Tuesday, September 07, 2010

Selection of Medical Teachers for medical education - Chap 11 from Dr Nadkarni's book, How to heal the sick healthcare system

The choice of the medical teachers leaves much to be desired. As per the Indian Medical Council rules, there are broadly three categories of medical teachers – lecturer, reader (variously called assistant professor, Reader, Associate professor etc. from time to time) and the professor. Post graduation in the subject and the teaching experience of three years as a senior resident or equivalent are the minimum qualifications to become lecturer. Three years' experience as a lecturer qualifies him to become a reader / Associate professor and after five years as Associate professor he can aspire to be a professor. Generally this appear to be on par with the stipulations in the western countries. There is always a big rush of qualified post graduates to become a lecturer, not because they like the teaching profession but because they wish to gain further experience in their own field of specialty. The applications for the post of reader / associate professor are far less and sometimes it is difficult to get the post of a professor filled; the applications are so few. Meager salary, bureaucratic attitude, lack of incentive and poor job satisfaction are the main reasons why the consultant doctors are not attracted to the field of education. I have also suggested that if these consultants from the level of Associate professor onwards, are allowed practice within the premises, that may be sufficient incentive for many of the consultants who are academically oriented or are not happy with the many gimmicks and marketing and unfair methods they have to adopt in private practice. But today it is a discredited field because of lack of incentive and inappropriate infrastructure. But not every one is inclined to practice and there are a few who are genuinely interested in teaching and research and it is necessary that the medical college hospitals-government or private – should encourage those who are truly interested in teaching and / or research. The lure of private practice within the premises for such consultants is unproductive. For them some other incentives must be available.
There are three desirable types of medical teachers. The first one is 'practice oriented'. They mix the art and science of clinical practice and render good medical service to the patients. This category is in the largest number. But as I mentioned earlier, many of them leave medical college hospital and enter into private practice which is more lucrative and more satisfying though more intriguing. Actually these teachers would have been an ideal example for the students to learn from and it is for the sake of retaining such consultants in the field of medical education that I have suggested private practice within the premises with 25% of the beds reserved for the paying class, Private practice allowed outside hospital premises is disastrous not only because the medical teachers are out of the premises for practice but, in addition, they develop too much of commercialization. In turn, they neglect their duties in the medical college hospital and thus become the worst examples for the students to learn from. Unfortunately, such a system of allowing private practice outside the premises is advocated and allowed in most of the government and private colleges due to the advice of the accountants and bureaucrats who are highly satisfied by the reduction of expenditure on the medical teachers. Besides, it relieves them of a big administrative burden. In the municipal medical colleges, for example, nearly Rs. 15,000/- to Rs. 20,000/- per month are saved per each consultant if he opts for private practice. Totally, in the eyes of the accountant, the corporation would save around Rs. six to eight crores. But they forget that the same teachers would have earned much more than these 20.000/- rupees per month and further brought another two lakhs of income to the hospital, if practice was allowed within the premises. In addition, the true benefit is the improvement in the medical education which will benefit the society for the next 2 generations in the form of better doctors coming out from the hospitals. This has been discussed in great details earlier. But the administrative burden on the accountants and bureaucrats would rise five fold. The second type of teachers who are equally desirable are teachers who read a lot and are truly interested in teaching. Every good teacher may not be a good practicing clinician, just as the best directors are not the best actors and the best coaches are not the best players. Teaching is a different art altogether and such teachers who are academically oriented and have enough art of teaching must be sought after. Similarly some amongst them may be deeply interested in research work and should become assets for the institution. The teachers who have truly come for teaching or for research are very few in Mumbai. Hardly 20 percent of the teachers at the most can be expected to belong to these two categories. They need different incentive. As mentioned earlier research workers can be encouraged to utilize the grants from the pharmaceuticals or I.C.M.R. funds and the college itself must have enough funds available for research. Foreign institutions are pouring funds for good research. Unfortunately in the present system, while every worker under him is adequately compensated, the consultant teacher, himself, who undertakes the project is not allowed a single rupee for the work he undertakes. This is most unfair and may be the root– cause why most of the teachers are reluctant to take research projects. This also leads to clandestine practice of the pharmaceutical companies paying in the form of gifts, foreign tour and so on to the Chief Investigator, thus inducing research workers to give favourable results for the company. The disastrous results of such corruption in research are obvious and drugs and medicines which can be harmful are finding their way easily into the market. Substantial payment to the research worker directly through the grant will help to make research more fruitful and honest. Similarly a good teacher must get adequate facilities to write books and monographs. Writing books and monographs separately for students, nurses, technicians etc. is a task in itself and apart from too much time consumed for it, it is also very expensive. Hence, he should be provided with adequate facilities to write such books. Such incentives would go a long way to improve the standard of medical education in the medical college. Both these classes of teachers deserve non–practising allowance and other perqisites, subject to performance. Therefore the performance of the medical teachers must be assessed, as per the specific expectations from each category.

Performance Assessment of Teachers

Unfortunately today there is no assessment of the performance of the medical teachers. It is only a confidential report of each staff member. The confidential reports submitted every year are a big farce. Basically the annual confidential report was meant to ensure at least the minimum output of work from every worker. If there were no adverse remarks, he / she was considered satisfactory. There was no added credit if the person worked more satisfactorily i.e. if he gave very good or excellent performance. The next promotion usually went with seniority. Of late, competitive selection (for example by M.P.S.C.or U.P.S.C. interview) has been introduced and 50% of the posts are filled by promotion and 50 % are filled by competitive selection. However, if one looks closely into the method of the so called competitive selection, it would be realized that there are no performance criteria and no performance records on which the selection is based as mentioned earlier. The ability of medical teachers needs to be assessed (a) by his clinical ability i.e. record of number of patients treated, number of different diseases tackled with their ultimate results. or (b) by his ability of teaching; the performance of the students in different examinations; under- graduates and post-graduates or (c) by the research work that the teacher has done. This last i.e. research papers read or published is no doubt considered during the assessment for competitive selection, but the quality of these publications is not analyzed at all. In fact, ‘The papers read or published’ being an important column in the application form, everyone tries to write or read some paper or the other in some journal or some regional conference. Most of them are trash. There is no distinction between the papers published in ordinary journals as compared to the papers published in well known journals or international journals. It is necessary, therefore, to substitute the system of confidential report by a performance record. It is important that the performance assessment must be done separately for each of the above three qualities required of a medical teacher. Administrative compliance, complaints or compliments from students or patients, ability to organize and conduct allied activities like seminars, lay education, participation in socially important events. clinical programs etc. could be the other facets considered in the assessment of the teacher. Unless such records are maintained and submitted to the selection committee in such a form with objective data, the competitive selection would remain a farce and at best, lead to the selection of more vocal street–smart applicants. The recent cases of massive corruption in these (MPSC) selection boards are eye-openers which have failed to open our eyes. The M.P.S.C. is so slow in its selection process that the posts are not filled for years together and thus the vacant posts are once again occupied, by seniority alone on temporary basis from the junior cadre. These ‘temporary seniors’ are continued for a decade or more. It would be preferable if the M.P.S.C. is substituted by another formal organization specifically appointed by government to enroll medical personnel and other professionals in the government organization. The confidential reports must definitely be replaced by the more objective performance record in which the performance of each would be graded as excellent, very good, good, satisfactory and unsatisfactory. It would be an excellent idea to inform every employee his / her performance report. This will help him-if he is dissatisfied, to protest and to put forth the objective data to get his report corrected. On the other hand, if he knows that his performance is good it will encourage him to do better. If his unsatisfactory report is confirmed, he knows definitely that he has to improve or perish. Such report once confirmed by the senior authority must be seriously considered at the time of competitive selection. This way some junior teachers may supersede the senior inactive teachers; and that will help to improve the medical service and medical education. It will create a fair competition amongst the teachers. During my tenure as Dean, I had done a small experiment and adopted this procedure. The then assistant commissioner Mr. Karandikar was also very keen to promote merit. Those employees whose work was declared just ‘satisfactory’ but did not have a record of ‘good’ or ‘very good’ for at least 2/3 rd of the period in their present post were denied promotion. The result was dramatic. Every lecturer and reader stepped up his/her performance and was keen to prove his/her mettle. Personally I conveyed the performance record to each and every member of the medical faculty. Those reports were personally prepared by me and were given as confidential letters personally to each of them. Thus, the confidentiality was also maintained, as required under the present rules. It was only the employee himself who could divulge his performance report to others-otherwise it remained confidential. There was another unexpected but highly desirable result. Earlier when only the adverse remarks were conveyed to a few of the members, they raised a lot of noise and complained bitterly about ‘partiality’ ‘corruption’ and so on in their conversation with other colleagues in the common room. All other members of the staff, not knowing what their own report was, promptly sympathized and the association of the teachers jumped on the authorities concerned namely, the Dean or the Commissioner to get the reports annulled. When I gave their performance reports stating clearly where they stand, a large majority, who now definitely knew about their own good report, were totally reluctant to join those few who received adverse remarks. Thus, it was much easier to discipline the teachers and make them perform their duties well. Unfortunately, after Mr. Karandikar left, as usual, senior committee members raised many objections and the practice reversed back to promotion seniority-wise. The committee doubted every adverse report. Yet this small experiment-even for a couple of years-has convinced me that if objective data are recorded, performance reports are prepared and submitted to each member separately (and confidentially if necessary) and if these reports are used seriously at the time of promotion, it ha a highly desirable effect. A competitive spirit develops and medical services improve. Besides the whole process is extremely transparent as rightly demanded by the association of the employees. As discussed earlier every one need not to be a good clinician but every teacher must show proficiency at least in one or two desirable qualities of a teacher namely, clinical work and / or teaching and / or research. This will also help in ensuring the balance between academically oriented teachers and practice oriented teachers.

Mandatory number of medical teachers required are clearly notified by Indian Medical council. In large cities where the work load in the hospital is high, the number of clinical teachers is short of the real need in clinical subjects. At present one professor, one associate professor and two lecturers, together form one unit and are allotted 30 to 40 beds for their clinical work. There are at least 6 to 7 resident doctors who are doing their post-graduation; 2 students every year for a 3 years’ course.They work and move around together all the while. Therefore, the total numbers in a unit are too many. Actually, they were not meant to be flocking. It would be more advantageous to have one professor, one lecturer along with 3 resident doctors to form a compact sub unit and the associate professor along with one lecturer and three residents to form another sub unit. This way
the role of each member will become more defined and all of them will have adequately defined work. However, in general it can be safely assumed that the number is too small to cater to the large number of patients attending medical college hospitals. As the pay scales of the teachers are being raised from time to time and as the hospital earns zero revenue, managements including those in the government become reluctant to appoint even one additional teacher than required by M.C.I. and if at all more teachers are enrolled, the expenses rise. That results in higher fees for medical students. This peculiar vicious cycle naturally affects the quality of medical care given to the patients in medical college hospitals. Regrettably no one is worried and the authorities point their fingers to the Indian Medical Council rules in justification of less number of teachers. The only exception appears to be the large reputed hospitals of medical colleges in Mumbai where number of teachers have gone up much above the stipulated numbers of Indian Medical Council due to the public pressure. This inadequacy of qualified professionals in the medical college hospitals can be corrected by appointing part-time or honorary qualified professionals to help in the services in the hospitals. The Medical Council strongly objects to the appointment of part-time or honorary doctors as teachers. I, therefore, make amply clear that qualified doctors thus appointed will not be called ‘Lecturer’, ‘Associated Professor’ or ‘professor’. They will merely work as ‘Honorary Surgeon’ or ‘Honorary Physician’. the appointment of the honorary or part time consultant – one in each unit –will help a lot both in improving the medical service as well as medical education. There are many successful consultants in the city doing good medical practice. They cannot be successful unless they have proper grasp of the art and science of the branch in which they practise. No doubt that there are some successful consultants whose success depends only on their business acumen. These are ‘commercially successful’ doctors. It will not be difficult for a good management to differentiate between the really competent doctors and the commercially successful doctors. Experience of these competent doctors or the skill in their hands and their capacity to observe and interpret the signs and symptoms of the patients will make an excellent example for the medical students to watch and learn from. As mentioned earlier, good teachers may not be skilled clinicians or surgeons but even their own teaching ability will increase by observing such skilled colleagues right in their own unit. Similarly retired or most eminent consultants who have highly specialized knowledge could be invited as emeritus professors. They will examine and treat such patients as are specifically referred to them by the concerned unit. The idea is to have the actual demonstration in their respective highly specialized field for the under-graduates and post-graduate students. In fact, such a practice exits in engineering, law colleges and IITs. Many industrialists or professional experts are invited to give lectures, and many visits to successful industries / institutions are arranged. There is no reason why similar practice could not be started in medical colleges. Today jealousy and the bureaucratic stiffness are the only reasons why this is not practiced in medical colleges but it is high time we do so. The addition of honorary consultant in the unit will help to minimize the expenditure as well as to relieve the burden of increased workload in the hospital. Besides, they will be able to claim teaching experience and become eligible to be lecturers, associate professors or even professors at the end of ten years. The availability of such senior teachers will enable the teaching institution to overcome the acute shortage (of senior qualified teachers). It will help to replace 'old dead-wood' by fresh competent professors and associate professors. Thus, there will be three consultants including three resident doctors, and an honorary surgeon or physician in each sub-unit. Highly specialized emeritus professors can also help and guide the unit in their more complicated cases and impart deeper knowledge in complicated cases.
As emphasized earlier they are not designated as teachers, therefore, they cannot set the question papers or become examiners. Beyond demonstrating and imparting their knowledge and skills to the students who desire to learn from them, they play no direct role in the mandatory medical education system. Yet they will contribute a lot to the standard of treatment and education in the medical college hospitals. The service will improve and the education will become more practically oriented. To me this step is as important as 25% paying beds in each unit. I do not expect Indian Medical Council to agree easily to such a modification. Technically and legally I see no reason why the Medical Council should object to the appointment of additional consultant doctor in each of the teaching unit. However, if council does object I feel it is time that the students, teachers and the management stand up and go to the court of law against the Indian Medical Council to support this system.

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