The recent Supreme Court order quashing the National Eligibility cum Entrance Test (NEET) was followed by the usual avalanche of criticisms regarding the current system of entry into the medical education system and editorials regarding the possible damage to public health that will be caused by doctors who have bought their degrees. While some of these arguments make entirely valid points regarding systemic corruption and the private college management-political nexus, some have gone overboard to the point of damaging patient doctor trust. Case in point…(http://timesofindia.indiatimes.com/india/Check-on-your-doctor-before-a-check-up/articleshow/21202441.cms )
The mainstream media’s approach to the issues facing medical education and its effects of public health has largely been populist and sensational. There is rarely any attempt made to get a point of view from one of the biggest stakeholders in this mess, namely the doctor. This article hopes to present a doctor’s viewpoint on the issue and possibly throw up some suggestions on the way forward.
But to truly understand the picture we need to have some facts. India has approximately 350 medical colleges producing around 35,000 MBBS graduates each year. Even at this rate our doctor to patient ratio is a little over 1:1500 far below the ideal of 1:500. Moreover, four states, namely, Andhra Pradesh, Tamil Nadu, Maharashtra and Karnataka, account for more than 50% of the total number of medical seats available. Also more than half of these colleges are privately run with the Government approving the opening of more private colleges in the recent past than government. The simple reason for this is that medical education is an expensive field. And running a medical college to the specifications laid out by the Medical Council of India (MCI) requires an investment running into hundreds of Crores. Of course, the fact that most private medical colleges are owned directly or indirectly by politicians is another matter altogether. Given the shortage of doctors and the inequitable distribution of medical colleges, the Government’s only option is to grant the opening of more colleges. How and where it does that is a matter of budgeting and policy, and beyond the scope of my understanding.
With regards to medical education, the NEET, would have gone a long way in simplifying the current process and making it easier for the average student to attempt exams all over India. But it doesn’t address the problem that a Multiple Choice Question (MCQ) format exam evaluating proficiency in Physics, Chemistry and Biology (PCB) simply does not begin to evaluate a candidate’s aptitude or eligibility to undergo medical training. The question of aptitude has not been addressed and many entrants, both merit and management, are overwhelmed by the nature and scale of the curriculum. Once a candidate has entered the hallowed halls, she then goes through the rigors of acquiring theoretical knowledge and the clinical skills to put this knowledge to use in a real life setting. Here’s where the curriculum again falls short. There is no stress on Medical Ethics or Behavioural sciences or communication skills. And nothing in the four and half years spent in college, prepares the candidate to function independently in the real world, especially in the rural setting that our netas love to send these freshly minted doctors to. A year of compulsory rotational internship in various specialties is usually spent preparing for the mad race that is the Postgraduate entrance and the candidates gain no clinical experience. Even with regards to the Post-graduate (PG) NEET, the system as it currently exists is far from satisfactory. For every 10 MBBS graduates there exists currently only 1 post graduate seat. So the competition is already intense. Further complicating matters, the MCQ format tests the candidate’s theoretical knowledge, giving absolutely no importance to his/her aptitude or skill level for a particular specialty or their own choice. The skill set required to do surgery is completely different from that required to take up psychiatry. But the current system makes no such differentiation. So most doctors just pick up whatever specialty their rank allows them to take. This particular scenario doesn’t make for the most committed and passionate doctors. And given that a PG seat is so hard to come by, it is rare for anyone who realizes he/she is unsuitable for the specialty, to give it up and try their hand at the NEET carousel again. The next step in the poor doctor’s life is the PG training. What most members of the public don’t realize is that in most medical colleges, both Government and Private, the bulk of the clinical work is done by these PGs. The senior doctors might attend rounds, if at all. The PG is on call 24*7 for the duration of the course (3years) and is usually grossly underpaid and in some private medical colleges, not paid at all. This little tidbit should put to rest the common argument that doctors are greedy and money-minded. In most cases, they’ve already done 3 years of public service.
So what is the way forward? Well, the first step could be to try and change the manner of entry to MBBS courses. Instead of the current system that focuses only on the PCB marks and NEET scores, an aptitude test should also be incorporated. This could be begun as a pilot test in AIIMS or JIPMER and then applied on an all India basis after the kinks have been ironed out. The current problem of capitation for medical seats also needs to be addressed. And although it is not politically correct to talk about it, caste based reservations are just as likely to throw up the same kind of impairments in the quality of medical candidates that the management quota system does. But instead of making the sweeping generalizations against both categories, what is needed is an understanding that this is a purely an individual problem. A simple entry, by whatever means, into a medical college does not make one a doctor. The sweat and toil of the next 5-6 years will decide the quality of the candidate. And this brings us to the next point of change, the curriculum. The curriculum must focus on improving communication skills and a doctor’s ability to recognize and deal with problems that he is likely to encounter in the community. An exam system that focuses now on the kind of rare diagnosis that the average MBBS graduate will not have to make nine times out of ten in his/her clinical practice does not test his/her ability. This needs to change. Also there has to be a focus on encouraging clinical research, something Indian medical graduates are woefully lacking in. The next point of contention is the compulsory clinical rotation. This is the time period which the freshly minted graduate desperately needs to develop clinical skills and also to get a taste of the various fields on offer. Measures have to be introduced to ensure that graduates complete this period of training in the manner originally intended, rather than on preparations for the PG NEET.
The PG NEET exam also faces similar issues as the undergraduate exam. In addition, the current shortage in PG seats ensures that nearly 4 out of every 5 graduates do not get entry into a PG course. And even when they do, it might not be what they are cut out for or want to do. The number of seats on offer has to increase and their distribution made more equitable. It is my contention, that in so far as the PG courses are concerned, NEET may not even be the best way forward. There exists a parallel system of post graduation run by the National Board of Examination which awards a Diplomate of National Board title to successful candidates. The training is just as rigorous, if not more so, but it mostly happens in corporate hospitals instead of medical colleges. As with most decisions involving medical education, the system allows corporate hospitals to take advantage of the cheap labour on offer but the trade off is a good clinical experience. More importantly, the system allows the candidate to choose his/her specialty. I propose that the DNB degree be scrapped and these graduates also be conferred an MD/MS degree. Also instead of a final exam at the end of 3 years, PG candidates across the spectrum be assessed every year for skills, aptitude and knowledge. This will ensure that only the truly interested and able candidate stays on and the disinterested ones have a way out allowing them to seek an alternative PG course, a recourse that doesn’t currently exist.
Before concluding, I’d like to dwell on that favorite panacea of our political class for all our public health issues, the compulsory rural posting. The last thing our poor need is a disinterested and ill equipped doctor whiling away time in an understaffed and poorly maintained PHC. The aim should have been to provide quality. This will include PG courses in Primary Health Care and Rural Medicine and also a focused attempt to improve infrastructure at these PHCs. Instead of making rural posting mandatory, Government should try and make it professionally and financially viable if not lucrative. The GoI and MCI have taken a number of steps to address these issues but a lot more needs to and can be done.
For more info on some of these issues visit www.savethedoctor.in or watch http://www.youtube.com/watch?v=ei_tyWEAtKw
- Dr. Sanjeev Nair
The Author is a Jr Consultant at the Dept of Nephrology, Madras Medical Mission, Chennai