate infrastructure to teach students in small groups and conduct multiple assessments
  • Lack of commitment among managements to bring changes in the existing system
  • Inertia among faculty and students for change
  • It is not a mandate from the Regulatory authority (like MCI).


All these challenges can be easily overcome by motivating faculty to undergo faculty development programs and bringing in, policy changes from the regulatory bodies.[35]


  Conclusion Top


“Change is the only constant.” The system of medical education needs to adapt itself to adapt the rapid changes taking place in the area of medical science and health care. We need to move away from traditional, teacher-centered, content-oriented mode of education to the student-centered, and outcome-oriented medical education system. There is a need to adapt CBME through adequate faculty training and stakeholder participation. In order to make an Indian Medial Graduate to an International Medical graduate, the model of medical education needs to undergo a paradigm shift.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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