Feedback on Vision 2015 document and recent amendments of MCI
(find the feedback at the end of this article)
It is worth appreciating that Medical Council of India has taken a step to reform the undergraduate and post graduate medical education in this country. The working groups have provided their recommendations.
The highlights of these reports are enumerated as below:
A) Undergraduate medical education:
1) The group recognizes that the Indian health care and medical education is facing systems and standards challenges.
2) The group also recognizes the wide disparities between different states and also urban Vs rural areas.
3) The group underlines the causes for the present problems as physician shortage (generalists and specialists), inequitable distribution of manpower and resources, and deficiencies in the quality of medical education.
4) The group accepts that India has highest number of medical colleges in the world.
5) The group attributes the “unprecedented” growth of medical colleges in past two decades to “response to increasing health needs of the country”.
6) The group feels that “the most significant challenge for regulatory bodies has been to balance the need for more medical colleges with the maintenance of quality standards”.
7) The group also underlines that “globalization of education and health care and India’s potential as destination for education and quality health care has brought the issue into sharper focus”.
8) The dour objectives for constituting this working group include: a) evolving a roadmap for the direction of medical education in India in alignment with national needs b) evolving broad policy regarding emphasis, duration and curricular changes that could be adopted as future strategies to make medical education in India comparable to global standards c) evolving strategies and plans so that medical education in India is innovative and is able to prepare undergraduates to be able to perform in the changing scenario of medical science d) To work on parallel tracks for immediate solutions and long term improvement in a steady, phased manner in the light of deteriorating medical education standards in the country”
9) Group’s opinion about present status: Current doctor: population ratio is 1:1700 compared to world average of 1.5:1000. The committee has come to a consensus that targeted doctor: population ratio should be 1:1000. The committee felt that current intake of medical colleges and the critical mass of doctors should be doubled at least to achieve this target.
10) The committee recognizes that the low number of doctors going for general practice or to work as medical officers in rural areas is due to the fact that “MBBS graduate doesn’t feel equipped with adequate skills and competence to take care of the common problems at the secondary and primary levels”.
11) The committee rightly mentions that in past curricular revisions have mostly added to the existing content without undertaking the exercise to remove what is obsolete/ outdated. The committee recommends undertaking exercise in a detailed and extensive manner to make the curriculum as efficient as possible.
12) The committee wishes to convert the conventional medical into competency based module to develop the skills of the basic doctor.
13) Early clinical exposure to medical students is a welcome suggestion.
14) Committee has suggested clerkship or student doctor method of clinical training.
15) Committee suggests that certification of skills is necessary before licensure.
16) Committee wishes to link medical college with local health systems including CHCs, taluk hospitals and primary health care centers to be used as training base for medical students.
17) Committee’s suggestion of using contemporary approaches such as skills lab, e-learning, m-learning and simulation is really appreciable.
18) Flexibility in curriculum is also a welcome suggestion.
19) The committee has suggested developing a network of units to train teachers in medical education technology. This is also a welcome suggestion.
20) The committee feels that with all these activities the impact achieved will be: a) improved and revised curriculum b) capacity building of faculty c) production of increased manpower d) improved quality of existing colleges e) sufficient number of teachers f) create motivating career pathways for students and teachers g) overall improvement in the health care of country with improved health parameters
21) The committee proposes to solve the problem of manpower shortage by: a) tapping consultant pool in government service departments b) dual/adjunct appointments c) interdisciplinary appointments d) employment of retired teachers e) increasing the age of superannuation in specific areas f) increasing the pool of young teachers by increasing postgraduate output
B) Post graduate medical education:
1. The group wishes to make post graduate medical education more relevant to the country’s needs by making it more relevant, skill oriented. It also wants to ensure adequate career options for medical graduates.
2. The group wishes to restore importance of internship.
3. The group wishes to bring uniformity in nomenclature and duration of PG courses.
4. It suggests the conduction of two national exit examinations.
5. The group wishes to increase post graduate seats almost four fold up to 2030.
6. Committee also has innovative plans for conducting national level exit examinations at the end of final MBBS and after completion of internship.
7. Committee recommends abolition of nomenclature like MS and MCh.
8. As per the recommendations there shall be 50000 MBBS graduates and 50000 M.Med post graduates, 25000 MD post graduates , 7500 fellowship holders and 5000 super-specialists as DM.
Feedback
1) The annexure mentioned in report is not available on the website.
2) The undergraduate working group like the board of governors has a strong “clinical” bias. It is interesting to note that there are three surgeons, 2 gynecologists, one radiologist and one person each from anatomy and pharmacology. There is no representation to subjects like medicine, community medicine, ear-nose-throat, ophthalmology, forensic medicine, physiology, bio-chemistry, pathology and microbiology. Similarly there also is regional imbalance. Four experts are from Delhi, two related to Maharashtra University of health sciences, Nashik and one each from Bangalore and Vellore. With this observation I humbly wish to doubt the ability of such a group to really take a holistic approach and then provide proper suggestions.
3) The members of the post graduate medical education group are not displayed on the website hence no comment can be made on that group.
4) Before the reports of working groups were made available on website of MCI the BOG has passed certain amendments on 17th September 2010. It is imperative that no meaningful feedback can be given without taking into consideration these amendments. There is a definite and strong link between the amendments and the recommendations given by the working groups. Actually this should have been other-way round! One must hence take the reports with a pinch of salt !
5) The mandate of MCI is to maintain the standards of medical education in this country. This it does by providing norms and standards for minimum requirements to be fulfilled by each medical college. It conducts frequent inspections to verify whether the medical college is adhering to these norms and then after satisfying itself recognizes that college for undergraduate and/or post graduate courses.
6) MCI is an authority for quality control. It is difficult to understand how it has presumed that its mandate is to decide upon the number of doctors required by this country. One may only consider this activity of finding out requirement of doctors as an academic activity and not more than that. The MCI as a quality control body should not and cannot take upon itself the responsibility of production of more doctors! Because the work of MCI is to certify the goods and not to produce goods! It appears that MCI is going beyond its jurisdiction while helping the states and private managements to produce more doctors. Unfortunately all the report of the working groups is haunted by this false need of producing more doctors without any valid ground for the same.
7) The committee mentions (in 2010!) that the doctor –population ratio in the country is 1:1700 when actually this was 1:1722 in 2005. If one calculates the ratio for 2010 it comes to 1:1450. It is difficult to digest such crudeness in a national level committee’s work! The doctor: population ratio calculated by committee’s findings that in India every year from 330 medical colleges 35000 doctors are coming out and with the growth rate as 1.4% the ratio comes to 1:1017 (in 2031) which is very close to what the committee wants to achieve by 2031 (Population-1546158000/ doctors-1520000… as per figures given by the committee).
8) The committee has not considered around 7000 allopathic doctors passing out from countries like China, Russia, New Zealand etc (This year 7000 doctors appeared for MCI’s screening test).
9) Committee has unfortunately turned a blind eye to the ground reality of availability of doctors in this country. In 2005, there were 7,50,000 doctors of Indian systems of Medicine in the country mostly engaged in general practice. Actually MBBS doctor in general practice has become an exception in many states. Considering these doctors the doctor: population ratio in 2005 itself was 1: 781.
10) It is not clear how the committee has come to a magic ratio of 1:1000. World Health Organization in its course book on “Health Manpower Planning” of 1980 describes four methods to decide number of doctors required by a country. The “Health Needs” method takes into account the biological needs of the society for deciding the requirement of doctors. The other two methods include “Service Target” and “Health or Economic Demands” methods. In all these methods one has to collect information regarding the disease load, existing number of doctors as well as the economic and social milieu of the country. The last method, the simplest one is to decide required number of doctors on the basis of population. In this method one should know population of the country. Here the number of doctors required by the country is decided by taking into account international comparison, suggested norms, the statistics available from countries with better health care and study of past trends. Though simple this method is crude.
Committee’s conclusion that India needs 7.5 lakh allopathic doctors is based on this fourth method. It makes no sense to decide doctors required by India on the basis of statistics that Cuba has one doctor for 250 people or USA has one for 500 people. Before coming to this magic figure, working group should have done some serious homework.
Firstly let us accept that more doctors do not necessarily mean better health. Healthy society will require lesser doctors! Secondly we must undertake the studies to find out workload for the doctors. The census can be used to find out the age and sex wise disease load in the country. Many of the services such as bandaging, giving injections, dispensing medicines etc are actually provided by nurses and pharmacists. Preventive and rehabilitative services are provided through paramedical workers. Doctors are required for curative services. The work of health promotion and protection is better done by farmers, teachers, environmentalists, engineers and scientists than the doctors. The curative services are on out patient or inpatient level. To calculate requirement of doctors for this purpose we should have data about various diseases. Then we can decide on the number of general practitioners, cardiothoracic surgeons, psychiatrists and pathologists. Of course this is a tough task involving collection of data at national level and its analysis. I wonder why after 60 years of independence this should not be possible!
In 1950 the WHO expert committee suggested a norm of one general practitioner for 1500 people. While suggesting this WHO had considered that a doctor will work for 2000 hours in a year (6.75 hours everyday for 300 days). In India the role of general practitioners is mostly taken by Ayurved or Homeopathy doctors. MBBS general practitioners are as an exception. If we consider the number of doctors of all pathies then the doctor population ratio comes to 1:781 far better than WHO or the working group’s expectations. Hence it is wrong to say that there is deficiency of general practitioners in India. India is unique country in the world which has almost equal number of doctors from other pathies. These doctors too learn medicine for 5 and half years. Without undue consideration to “Cross practice” it is logical to allow them to use a few modern medicines by giving adequate training. This will bring them under the regulatory net and also avoid misuse of medicines. The society will also get benefits of modern medicines. If we do not consider this peculiar situation of India and produce more allopathic doctors then we are encouraging mal practice and unethical competition amongst the doctors both of which damage the society ultimately.
11) It will be clear that India doesn’t require more general practitioners. We require more of psychiatrists, anesthetists, cardiothoracic surgeons, neuro physicians and dermatologists. For this we will have to increase post graduation seats in medical colleges. The working group on post graduate medical education has given some good suggestions to increase these seats in a phasewise manner. In a college with intake capacity of 150 there should be 150 post graduate seats. MCI may relax norms to achieve these numbers. This will help our people.
12) While giving attention to team leader of “Health Team”, the doctor, are we thinking about nurses and technicians? The obstructed labor of “Paramedical Council” is an eye opener in this regard.
13) The recent notification of MCI has given equal status to DNB as MD/MS which is incorrect. MCI conducts inspections in the colleges which grant the degrees of MD and MS. I am not aware whether MCI gives recognition to DNB courses! Before taking this bold step of allowing back door entry of DNB candidates in the main stream of medical education has the MCI conducted any inspections of the institutes that conduct these courses? Secondly the admission to the DNB courses is not on the basis of a national or state level entrance test but it is of adhoc nature where there is no transparency in the selection process. Many institutes are known to take huge capitation fees from the students. Is it fair to treat these candidates at par with MD/MS doctors who toil hard to pass the tough entrance examinations and get the seat in second or third attempt wasting 2 to 3 years of their career?
14) The working group mentions that India can become a destination for medical education for the world. If this is so MCI may encourage organizations to open colleges for foreign nationals (Export oriented units!!) that may earn the country some foreign exchange! This should not form a basis to start new medical colleges.
15) On one hand the group accepts that the MBBS doctor doesn’t go for general practice or MO-ship as there is lack of adequate skills and competence. The group also suggests teaching more skills to students. It is well known that to teach skills we require small group teaching methods which need more teaching staff. Contrary to this the MCI regulations of 17th September 2010 has reduced the norm for staff in many subjects.
16) The group proposes to adopt PHCs, CHCs and district hospitals for providing more opportunities for students to learn clinical skills. In the amendment of 17th September the MCI reduces the norm from 1500 beds to 900 beds for starting a medical college of 250 admissions. Same reductions have been done for norms related to all medical colleges with admission capacity of 50, 100, 150 and 200. There is no logic and coherence in the recommendations by the group and amendments by MCI.
17) In order to fulfill the imaginary shortage of teachers (which is due to opening of unnecessary medical colleges in the country) the working group has proposed to tap consultant pool from Government service departments…the public health departments, dual/adjunct appointments and increasing age of superannuation of teachers in specific areas. The health departments in almost all states are themselves short of doctors! The bad effects of dual appointment on teaching have been already seen from the honorary system in many states. Now many states are asking for full time teachers and MCI also is not recognizing part time or honorary teachers. Does the group wants to take a reverse turn? Similarly increasing the age of superannuation is a stop gap arrangement. Very few medical teachers have the capacity both physically and mentally to perform their duties after the age of 55 or 58 years. If at all some of them are fit to work they can be given appointment as professor emeritus and utilize their services for teaching purposes. Increasing the age of superannuation without any such clause will damage the medical education in particular and the morale of young teachers in particular.
18) In many government medical colleges there are many lecturers and associate professors who have teaching experience on their posts of 10 to 15 years but still they are not promoted to higher posts. As a result many posts of professors and associate professors are lying vacant and the state has to resort to deputation or transfer on loan basis of senior teachers for the MCI inspections. Now in sixth pay commission the salary of associate professor and professor differs only due to a grade pay difference of Rs. 1000/00. MCI should ask the state governments to create more posts of professors and associate professors in their medical colleges so that the deserving candidates can be promoted. Time bound promotions shall go a long way in boosting the morale of medical teachers. If these measures are taken then medical colleges shall easily get the staff.
19) The working group has mentioned about regional differences but has not spelt out anything about the ways of tackling this pertinent issue. Actually it has created a mess by providing general recommendations for all parts of the country.
20) The working groups have not gone into the causes of doctors not going to rural areas. Just by increasing the number of doctors or by starting medical colleges in rural areas this problem cannot be solved if we wish to learn from past experiences.
21) The neglect to the subject of community medicine has proved very costly for the country. Actually the cause of present scenario is this neglect. The working group advising to adopt PHCs and CHCs seem to have forgotten about the silent death of ROME scheme!
22) Every one speaks loudly in public speeches that community medicine is the fundamental need of our country and we must produce a basic doctor or community physician. But there is lot of gap in what we preach and what we practice. The absence of any specialist of community medicine from the Board of governors and also from the working group on undergraduate medical education proves this point! The time has come that cardiologists and surgeons are deciding upon the “Public health” of this country! Surely this is not due to lack of leadership in the men of community medicine but is due to the might of clinicians who are close to ministers and other high profile personalities!
23) The working group has spent 1000 crore rupees and almost half of the pages on developing medical education units in the country! Instead of doing this the group should have recommended the establishment of Bachelor of medical education colleges in all the states! Earlier a course of two weeks was thought to be sufficient for medical teachers to learn the teaching skills. It seems that the ability of present teachers has deteriorated to such an extent that they all need training for six months or one year. To run such units at each college and regional, state and national level from where the group expects the source of faculty? Such recommendations only show the skewedness of the group due probably to a mighty member (or a member giving more time!) interested in this activity.
24) The suggestions of working groups are not very specific and also the actual detailing is missing. Words like horizontal and vertical integration are used without providing proper means to achieve this objective.
25) To conclude the recommendations of the working groups are just to support the BOG’s whim of starting new medical colleges, allowing back door entry of DNBs in the main stream, giving a cake walk to private managements for opening new medical colleges ultimately creating a chaos in medical education of this country.
26) I strongly feel that all these recommendations including the amendments by BOG should be kept on hold till a democratically constituted MCI comes into existence.
Dr.J.V.Dixit
Associate Professor,PSM Department,
Government Medical College, Aurangabad-431001
and Senate member, Maharashtra University of Health Sciences, Nashik
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