How to improve medical education in India

Soumyadeep Bhaumik, a doctor, says he is shocked at the levels of "knowledge and practice of clinical ethics among healthcare providers in a government hospital, Chennai" as published in the Indian Journal of Medical Ethics Time flies fast at times and drags on at other times. Well, for me Time seems to drag on when it comes to introducing crucial reforms in education, especially medical, and it has already been a year since I shared my concern, obviously with little result, on issues like the urgent need for implementing a uniform, transparent and merit-based admission procedure in both government and private medical colleges . The same problems and anxiety which dogged aspirants last year have surfaced this year too with similar short cuts for instant relief .When I read that the "Supreme Court clears decks for admission to medical colleges", it brings a sigh but not one of relief as it only shows that we are just skirting the problems instead of solving them. In such situations, can medical ethics, clinical research and concern for patients ever be given their due? Being an optimist, I feel that good times are ahead and knowing all these areas where we need to improve will surely make us implement better changes shortly. Regarding the sorry state of medical ethics, in his recent post, a review of Indian Medical papers, Soumyadeep Bhaumik, a doctor and independent medical researcher from Kolkata, and a freelancer for various national and international medical journals, says he is shocked at the levels of "knowledge and practice of clinical ethics among healthcare providers in a government hospital, Chennai" as published in the 'Indian Journal of Medical Ethics.' It revealed that "30% of the responders did not give a definition of healthcare ethics, and 40% did not name a single ethical principle while alarmingly, "25 out of 51 physicians stated that they did not have time to listen to their patients." He adds that 25 out of 51 physician responders also did not respond to the part of the questionnaire that asked them to name the principles of the Hippocratic Oath. I wonder if the proposed introduction of medical ethics in the medical curriculum would bring any change so long as the motives for pursuing the profession are purely mercenary, the doors for admission are open not on merit but financial concerns and pressure to fulfill parents' dreams rather than genuine interest in the line. If research in all fields is bypassed for immediate monetary gains and career prospects, our doctors' commitment to research seems to be always on the back burner, what with the government's indifference to promoting it, shortage of qualified doctors, and lack of adequate motivation, facilities and recognition for any genuine work done. So, though we do not lack intelligence, we do not make pioneering strides which deserve international recognition. Mumbai has more MRI machines than there are in the whole of the United Kingdom but significant breakthroughs in radiological research are seen exclusively in the United Kingdom, and not in Mumbai. If we also keep aside at least some MRI machines exclusively for research purposes and not for commercial ends, can't we contribute to research? This brings me to another angle from which we can consider promoting research, skills and ethics. Will an undergraduate degree as a pre-requisite to medical courses help in enhancing the desired skills? The literature on this topic is extensive with recent and on-going international debate. Adopting and adapting healthy or successful measures from the global scenario saves a lot of experimentation and I would like to present here the American experience in this area. In the early 1900s, the American medical education community followed the recommendations of Abraham Flexner to raise the standards of entry into medical schools, to standardize a rigorous medical curriculum and to engrain the scientific nature of medicine by uniting clinical teaching with scientific research and it required an undergraduate degree prior to entry into medical schools. With due acknowledgement to the young doctor, Abhijeet Gummadavelli from the U.S , who has keenly studied the advantages as well as drawbacks of having an undergraduate degree for medical education, I put forth here, in his own words, some of his 'evidence-driven' findings for our policymakers to consider. "The systemic application of the scientific method in pre-clinical and clinical training as a consequence of Flexner's recommendation may be strength of graduate-entry medical programs. In combination with other requirements, most American medical schools demand at least a year of coursework and laboratory training in undergraduate-level biology, chemistry, physics, calculus, English/literature and often a semester of biochemistry. The robust foundations afforded by university-level basic scientific knowledge are necessary for the application of research methods during medical training. This is not limited to performing medical research but also for interpreting the plethora of biomedical research and translating it to clinical practice. The answers to clinical questions are found not only in textbooks but also in journal articles. Improvements in patient care are so rapidly and constantly updated that almost every textbook is outdated by the time it is published. It is a reasonable expectation that a well-trained physician will have the skills of self-directed study to seek and find that information." Further, "Undergraduate education doubly serves to cultivate the humanist characteristics bred through a liberal education and independent living. These are years when a student may leave the comfort of home and begin to experience life as an independent person, matures his sense of personality and interacts with many different types of people from diverse backgrounds, and directs his study based on personal interest while meeting the practical demands of ordinary life. These are years when the qualities of compassion, empathy and conscientiousness can emerge through experience rather than didactics. Such are the very same qualities that are desired and expected in medical trainees and physicians alike which are also amongst the hardest to teach or learn. It is the experiences gained during the undergraduate years that lead to the maturity and means to handle gravid situations in patient care. The emotional intelligence to navigate the delicate psycho-social aspects of interaction with very sick people and the conscious desire to be in that role needs the proper time and experience to bloom. "In Australia, New Zealand and the United Kingdom, undergraduate-and graduate-entry medical programs coexist. A UK study showed no difference in medical degree completion rates; however, graduate-entry students were significantly more likely to receive honors degrees (Calvert et al, 2009).Research has also considered the relative impacts of age, motivation, maturity and emotional differences. Medical program entrants that were graduates were found to be of widened socio-cultural diversity in the student body (James et al, 2008; Powis et al, 2004) with ostensibly more diverse life experiences and were motivated by professional independence and desire to prevent disease (Rolfe et al, 2004). Age strongly impacted motivation and career choice certainty while prior degree affected studying approaches and cooperativity (Wilkinson et al, 2004). Furthermore, graduate-entry students were less anxious with transition to medical education, explained by increased maturity and communication skills (Hayes et al, 2004)." Based on his experience which is backed by the evidence he has presented, Dr. Abhijeet Gummadavelli supports graduate-entry programs with the focus to train physicians with three characteristics: conscious and intrinsic motivation; foundations in clinical science and research interpretation; sense of emotional intelligence in patient care .Let us not overlook the benefits of such time-tested measures. Let us not rush to satisfy our public by adopting policies which are counterproductive in the long run. Let us search for an alternative to the shift from intensive coaching centers to the portals of medical study where the entrant has never had an opportunity for anything but rote learning to his credit while what is expected of him is beyond his experience. Let us create an environment which promotes world class physicians with knowledge, empathy and zeal to stretch the frontiers of health science.