|Year : 2020 | Volume
| Issue : 2 | Page : 117-120
Undergraduate medical education in India
Muthu Krishna Mani
Professor Emeritus of Nephrology, Apollo Hospital, Chennai, Tamil Nadu, India
|Date of Submission||09-Sep-2020|
|Date of Decision||10-Sep-2020|
|Date of Acceptance||11-Sep-2020|
|Date of Web Publication||15-Dec-2020|
Dr. Muthu Krishna Mani
Professor Emeritus of Nephrology, Apollo Hospital, Chennai, Tamil Nadu
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Mani MK. Undergraduate medical education in India. J Med Evid 2020;1:117-20
The purpose of undergraduate medical education should be to produce a competent general practitioner. I mean nothing derogatory by this term. A general practitioner is not an inferior doctor. He should be an expert in treating all diseases that are commonly found in this country. A specialist may know more about a smaller part of the body, but is in no way superior to the general practitioner who handles many diseases and the entire body.
When someone falls seriously ill, he or she seeks the best doctor available. No one selects a doctor on the basis of religion or community, or because he is the son or nephew of some powerful politician. It is the responsibility of the authority running medical education to provide that best doctor to every patient in the country. Entrants to a medical college should be selected on merit. Injustice that has been done to any group of people in the past should be remedied at an earlier stage of education, and everyone should be brought up to the level of the best so that he or she can compete on equal terms with all the other aspirants for a seat in the medical college.
Given the vast diversity of systems of schooling in the country, I believe the National Eligibility cum Entrance Test (NEET) is the best system we have of selecting the person most likely to make a good doctor. I am conscious of one great lacuna in this test. The greatest genius may not be a suitable candidate to become a doctor if she or he lacks empathy for suffering humanity. There have been two recent incidents of medical selection going horrendously wrong. Two medical students in Chennai threw a puppy from the second floor of a building and filmed it falling. Fortunately it survived, though with a broken leg, and some humane persons rescued it and had it treated. A monkey was brutally assaulted by a group of medical students in Vellore, its limbs broken, its intestines perforated by a rod inserted into the anus. Fortunately, the animal died without lingering on for days of agony. How can these people be trusted to serve patients? Even if these are extreme examples, how can we account for ragging of junior students in medical colleges being more brutal than in any other institutions? The impersonal NEET cannot identify and weed out these monsters. I am not aware of any system that can pick them out on a large scale, and have no solution to offer to my own poser. I do feel strongly that any student who displays such inhumanity, either to animals or to other students, should be dismissed from the college immediately. No other punishment would suffice.
The Government and the educational authorities who devised NEET and thereby select the students best qualified to make good doctors, do not seem to give the same weightage while selecting the best teachers for them. Today, teachers are usually selected on the basis of having passed an examination and then having been in service for an adequate number of years. Some weightage may be given for the quality of research papers published, but a great research scholar is not necessarily a good communicator. The Professor in a medical college should be expert in his subject, and should have clinical acumen, an enquiring mind so that he can push the boundaries of medical knowledge, a great deal of human kindness, and the ability to communicate all this to his students and inspire them to be truly great doctors. He should adhere to medical ethics in every aspect. He should be an exemplar and not just a preceptor. There is no objective test for all this, but the students and the colleagues of such a great teacher recognise him. It is sad that there is no weightage given to this factor in the appointment of teachers.
In my ideal medical college, having selected the best of teachers and provided them the best of students to teach, how should medical education be organised? When I was a student, the anatomy examination was much more difficult than Physiology, and correspondingly we devoted more time to that subject. Today, I try to recollect my knowledge of Anatomy. I remember so little of the thousands of facts I could once rattle off. Obviously they have been of no use to me in my profession, as were most of the intricate particulars of the working of muscles and nerves we studied in Physiology. I remember hours spent in coaxing a frog muscle to respond as it ought to an electrical stimulus, thereby moving a lever to mark a characteristic curve on a piece of smoked paper wound on a slowly revolving drum, and the discovery that a flick of the human finger could produce the perfect tracing. We poor overburdened students could have been saved hours of agony had we been taught Anatomy by the surgeons who use that knowledge, and Physiology by the physicians. They would have seen that we learned what we needed to know. The specialist anatomists and physiologists who taught us, and who continue to teach the students of today, know too much and are enthusiastic to see that their pupils become little masters of the science. They are needed to teach postgraduate students in their fields, and to conduct research, but undergraduate medical students should be protected from them.
We were similarly overburdened with details of culture media to grow bacteria, and of drugs that are hardly ever used. We had a brilliant Professor of Pharmacology, Dr. Iswariah. He said, “There are only three subjects in Medicine: Physiology, the science of the body in health, Pathology, the science of the body in disease, and Pharmacology, the bridge between the two. If you know Pharmacology, he said, you will convert Pathology into Physiology, but if you do not, he warned, you will convert Physiology into Pathology.” I am a firm believer in this aphorism. Sadly for us, he retired after his introductory lectures, and his replacement dictated, and insisted that we take down, details of all kinds of obsolete drugs that belonged in history. Basic sciences should be taught by the clinicians who handle the diseases we actually treat. I have found that most of my students have no idea of any of these subjects and I teach them all they need to know. That clearly indicates that their time in the basic science departments was wasted.
Sincere medical students of today have a great advantage over me and my contemporaries. Just about all they need to know is available on the internet, and it can be accessed in the comfort of their rooms without having to run from library to library hunting for references. Our basic medical degree, the MBBS, should qualify us to be good general practitioners. That means we should know how to treat the common conditions that are found in abundance in the outpatient clinics and the wards of the teaching hospitals, and to recognise patients that need to be referred to a specialist. When I was a teacher of medicine in the medical colleges of Madras (now Chennai), I used to take the first six patients waiting on the bench of the outpatient department, and give them to students to make a diagnosis in 10 min and plan treatment. In the wards, I began from bed No. 1 on the 1st day, and moved from bed to bed irrespective of the diagnosis. In a 3 months' posting with me, the students would see all the common conditions that came to the medical wards and outpatient clinics of the hospital, and learn to identify the signs of diseases that needed to be sent to a specialist. Since the students were asked to briefly see each of these patients every day till the patient was discharged, it also enabled them to learn the treatment used, the response to the treatment, and the side effects, if any. Teaching should include the social and financial problems the patient and the family would face, and the ethical issues that arise. If the disease is chronic and incurable, how can we best help the patient to manage problems at home and at work, and keep the disease from progressing?
The students recognised that this was the best way to learn what would be useful to them in practice. Unfortunately, their examiners did not. The student's primary aim is to pass the examination and get his/her degree so that he/she can get on with his/her life. He/she will study what he/she is likely to be asked in the examination. It is a great tragedy of medical education in India that, 73 years after we were able to get rid of the British, we remain slaves to the system of education and examination they established in our universities. Meanwhile, they have changed the examination system completely, and moulded it into a far more efficient test of what candidates should know. Our examiners stick to the old system, and demand patients with valvular or congenital heart disease, or complex neurological and respiratory conditions. I am told by more recent graduates that there has been no progress in the MBBS clinical examination even today. I spent 2 years in general practice after my MBBS career with a creditable performance in the examination. I had no idea of how to approach a patient with chronic diarrhoea, nutritional deficiencies, anaemia, even simple viral infections, and I had to learn all this at the expense of my patients. In those 2 years, I saw three patients of the type I saw in my final MBBS examination, and I sent all of them to the hospital. Ultimately, the student wants to pass the examination and enter practice, and will prepare accordingly. As a teacher, I taught them what would equip them to be good general practitioners, but they spent their time learning about diseases they would not treat unless they specialised in some branch of medicine, and roamed the hospital trying to see those patients. People are failed in examinations for missing or misinterpreting cardiac murmurs, but even cardiologists today will not make a diagnosis of mitral stenosis without an echocardiogram, at the least. There is no justice in our world.
What use should we make of the lecture theatres in our ideal college? I would assume the students will avidly seek medical knowledge, not come passively to the college and expect to be spoon fed. I would start clinical teaching from the 3rd month, after the briefest of introductions to anatomy and physiology. I have already indicated the use that should be made of the outpatient clinics and the medical and surgical wards, to teach students about the common diseases we see in the general medical, general surgical, dermatology, ENT and dental departments of a general hospital. Let me use an example from nephrology, since specialisation has led to my knowing precious little of other branches of medicine, though I do not yet know as much as I should of my own speciality. Acute glomerulonephritis is a common condition and any doctor should know how to handle this disease. I would expect my students to come prepared to the lecture hall, not to sit passively and sleep through a lecture. I would mark out the parts I want them to read in advance in the anatomy and physiology books, the structure and function of the glomerulus. I would expect them to read the pathology of the disease from the appropriate text book, and they should read the chapter on the disease in the text book of medicine. Acute post-infectious glomerulonephritis normally does not require any drugs except sometimes anti-hypertensives. I would mark out some anti-hypertensives for them to read about before they come to the class. In the lecture theatre, I would first ask what doubts the students have after having read all this material. They would have seen at least one patient with the disease in the wards or the outpatient clinic. Dietary control and management of fluid and electrolytes are essential. After solving the doubts the students raise, I would add some questions to make sure they would be able to handle a patient. If 1 h does not suffice, we extended the time to the next class. I wanted every student to express dissent if he or she disagreed with whatever was said by the one to whom the question was addressed. The average Indian student is reluctant to express an opinion. The philosophy seems to be, 'Better to remain silent and be thought a fool than to open your mouth and prove it.' I assured them that they really had everything to gain and nothing to lose since I started with the impression that each one of them knew nothing. If they made a mistake, it only confirmed what I thought earlier. On the other hand, if they gave me a correct answer my opinion of them soared. The class should consist of a free exchange of ideas.
Ideally, therefore, medical education should be integrated among all disciplines, with some flexibility to move between the wards and the lecture theatres. May be students should spend 6 months at a stretch with one teacher and then move on to another. There should be a loose curriculum that should be covered during the entire course.
You will see that in my ideal medical college, most teaching would be in the form of tutorials. Is there no scope for a lecture? Certainly, there is no point in the teacher repeating in his lecture what is found in that chapter of the textbook. If a teacher has made a particular study of some topic and has knowledge of the disease as seen in our population which might be much more than what the textbook has to say, or if the topic is rather difficult to grasp, a lecture might be called for. If the teacher's experience differs significantly from that of the author of that chapter in the book, he should certainly bring that out either as comments during a tutorial, or, if it would require more time, as a lecture.
That leads me to my next expectation from my teacher. How would he find that his treatment is better than that of the author of the text book? The outlier always sticks in our minds. When one has hundreds of students, the teacher remembers the best and the worst. The bulk of the students are not memorable, and do not remain in our memory. But clearly, it is the majority to whom we should devote our attention. All of us remember the patient on whom we made a brilliant diagnosis, the one given up for lost by most doctors, who came to us as a last resort, and we cured him against the odds. We tell everyone about this patient. We never forget him. We also remember the patient who walked into the hospital, in whom, we went horribly wrong, and sent the patient home in a body bag. We never mention him to anyone, but the memory haunts us. However, neither of these is really important. The ones who really matter are the ones in between, the bulk of the patients, and we need to know what happens to them.
What I am driving at is that we need to document all our patients adequately, and at some period, may be once a year, we should review our experience of each of the common diseases, and see how we have done. If our outcomes are better than those described in the literature, why What are we doing better than the authors we have read? If we are not doing as well as the books, why Where are we going wrong, and how can we improve our outcomes? Both are points worth teaching.
Any good medical college hospital in India has patients in large numbers, though we may not be as well equipped to investigate them as some hospitals in the developed countries. However, the numbers give us a great opportunity to study the disease in great detail, to know the natural history, to influence its course with drugs or dietary manipulations. When I was a student in the Madras Medical College I always wondered that my teachers referred to books by English authors to teach us about typhoid when we had an entire ward, called Mary ward, that was always full of sufferers from this disease. They should have been the world's leading authorities on typhoid. At least, we have studied tuberculosis well and many Indians lead the world in handling this disease.
As students, we read textbooks of medicine edited by Conybeare or Davidson. A new edition of Price's textbook of medicine came out in 1956. Our final MBBS examination was in December 1957. The better students among us read Price and thought we knew all there was to know about medicine. A few days of internship were enough to bring us down to earth. In our undergraduate studies, we had no exposure to journals, and thought the textbook was the last word. It is very important that the undergraduate student should know that medicine is a constantly changing field, and that today's dogma can be completely disproved tomorrow. I was a student in the Intermediate course in Arts and Science (corresponding to the plus 2 level today) and suffered from a severe bout of infectious hepatitis. The Professor of Medicine kept me on salt free diet and an obnoxious preparation of amino acids, and insisted that I should be confined to the house for 4 months. Seven years later, I was a final year student under that same Professor and he let a youngster with the same disease be on a normal diet, and stay at rest only while the jaundice was severe. I reproached him about the torture he had inflicted on me. He apologised but excused himself saying medical ideas were always in flux, and had changed considerably in the interim. The new edition of any textbook has been in preparation for 3 years before it appears in print, and some parts of it are already out of date. Students should realise that medicine is a constantly changing field, that we never know all there is to know about any disease. They should read journals such as the British Medical Journal and the Journal of the Association of Physicians of India regularly to have this fact impressed on them. They should be introduced to PubMed and the world of knowledge it opens to us.
Obviously, a doctor should be a good communicator. His patients should be able to understand his instructions clearly. We hardly pay any attention to this in the medical college, and I believe that while making students discuss clinical problems we should pay some attention to the clarity of their language, and how they should address the patients and their families. Some reading of the humanities should be encouraged, to help us to face the stress of tackling disease, and to enable us better to empathise with our patients.
'Education is not the filling of a pail, but the lighting of a fire'. These words are generally attributed to WB Yeats, but some people dispute this and say he merely rephrased a thought someone else had expressed earlier. I am not competent to adjudicate on this matter. No matter who said it, the words should inspire every teacher of medicine to strive to make himself or herself a truly great exemplar.
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