A revamp of medical education is needed

RECENTLY, two contrasting news items were published. One said the government had given sanction to 50 new medical colleges, which would increase the number of MBBS seats to over 1,07,000. The other said 38 medical colleges had failed to meet the criteria for the continuation of recognition to them to admit fresh students and over 100 more colleges faced similar action. The colleges were found to be non-compliant with the norms laid down by the National Medical Commission (NMC). The lapses included non-compliance with biometric attendance by the faculty. This could be due to an actual shortage of faculty on the rolls or its non-availability due to commitments elsewhere. Pertinently, most government and private college teachers are allowed to do private practice or they do it on the sly.

The Minister of State for Health and Family Welfare had in June 2022 informed Parliament that there were 13,08,009 registered allopathic doctors in India. Assuming 80 per cent availability (the rest having retired or died or migrated), that makes more than 10 lakh active doctors. When over 5.65 lakh Ayush doctors are added to the overall pool of doctors, the House was told that India easily met the WHO standard of one doctor for 1,000 people.

The number of medical colleges has increased from 387 in 2014 to 695 in 2023. The government had recently proposed to convert over 75 district hospitals to medical colleges and many such conversions have taken place. A district or an ESI hospital cannot be overnight converted into a college. The kind of infrastructure, trained faculty and work culture needed is totally different.

At the current rate of over one lakh MBBS doctors graduating every year, in the next five to seven years we will have over 15 lakh of them. Assuming that India’s population reaches 150 crore by then, we will have one MBBS doctor per 1,000 people. That raises the question of how many more doctors are needed every year and whether we are in a position to employ them all productively.

Currently, an MBBS student has little exposure to the practical aspects of medicine as he is preoccupied with efforts to get into the post-graduation course. The number of postgraduate (PG) seats falls short by one-third of the undergraduate seats. A majority of MBBS students aspire to do PG courses and, they should do so. There is a need to let them choose the subject according to their aptitude.

The number of PG seats could be altered as per the regional or national needs. For example, for Community Health Centres, we could have PGs in family medicine. For developing emergency medical services or trauma services, corresponding proprtion of PGs would be required. Only those with an aptitude for teaching and research should be trained as teachers.

In healthcare, there is an urban-versus-rural dichotomy. While almost two-thirds of the country’s population resides in rural areas, less than 30 per cent of the doctors work there. As per the Rural Health Statistics, 2021-22, there is more than 50 per cent shortage of doctors at Community Health Centres.

Additionally, the distribution of healthcare workforce across the states is skewed. Though Kerala, Tamil Nadu, Karnataka, Andhra Pradesh, Goa and Delhi have one doctor for 350-750 people, Jharkhand, UP and Bihar have one doctor for 3,000-8,000 people. Strikingly, 40 per cent of the doctors in Karnataka are in Bengaluru alone, leaving many rural areas understaffed. On the other hand, Kerala, with better infrastructure, has hardly any rural vacancy.

Is the government’s policy to increase the MBBS seats an effort to push the doctors to rural areas once the cities are saturated? Doctors hesitate to go to rural areas because there is no infrastructure or support system, no compensation for the hardship and poor family life. Rural jobs are all in the government sector, with inadequate remuneration which falls short of the expected ‘return on investment’, especially if a doctor has graduated from a private college.

The other aspect of medical education is the quality of doctors being produced. While the curriculum needs to be revised periodically, it should give more emphasis to practical aspects, especially in handling problems peculiar to India. The pace of creating new colleges is not matched by the availability of infrastructure, equipment and trained medical teachers. A telling example is that there are hardly any applicants for posts of superspecialist in many state government colleges, but the new AIIMS institutes are able to get them because the latter have infrastructure, equipment and freedom to work.

The NMC has succeeded in regulating entry to MBBS through NEET, but with nearly half the colleges being private and students with very low ranks getting admission in them, there is little uniformity in the standard of education. There has to be uniformity as well in infrastructure, teaching and training with modern teaching aids. One wonders why telemedicine is not being used widely and why the same content cannot be taught across the country. Surprisingly, some states have gone retrograde by introducing teaching in regional languages.

What is needed is a revamp of medical education in India, like it was done in the US following the Flexner Report in 1910. Medical curriculum was revised, the number of colleges trimmed from 155 to a few score and minimum standards and duration of training in each field were laid down. The same pattern was followed in Canada and Europe.

India needs to rationalise the number of medical colleges and their intake, taking into account the future projections of the need for doctors at primary, secondary (specialist) and tertiary (superspecialist) levels.

We need to be flexible in our approach. For example, in 2025, we could be needing more paediatricians or ophthalmologists while five years later, there may be a greater requirement of critical care physicians or neurosurgeons. We must also ensure that an India-centric approach is taken in the revamping of healthcare, which faces the twin burden of communicable as well as non-communicable diseases. The disparities in infrastructure, equipment and specialist manpower between different states and between newer and older, well-established medical colleges must also be removed.