Wednesday, September 08, 2010

How to improve the Medical Curriculum - from Dr Nadkarni's book, How to heal the sick healthcare system

I would not like to go too much into the details about the curriculum for the undergraduates. Basically a student used to spend 1 1\2 year to learn normal structure and function of the body i.e. the studies of anatomy, physiology and biochemistry during the period of first MBBS. Another 11/2 year in second MBBS was devoted to the study of diseases of the body and drugs and medicines to be used for the patients – pathology and pharmacology. He also studied medico legal aspects in the subject of forensic medicine. The students are posted in the hospital in the morning hours from 9.00 am to 12.00 noon after the completion of the first M.B.B.S. for a continuous period of 3 years. They attend various departments as per the schedule recommended by the Indian Medical Council. It is here that they get maximum practical experience by observing patients being treated both in the ward as well as in the out patients department, through bedside clinics by the senior teachers. The knowledge of preventive medicine, ENT (Ear, Nose and Throat) and ophthalmology (eye disease) are studied in the 3rd MBBS during the fourth year while in the final examination 41/2 years later, the student appears for Medicine, Surgery, Obstetric & Gynaecology and Paediatrics. If the student passes the examination, he is excepted to work as an internee for a period of one year, working in the department of medicine, surgery, obstetrics and gynaecology and preventive medicine wherein he works at urban and rural health centres. Thus, it is long course of 51/2 years. There is a craze amongst experts of several new branches in the medical field to insist on including their portion in the curriculum of the M.B.B.S. course. Yet, despite criticism and shortfalls, and insistence of new branches to add to the course, I personally feel that the medical course as implemented for the last 50 to 60years or more is quite adequate. Unfortunately the Medical Council has decided, of late, to reduce the first M.B.B.S. course to just one year. One year is too short a period to learn the normal structure and function of the body. The period gets shorter due to the fact that admission process gets prolonged every year and the students get admitted to the college as late as in September instead of in June. Thus, the period for the actual study of anatomy and physiology turns out to be hardly 7 to 8 months. Unless the basic knowledge of normal is sound, the abnormal cannot be grasped. It is the opinion of almost all teachers that shortening the course to one year for first M.B.B.S. is not adequate. It should be reverted back to 11/2 year at least. Secondly, the habit of condoning the shortfall in the period of education must be strictly prohibited. If the students get admitted in the month of September they cannot appear for the examination in the month of April of the next year and will have to appear at the next term namely October (or November). It is true that admissions are delayed for no fault of the students but the fact remains that the period of training was not completed. The same thing is true when the absence is condoned for final M.B.B.S. examination for reasons such as illness, strike and such other circumstances. It is unpardonable. Period of training as scheduled is the most minimum that is required to train him to become a good matured doctor. Hence prolonged absence due to any reason, however genuine, is not pardonable. The ill effects of partial training are finally suffered by the population at large. As regards the curriculum of the other branches of medical faculties-Ayurvedic, Homeopathic, Unani etc.. It is an established fact that most of them do practise allopathy to a very large extent. To some extent this has helped the community because 80% of the general practitioners now belong to these other faculties of the medicine. Therefore, it is imperative that their curriculum is adjusted to include at least two years of allopathic medicine during their course. The exposure to the allopathic system for these students at present is too inadequate. Exposure to allopathy for two years would be akin to creation of a ‘basic’ doctor with the training which is much below the standard of M.B.B.S.; however, adequate for basic needs of the large poor population.

The Indian Medical Council is strongly opposed to the idea of training an ‘inferior’ type of doctor and has thwarted the efforts of the politicians to create three years, four years programme at various times. However, the same council stands helpless when the graduates of the other faculties practice allopathy freely as mentioned earlier. Therefore, I feel that increasing their exposure to the allopathy for a period of at least two years is a good compromise-solution to the present problem of shortage of general practitioners for the community especially in rural and semi-urban areas.

After completion of internship, the M.B.B.S. graduates are now compelled to appear for a common competitive test if they desire to enter into postgraduation studies and become specialists in various branches. Nearly 80% of the students desire to do postgraduation. Earlier there was no such competitive (C.E.T.) test and the students were selected as postgraduate students in various branches as per the marks obtained by them at M.B.B.S. examination. The competitive test has now added a new burden on the students during the period of internship. Actually this period of internship was the best time in the life of a medical professional; some ‘donkey’ work but almost no responsibility and no examination to face! It would have been the best time, when they could have been made to develop a deep interest in social and administrative aspects of clinical practice, so that they would be better prepared to face the competition in actual life and give proper service to the community when they are thrown into the field of medical practice as full-fledged responsible doctors. Men, money and material are the three ‘M’s, every body has to learn to manage to become a professional. A glimpse of training of financial and personnel administration and administration of medical store could have been usefully included during this period of internship, through lectures, seminars, visits to these departments and discussion with the officers in the various departments of the hospital – if only they did not have the burden of competitive tests. A good perspective about socio-economic conditions and the psychology of the people in rural and urban areas and of the poor and lower middle class would also help to make these doctors more sympathetic to the needs of the common man, through lectures by competent social workers and teachers in social studies. As I mentioned earlier, majority of students are now from the upper strata of the society and have very little idea of how 60-70% of the population manage to live. Therefore, I suggest that the competitive test (C.E.T.) should be taken immediately after M.B.B.S. – say within 3 months after the M.B.B.S. examination. The portion for the competitive test is not different from the portion for the M.B.B.S. test. The student has to choose the subject in which he wants to specialize. Therefore, for this test examination, three months period after the final M.B.B.S. examination is quite adequate. It would be an ideal timing when the graduate is quite fresh with his M.B.B.S knowledge and can take another examination easily in his stride. The management course and socio-economic awareness course can now be conducted in the remaining 9 months. Even the students are aware of the importance of the subjects I mentioned above, namely financial and personnel administration and socio economic aspects of society and most of them are very keen to undergo this training.

There is no need to have any examination. If one is taken, it would be optional – for an individual to know the proficiency he has reached. Lack of knowledge of the socio–economic problems of the poor society is one of the root–causes of the alienation of the doctors from the masses; greed for money being the next important cause.

However, there is an absolute and urgent need to introduce a post–graduate course in General Practice. Like the other P. G. courses, this course will also be for the duration of three years. Today, there is no special training for a general practitioner. Not only that, it is a tragedy of sorts, that those students who are unable to secure a post graduate seat in any specialty, finally decide to go in for general practice without any special training. No wonder, the most important primary health care remains the most neglected aspect of health care system. with more and more emphasis on 'super specialty modern medicine.' If specialization was provided for 'General Practice' - M. D. (G. P.) it is quite likely that good students with good marks would opt for general practice.

Like all other P. G. students, these students also will have a three year residency program. In the morning hours, from 8 am to 1 pm they will be posted, by rotation, in various departments, like Medicine, Surgery, Ob & Gyn. Paediatrics Orthopaedic in one unit or the other, for a period of 4 months each and will have an option of choosing any three minor specialties for a period of 3 months each, like E. N. T., ophthalmology, dermatology, psychiatry, preventive medicine, etc.. Last 6 months, they will return back to general medicine. While attending these specialties, they will learn more about when to admit and what is to be done after discharge as much as what is being actually done for the patients in the wards. Naturally O. P. D. and follow-up clinics are mandatory. And in the evening, they will attend attached dispensaries, from 4 to 9 or do a Night duty in the dispensary.

Even after passing the M. D. examination and starting general practice, they could continue to work for a further period of 3 years in any non-teaching secondary care hospital. The society will gain a lot, if such matured doctors enter general practice after due formal training.

Finally, I firmly believe that super specialty departments should have no place in the medical college premises. They hamper the flow of patients in general specialties. Also the general specialists develop a tendency to refer and push, even the cases that they could have handled easily. This tendency would no doubt, be curled to some extent, by evolving the charges for consultants, as mentioned elsewhere. It would be wiser to establish super specialty centres, close to but not within the medical college and hospital premises.

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