Whither medical education in India?
WHITHER MEDICAL EDUCATION IN INDIA?
India is a convention-ridden society. Conventions imply the absence of change, whereas all progress depends on change. Medical education illustrates beautifully absence of progress due to our resistance to change. When the All India Institute of Medical Sciences (AIIMS), New Delhi, was established in 1956, it adopted the then most progressive undergraduate medical curriculum based on Abraham Flexner’s model of three phases: Pre-clinical, paraclinical and clinical. Added to that were moderate degree of integration of disciplines, and introduction of community medicine and psychology right in the first semester. Realising the need for progressive improvement, AIIMS was kept out of the purview of the Medical Council of India and given the freedom to innovate and experiment. How little use of this freedom AIIMS has made may be seen from the fact that over a period of more than 60 years, all the revisions in the curriculum put together have been little more than cosmetic changes in small doses. On the other hand, the world has changed so much within the same period that today the curriculum stands badly in need of sweeping reforms in the architecture of the MBBS course, its content, the tools of learning and the tools of assessment.
The sequence of the three-phase curriculum: Pre-clinical, paraclinical and clinical, is logical but fatally flawed. It does nothing to facilitate integration of basic and clinical sciences. If the study of the anatomy and physiology of lungs is separated from that of pathology by a year and that of diseases of the lung by another year or two, any integration of knowledge achieved is because of the ingenuity of the student; the curriculum can take no credit for it. The solution that progressive medical schools have adopted for several decades now is to have only two phases instead of three. That leaves scope for a system-based approach. For example, all aspects of the lungs are studied as a block in the most reasoned sequence, and the student also gets to see a few patients of respiratory disease around the same time. The result is that in a period of about 3 months, he has mastered the knowledge related to health and disease of the respiratory system.
The content of the curriculum needs a thorough overhaul for a variety of reasons. First, we teach a lot that is of little importance. Second, the emphasis is on hard-core scientific facts, giving the student the impression that that is, what really matters in medical practice. Third, we neglect vital areas such as communication skills, ethics, mind-body medicine and fundamentals of other systems of medicine such as Ayurveda and Homeopathy, yoga and spirituality. The result is that a doctor who has done a course in modern scientific medicine (allopathy) may get angry with a patient for having tried Ayurveda (even if the patient got better!) and may look lost if the patient asks a question related to Dean Ornish’s program for ‘reversal’ of heart disease through yoga. As Norman Cousins, the father of psychoneuroimmunology, demonstrated through a study, patients change their doctor not because the doctor does not know enough science, but because the patients felt that the doctor had not understood them, the doctor did not care for them, the doctor started writing tests even before the patient had finished speaking, the doctor broke bad news in a cold matter-of-fact manner, the doctor smoked, the doctor had put on weight and so on. So attached are medical teachers to what they have been teaching, and so ill-informed are they about ‘soft, peripheral, non-academic’ considerations that are at the heart of medical practice that any talk of adding anything new is greeted with the stock excuse, ‘the students are already over-burdened; there is no time to teach anything more.’ Behind this good-looking excuse is also the unspoken aversion to spending ‘precious time on soft areas.’ On the other hand, while hard scientific facts are available today on the internet, soft skills and attitudes can still be best learnt from a teacher in flesh and blood. Psychoneuroimmunology has been around for about 50 years, is relevant to communicable as well as noncommunicable diseases, including autoimmune diseases, allergies and cancer, and yet on talking to several young doctors, I have discovered that they never heard the word ‘psychoneuroimmunology’ in their 5 years of study as undergraduates. While India is the cradle of spirituality, it is George Washington University that has prepared a curriculum on spirituality for health professionals, and it is medical schools in the West that offer at least optional courses on spirituality.
TOOLS OF LEARNING
Problem-based learning (PBL) is a tool that has been around in a big way since at least 1968. It is a good tool that encourages self-learning, lateral learning, contextual learning and student participation in the teaching-learning process, and enhances the faculty of application of knowledge. We also talk about PBL in our documents, but forget that in the three-phase curriculum, neither integrated teaching nor PBL is possible in the pre-clinical phase. In less than a year available for teaching Anatomy, Physiology and Biochemistry, and the sword of the first professional examination hanging on the student’s head, neither there is time to bring in PBL in a significant way nor would the students have the motivation or capacity to benefit from it. Without adequate application of mind, just sprinkling fashionable terms in our documents would not improve education.
TOOLS OF ASSESSMENT
The tools of assessment need a radical improvement in their validity. Instead of the focus on factual recall, we need to have questions that test faculties higher than memory, such as application of knowledge, critical thinking and logical thinking. These faculties were always more important than knowing facts, but have gained further in stature because of the easy availability of facts even on smartphones, which a doctor is likely to carry all the time. Questions that test factual recall are much easier to frame than those which test higher faculties, but it is possible to test higher faculties of learning through multiple-choice questions as well as short answer questions. Long essay questions are best avoided anyway. Assessment works like a hidden curriculum because what the students learn, and the way they learn, is determined by what is rewarded in the exams. We may pay as much lip service to logical thinking as we like, but if memory is what is rewarded in examinations, the students will learn facts by rote memory. As Stella Lowry has said, ‘Assessment is the tail that wags the dog of education.’
The latest version of the medical curriculum published by the Medical Council of India (now, National Medical Commission) in 2018 is about 700-page long, organised into three volumes, and one can appreciate the enormous effort that has gone into it. But once again, the exercise has succumbed to the tendency to resist any radical or revolutionary change. More than the curriculum, the outcome of the teaching-learning process depends on the quality of the students. Medical students are among the best products of a terrible system of school education. Schools impart knowledge; they do not equip children to think; even less do they nurture the qualities required to generate new knowledge. Whatever ability to think critically and question clearly might have survived the school system stays in suspended animation for the sake of clearing the competitive entrance tests for getting into medical schools. About the contribution of the society and medical school in inculcating the humane and spiritual values that a doctor should have, less said the better. The fact that we still produce doctors in large numbers, many of them competent and caring, is a miracle for which the credit goes to mysterious but imperishable instincts planted in us by mother nature.
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