M.S. Sridhar

The Journal of Clinical and Scientific Research

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193Editorial SridharEditorial:Undergraduate medical education: where are we?Medical care is essential for ensuring effective existence of the individual as well as the society. Irrespectiveof the nature of aims and priorities of the society, ensuring the health of the human resources is essentiallyan automatic priority of highest value.  Medical and health care are highly personalized services and shouldcater to the individual needs which are unique and has a wide spectrum of activities. No country is in aposition to provide the services in full measure. A hierarchy of facilities of graded complexity which arelinked together functionally is the partial but practical answer to the problem.The personnel rendering the services are, in turn, of varying background education. They have to be knittogether as a team. Traditionally, medical doctor is designated as team leader but doctors are not specificallytrained in administrative and managerial aspects of health care. When, ultimately efforts are made to trainthem at a later date, after graduation, they do not evince sufficient interest to the extent that they becomeless amenable to be trained.The stated aim of undergraduate medical education is to contribute toward the training of a non -specializedphysician (general or basic) whose formation is in keeping with the health needs of the country, the evolutionof medical science; and the requirements springing from the nature and responsibility of the physician'sfunctions and his position in society.Medical education by itself is a subculture. Like the culture of the humanity in general, it evolves. At macro-level, the responses of the humanity to problems encountered are limited in nature but there is enormousscope for refining the response. So, the evolution occurs in a spiral fashion. But the question to be answeredis whether this is an upward spiral or downward spiral or a horizontal spiral which, in effect, amounts togoing in circles without a real change! One of the profound changes that the medical education has tocontend with, at present, is rapid transition from labour intensive profession to capital and technologyintensive industry.1,2As for the curriculum, insistence on uniformity of syllabus and stereotyped framework for Institutions atvarying degrees of development is a retrograde step and smacks of lack of imagination. This fostersmediocrity and kills the instinct to innovate.  The education of the health care professions and the developmentof the health care services and scientific research are intertwined. Hence, while planning the curriculum forthe medical education there is need to focus attention beyond the current level of development in theregional health care services and simultaneously bring changes in the structure and function of the healthcare institutions such that trained personnel can apply as much of their knowledge and skills as possible forthe benefit of the community at large.3 This is imperative considering the fact that the government contributesgreater part of the expenditure for the health of the community. However, the high cost of quality medicaleducation makes it ineffective to plan for all centers to meet immediately the same standards as thoserequired for the national institutes of excellence. As a part of the medical education policy, focus should beon practical and operational aspects of use of existing knowledge. This effectively serves to strengthen thelinkage between teaching Institutions and other health care institutions in the health care delivery system.However, such coordination is hard to find anywhere.Analogous to the principle of primary health care as the underlying principle for "health for all," we have tothink of primary medical education that addresses the concerns of the Society in a spirit of self determinationand self sufficiency. Too much stress on minutiae and details leads us to nowhere and the young studentsget disenchanted with the whole system of medical education. They are spending a major part of their194formative period in one medical institution and their future is made or marred there itself.  Medical  teachersas part of the institution are solely responsible to shape their future.The education of the future basic doctor has to be on a strong scientific and social foundation.3 However,the present system of medical education is totally divorced from these aims. The student selection is basedon the power of cramming than anything else. By the time student joins the medical institution, he/she isalready drained of energy and there is need to rejuvenate. The whole gamut of basic sciences has to bemastered in first year of their study in a new and strange milieu. Admissions drag on for a month and apreparation time of at least one month is given prior to university examinations. In addition, there is provisionfor vacation of one month.  This leaves us with an effective training period of nine months. However, thisgets truncated due to days spent on three formative assessment tests and public holidays. This leavesstudents with a period of about 8 months to attend lectures, practical sessions including record work andto study and assimilate the subject matter and then prepare for the examination. The practical and viva-voce which are introduced for the first time in their educational career are too stressful for them to cope upwith.4 It is shocking to know that most students spend, on average, three months for anatomy, two monthsfor physiology and one month for biochemistry. One can imagine what type of an edifice can be built onsuch a shaky foundation. It is not difficult to surmise what happens afterwards when they pursue theirclinical studies from 3rd semester to 9th semester. The scheme for implementation of the clerkship forinculcating clinical skill and mentoring for fostering appropriate attitude and desirable behavioural traits forthe doctor in making are far from satisfactory save for a few exceptions. The difficulties of the youngstudent are so much compounded that only those with strong mental fibre are able to get along unscathed.The other and more important aspect of medical education is the actual teaching. If the student has abidingfaith in his teacher, he/she can learn steadily and at an accelerated pace. Analogous to the aphorism that"when everything fails, doctor is the medicine", it can rightly be stated that ‘‘when everything is amiss, agood medical teacher is the education’’, as the power of the teacher as a role model is enormous. While afew have innate talent in teaching and communicating, majority of medical teachers have to be 'trainedteachers' or lay teachers. Traditionally, the medical teachers either assume the role of a teacher or it isascribed to them without reference to the fact of their being specially trained for the purpose. The assumptionis that a doctor with a postgraduate medical qualification automatically qualifies as a medical teacher. It isfallacious as there is no systematic training in pedagogy in most of the medical colleges. Only for the pastfew years systematic efforts have been in place for at least orienting the medical teachers in the nuances ofmedical education and content and methods of teaching. This aspect of medical education is much neglectedas it is considered as domain of only Medical Education Technology Unit.  The principles underlying themechanics of adult teaching-learning process are utterly neglected both by the teacher and the taught. Thisdeprives both the teacher and the student of the sense of mastery and self fulfillment. Medical Council ofIndia (MCI) regulations specify that two thirds of the teaching hours should be spent for non-didacticteaching.5,6 This aspect varies from Institution to Institution and the experience needs to be shared andexplored for better transaction of curriculum in this arena. Inspite of all the constraints, it has to be ensuredthat each student gains mastery over basic and essential aspects of practical medical and health care of thepeople. With large number of admissions, the identity of the students is getting dissolved and the statedgoal is becoming more and more difficult to achieve and maintain.A basic doctor is supposed to cater to the health needs of the population of the region. As majority of ourpeople reside in rural areas, the student needs to understand the nuances to fulfilling their aspirations.Editorial Sridhar195Training of students with rural orientation has always been rightly stressed by politicians and policy makers.But the irony is that no worthwhile effort has been put to plan and effectively carry out training in ruralmilieu. Shortages of qualified personnel with appropriate motivation and issue of logistics have alwaysremained as unsolved problems. Central and state government orders and circulars and budget allocationsgenerally ignore the Rural Health Training Centres which are supposed to be the training ground for futureMedical Officers of Primary Health Centres and Community Health Centres for which substantial budgetallocations are made. If only the Reorientation of Medical Education (ROME) Programme launched in1977 had properly been implemented and continued, all health care facilities of a region must have comeunder the direct influence and direction of Medical Colleges of the region by now.7 Unfortunately, it hasalways been the story of missed opportunity.The formation of Universities of Health Sciences and proliferation of institutions of Health Profession hasadded another dimension to the constraints of medical education. In the name of safeguarding the standardsof education, senior faculty members are often drafted for supervision, observership, administrative meetingsand inspections. In addition, the services of Medical teachers are often requisitioned for training of othercadres of personnel whose educational standards are governed by university rules and rules of the respectiveCouncils. The inevitable consequence is inability of the medical teachers to maintain undivided attention totheir tasks of training medical students. While the importance of medical college, as a part of the generaluniversity, in training a humanistic doctor was recognized in the past by many, now the specialization andsubspecialization in a profession oriented University are ruling the roost and general public is caught in thewhirlpool of explosion of knowledge dissemination and specialization culture and lack of financial resourcesto meet the expenditure for extensive, exhaustive and specialized care. In the summative assessment,adoption of newer methods like Objective Structured Clinical Examination (OSCE) and bedside rounds insome Institutions appear to be so defective that the remedy appears to be worse than the malady.Other equally important aspects of education in general are maintenance of complete health and shaping ofthe personality of the individual student by participation in extracurricular activities and inculcating the habitof conducting oneself ethically. For this, full fledged facilities need to be created and tokenism will not helpin any manner. This and participation in other group activities fosters buddy feeling. Formal shaping ofbuddy system as a source of strength needs to be fully explored. Just as treating doctor is the advocate forthe patient, the Medical teacher should become an effective advocate for the student. The MCI andgovernments also stress on this aspect but implementation is far from satisfactory.While solution to all the questions cannot be found instantaneously, it is important to recognize whetherproblems exist, whether they are real or imaginary and intellectualized, whether they are personal orInstitutional and who are all the people responsible to solve them and how they can be solved effectively.In this quest let it be recognized that "the old order changeth yielding place to new, lest one good customshould corrupt the world" but let it also be ensured that "the clear stream of reason does not lose its wayinto the dreary desert sand of dead habit".Organization of vibrant and effectively functioning Medical Education Technology Unit, thus, becomes avery important component of medical education system.8 This unit should shoulder the onerous responsibilityof inculcating desirable attributes and characteristics of 'social physician ' so that the pristine position of thedoctor is preserved in the society.We have to rely on our ancient wisdom of 'parasparam bhavayantah' - let us help one another and alsoensure that ‘Sahanavavatu, sahanoubhunaktu, sahaveeryamkaravavahai, Tejaswinavadhitamastu,Editorial Sridhar196ma vidvishavahai’- May we (the teacher and the taught) together acquire the capacity for knowledge.These are the first steps to ensure Health for All in the spirit ofSarve santu sukhinah,Sarve santu niramayaha,Sarve bhadrani pasyantu,Ma kaschid dukha-bhag bhavet.Can we hope that the present generation of teachers will live up to the task? Hopefully, yes!M.S. SridharPrincipal,Sri Venkateswara Medical College,Tirupatie-mail: sridhar.ms68@gmail.comReceived: 23 July, 2013.Sridhar MS. Undergraduate medical education: where are we? J Clin Sci Res 2013;2:193-6.REFERENCES1. Supe A, Burdick WP. Challenges and issues in medical education in India. Acad  Med 2006;81:1076-80.2. Ghosh K, Ross C. The teacher and the taught: medical education in India at the crossroads. Natl Med J India2009;22:147-9.3. Jayakrishnan T, Honhar M, Jolly GP, Abraham J, T J. Medical education in India: time to make some changes. NatlMed J India 2012;25:164-7.4. Holla SJ, Ramachandran K, Isaac B, Koshy S. Anatomy education in a changing medical curriculum in India:medical student feedback on duration and emphasis of gross anatomy teaching. Anat Sci Educ 2009;2:179-83.5. Medical Council of India. Regulation of Graduate Medical Education. 1997. Notification. Gazette of India, part III,sect. 4, May 17, 1997.6. Vision 2015. Medical Council of India. Available at URL: http://www.mciindia.org/tools/announcement/MCI_booklet.pdf. Accessed on July 24, 2013.7. Poulose KP, Natarajan PK. Re-orientation of medical education in India past, present and future. Indian J PublicHealth 1989;33:55-8.8. Adkoli BV, Sood R. Faculty development and medical education units in India: a survey. Natl Med J India 2009;22:28-32.Editorial Sridhar

Undergraduate medical education: where are we?

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