Beißen Gedanken: Jigger of Medical Education in India

Mr. & Mrs. Professor Dr. Vijay Pithadia

It has been observed that macrocosm is at its selective best, mediating quality control in human reproduction. This is evident from the fact that 50% of the pregnancies with chromosomal frenzy abort fortuitously. As early as 1859, Charles Darwin in his book, "The Origin of Species", stated about natural selection of species. The mankind, homosapiens are the highest evolved and also natures selected best on this earth. Their caretakers are the doctors’ i.e. medical professions. Since time antediluvian health has been an incessant concern of the mankind. Charaka mentioned that diseases and mankind coexisted all along.

In India and perhaps in the whole world, during Arsha period (period of the rishis), two great universities came into existence, where course included medicine and surgery. One was Banaras and the other was Takshashilla. The cardinal of the medical sections was Sushruta and Atreya, apiece. [1] The universities grew in the Buddhist epoch, producing medical literature not only for students to learn, but also for the teachers to enlighten. During the post - sovereignty era there was a spurt of setting up of private medical colleges without commensurate resources and dictate.

# Systems focus to medical education

A medical institution could be considered as a system. The input is the students; process includes the teaching learning activities and the output is the juvenile medicos, who are the products of an institution. The role of environment in a system is quite significant. The environment in this context is the society at large. We take the students from the society and after training them leave them back to the society. The society would embrace them only if they can take care of it and its needs; hence it is very important that the training imparted to them is a need based one.

# Trustworthiness of Medical Professors

Medical professors are the architects and builders of students’ behavior using a standard program. They are also the curricular developers and transact and thus have a pivotal role in shaping the future medicos. Charka samhita lays down that teacher should be one "whose doubts have been all cleared in respect of medical scriptures-possessed of experience-clever in the practice of his profession. Conversant with nature-his knowledge of medical science supplemented with a knowledge of other branches of study -without malice-of a peaceful disposition-capable of bearing privation and pain-well affected towards disciples and prone to teach them-capable of communicating his ideas etc."[2] The professional temperament of the doctor with capability for clinical training/educational tutelage is as follows:

Every doctor who is appointed to afford clinical or educational supervision for a doctor in training, or who undertakes to provide clinical training and supervision for medical students, should demonstrate resolution to our professional guidance in Good Medical Practice. This will encompass:

· presuming a high standard of professional and personal values in relation to patients and their care

· being available and accessible to patients

· maintaining a high standard of clinical competence

· an ability to communicate effectively

· a assurance to personal, and professional, development as a doctor

· a assurance to professional audit and peer review

· a assurance to team working in a multi-professional environment

· An understanding of the multi-cultural society in which medicine is practiced.

· an enthusiasm for his/her specialty

· a personal assurance to teaching and learning

· impressionability and responsiveness to the educational needs of students and junior doctors

· the capacity to promote development of the required professional attitudes and values

· an understanding of the principles of education as applied to medicine

· an understanding of research method

· practical teaching skills

· a willingness to develop both as a doctor and as a teacher

· a commitment to audit and peer review of his/her teaching

· the ability to use formative assessment for the benefit of the student/trainee

· The ability to carry out formal appraisal of medical student progress/the performance of the trainee as a practicing doctor.

# The exigency to impart faculty members

Selecting the ‘right’ trainer may not be always possible but improving them by periodic training program is feasible. An ‘effective’ teacher will be one who is ‘competent’ (has knowledge and skill) and is a ‘performer’ (can use knowledge and skill in a classroom) to complete ‘teacher goal’. MCI formulated its recommendations in 1981 and declared that the recommendations were oriented towards training students to undertake the responsibilities of a physician of first contact. But while depicting the situation analysis, draft ‘Medical Education Policy’ in 1993 laments that ‘Advancements in medical education both in quantity and quality have not resulted in parallel achievements in the field of health care’.[3] To bridge this gap, Medical Council of India (MCI) outlined need based curriculum. The steps to be taken were (1) Clear delineation of goals and objectives of education (2) Adjustment in the course structure (4) Updating course content (5) Rationalizing assessment strategy and (6) Emphasis on structured and skill oriented internship.[4] The President, MCI while concluding his foreword to the document embodying the revised curriculum adopted by the council rightly mentioned that ‘This curriculum can only be successfully implemented through appropriately oriented and properly equipped teachers’. This felt needs prompted the Medical Council of India to recommend setting up of Medical Education Unit in all medical colleges in 1981 (curriculum of graduates) and 1992 (Need Based Revised Curriculum for graduates).[5] The Parliamentary Committee on Subordinate Legislation has also strongly recommended that MCI should make it compulsory for all medical colleges to prescribe for a minimum number of lectures to be imparted using audio-visual techniques in substitution of conventional lectures by teachers/professors in classrooms.[6]

# Management of Medical Students

When a medical student becomes a member of a health care team or is in a rotation where he or she is expected to participate in the delivery of health care, the supervisor and/or most responsible physician must provide appropriate supervision. This includes:

1. Assessing the medical student's level of expertise through direct observation, and ensuring ongoing evaluation to determine the medical student's clinical competence and educational requirements;

2. Authorization that the medical student to whom they are delegating has the appropriate knowledge, skills and judgment to perform the delegated act such that the patient is not put in jeopardy

3. Rendezvous regularly with the medical student to discuss his or her assessment, management and documentation of patient care.

4. Guided by the principles of level responsibility, students may carry out controlled acts, under direct or remote supervision, depending on their level of competence.

5. Criticism and countersigning documentation by a medical student of a patient's history, physical examination, and diagnosis, within a fixed time period, as well as progress notes.

6. Catchword all orders concerning investigation or treatment of a patient, written under the supervision or direction of a physician. Prescriptions, telephone or other transmitted orders of a physician may be transcribed by the medical student, but must be countersigned at a later date.

Since the benefits of the research are not always certain and may not be experienced by the participants, you must be satisfied that the research is not contrary to their interests. In particular:

· Medical college must be compensated that, in therapeutic research, the foreseeable risks will not outweigh the potential benefits to the patients. The development of treatments and furthering of knowledge should never take precedence over the patients' best interests

· In non-therapeutic research, you must keep the foreseeable risks to participants as low as possible. In addition the potential benefits from the development of treatments and furthering of knowledge must far outweigh any such risks

· Before instituting any research you must ensure that ethical approval has been obtained from a properly constituted and relevant research ethics committee - such committees abide by the guidance for local and multi-center research ethics committees, the university sector, the pharmaceutical industry, or elsewhere.

· Researcher must conduct research in an ethical manner and one that accords with best practice

· Researcher must ensure that patients or volunteers understand that they are being asked to participate in research and that the results are not predictable

· Researcher must report evidence of financial or scientific fraud or other contravention of this guidance to an appropriate person or authority, including where appropriate the GMC or other statutory regulatory body.

The process of becoming a doctor and a member of the medical profession is a social one. Professional socialization requires a medical curriculum, which would include training in communication skill, medical ethics, health economics, and consumer right besides clinical skills and subject knowledge.[9] The Medical Education Units should pay attention to the development of this collateral curriculum. It should plan a curriculum for ‘Tomorrow’s Doctors’ where ‘core and options’ curricula are exemplified. Communication, patient autonomy and doctor -patient relationship must underpin the whole educational process.[10] In one of the SEARO publication (1998) Dr. Myatu had mentioned that ‘if doctors are to remain relevant to the changing needs of the society they have to shape their roles with in the context of total human development’.[11] For M-E-T to gel there is a need to include an educationist and human resource development manager as a part of the team.[12]

# Proposition for improvement of Medical Education

1. Pedagogues Development: Professors need to be trained in framing objectives, selecting appropriate teaching learning methods and media, and proper evaluation methodologies. To improve the quality of teaching, staff development programs should be incorporated.
2. Medical Edification: This could be in the form of investigation driven system in various aspects of medical education.[7]
3. Continuing Medical Education: Technological elevation and knowledge explosion are advancing at a jet pace. To keep up with the latest, the medical methodologist must be updating their knowledge at regular intervals. The need for quality care is being sought after by the society. Gone are the days of ‘quantity’ care.

4. Policy Outgrowth: This should be a joint venture between teachers and policy makers. It should be based on economics, infrastructure and requirement of the country.
5. System of Evaluation: Uniform revision in the system of assessment needs to be done correlating with the objectives laid down.[8]
6. Communication Padlock: With other institutions both in India and abroad

7. Instructional Arrangement: Medical Education Technology Unit should take up the responsibility of providing guidelines to modify curriculum and implement the changes effectively. Today, in the world of knowledge explosion, emphasis should be on the processes for retrieval of information and its appropriate use. One need to use criterion-referenced evaluation is needed to find out whether the graduate is competent to serve the society needs. Teachers should be taught to evaluate objectively, reliably and without loosing the insight for relevance.

At cessation, we would like to say that the technological progression and knowledge explosion in medical science and pedagogy has necessitated the need for training medical teachers. For a teacher to be conversant with the latest trends he has to keep upgrading himself at frequent intervals and continue a lifelong sage.
"Men are men before they are lawyers, physicians or manufacturers, and if you make them capable and sensible man, they will make themselves capable lawyers and physicians".

# References

[1] Dahanukar S, Thatte U. Historical Survey of the Evolution of Ayurveda In: Ayurveda Revisited, Popular Prakashan, 1989, PP 10-27.

[2] Chaudhuri B R. Neglected Priorities in Medical Education, Paper Presented at the National Conference on Training Teachers Today for Tomorrow’s Needs, Diamond Jubilee Celebration of Medical Council of India, Indore, MP, 1994.

[3] Chaudhuri B R. Neglected Priorities in Medical Education, Paper Presented at the National Conference on Training Teachers Today for Tomorrow’s Needs, Diamond Jubilee Celebration of Medical Council of India, Indore, MP, 1994.

[4] Kacker S S K, Adkoli BV Need Based Undergraduate Curriculum, Indian J Pediatr 1993; 60:751-7

[5] Medical Council of India, Recommendations of National Workshop on ‘Need Based Curriculum for Undergraduate Medical Education’ 1992.

[6] Medical Council of India, Circular No MCI-34 (1)/96-MEU/ 29968 dated 2/1/97.

[7] The Consortium of Medical Institutions; Deliberations made at the National Workshop held at CMC, Vellore, Feb. 1994.

[8] Mehta M, Adkoli BV, Nayar U. Attitudes and Skills of Doctors, In: The Art of Teaching Medical Students, MET Cell, Seth GSMC And KEM Hospital, 1996, PP 61-70.

[9] Bhuiyan PS. Do We Need To Change! The Indian Practitioner, 2000; 53(9): 584-585.

[10] Jolly B, Rees L. Medical Education into the Next Century, In: Medical Education in the Millennium, Oxford University Press, 1998, PP 246-256.

[11] Sharma S. Training Teachers Today for Tomorrow’s Needs, Paper Presented at the National Conference on Training Teachers Today for Tomorrow’s Needs, Diamond Jubilee Celebration of Medical Council of India, Indore, MP, 1994.

[12] Joglekar SS, Bhuiyan PS. Role of MET Cell, Medical Education Technology Cell Bulletin, Seth GSMC And KEMH, 1998, PP 6.