IS THE PRESENT MEDICAL EDUCATION RELEVANT TO INDIA’S NEEDS?

Medical education in India has undergone very little change since its inception in 1857 by the East India Company in the three medical colleges in Madras, Bombay and, Calcutta those days. Much water has flowed under the Hoogly Bridge since then and we have seen sea changes in all walks of life but medical education, in essence, has not changed a wee bit. The reasons are not far to seek. We are still slaves of the western thought. Just as in the west, especially in America, medical education is in the hands of the powerful drug and technology barons, we follow on their footsteps. The medical claptrap makes us believe that there is no better method to teach students and make them good doctors. In the bargain our new doctors do get a reasonably good western type of education within the four walls of the medical college hospitals where only 0.01 per cent of the filtered sicknesses are seen by the students. Student teaching is mainly based on hi-tech gadget based investigative methods of diagnosis and management. This is far removed from the realities in India, nay anywhere else in the world.



Today a newly qualified MBBS doctor is incapable of practising medicine in a village all by himself/herself. This is due to their paucity of understanding minor illness syndromes in the community and their total dependence on hi-tech gadgets for diagnosis that are lacking in a village! A conscientious young doctor would feel frustrated and would feel guilty of missing important clues due to the lack of infrastructural inadequacy. He would either become depressed or leave the place or would use his political clout to get transferred to a teaching hospital either for a junior job or a postgraduate training course. This makes medical education today totally irrelevant to our basic needs.



Are hi-tech gadgets an integral part of diagnosis?



Many studies in the west, and a recent one in London, a very good one at that, have shown that the best gadget to make a diagnosis is a well trained doctor. “If you listen to your patient long enough he/she would tell you what is wrong with him/her.” wrote Lord Platt, a great British clinician of the last century. Recently five of his old students, who now man the top rung of British medicine, showed, in their elegant study, that carefully listening to the patient, without even touching him/her, would give eighty per cent accuracy in the final diagnosis and one hundred per cent accuracy of the future management strategies.



For a developing country like India these studies have an important message. We must change our medical education to train basic doctors that are capable of practicing medicine out with the hi-tech, self defeating systems, of diagnosis and management. A small per cent of patients would need that kind of medicine to get better. That could easily be done in a few hi-tech centres specially reserved for this kind of patients where we could have specialists and sub-specialists. The number of such patients is very small indeed and not more than ten per cent at any given time. Ninety per cent of the patients would do well without hi-tech. The highest technology that is needed for universal patient care is the kind words of a good doctor that stimulate the patient’s immune system. It is the immune system that heals and not the drug or the surgery that the doctor performs. A humane doctor has a placebo effect on the patient’s immune system. The future medical training must be such that the young doctor feels confident to make accurate diagnosis and arrive at management protocols based on his bedside skills alone. Only when such skills fall short of the expectations, and then only, should the doctor refer such patients for further investigations to the special centres set up for such procedures.



What is wrong with the present system?



Many of my generation of teachers feel that all is well with the system and there is no need to change and they also feel that it is the best because it is being done in the west and also that we are products of the same system. This kind of status quoist attitude has killed innovation in medical education in India all these years. We have this ostrich like attitude because we do not seem to look beyond our nose tip and are not prepared to put our nose to the grinding stone to support our ideas. Knowledge advances not by repeating known facts but by refuting false dogmas. History is replete with instances where courageous thinkers have changed the direction of mankind’s progress on this planet. Time has come to ponder over what we do or do not do for our patients in the present modern medical hi-tech technology based system. Let us look at some of the audits in the field.



Cancer is not defeated despite our claim that we have better understanding of the disease. AIDS deaths are on the rise. Death due to true cardiogenic shock has not come down from its ninety-five percent mark even with all the hi-tech that we seem to use these days. Interventions, even after major trauma, in the context of the recent wars in Vietnam and Falklands, seem to do more harm than good. Per capita deaths in Vietnam, where the Americans had a five-star hi-tech hospital in Saigon where the wounded could reach within minutes, were twice as many as in Falklands where the British wounded soldiers, at times, had to be left in the snow for as long as twelve to twenty-four hours without any assistance! Doctors striking work recently in Israel, years ago in Los Angeles county and Saskatchewan in Canada, has had a good effect on society. In fact, death rate fell down during the strike period only to go back to the original levels after doctors came back to work. Screening apparently healthy people is another pathetic story. It could be very dangerous to human health and happiness. We do not have a correct definition of normality in the present day medical methods based on linear mathematics used in a dynamic system like the human body.



All is not well with the present system. Most, if not all, drugs used on long term basis in chronic degenerative diseases have resulted in more people suffering and dying compared to those helped by the drugs. There has never been a proper study done on drug combinations in science. While studies were done on single drug in ideal laboratory conditions, in reality, multiple drugs are used for patient care in anything but ideal situations. Patient compliance is so poor that one wonders if patients are alive because they do not take drugs in doses that are prescribed by doctors! There is confusion all over. To cap it modern hi-tech medicine has become prohibitively expensive even for the rich nations. Poorer nations can not even think of giving universal medical cover using hi-tech medicine to their masses.



What should be the bija mantra of medical education?



Doctor is trained to look after the health of the public. Doctors are not trained only to intervene with quick fix methods when the human machinery fails, although the latter is very important for the individual concerned at that point in time. Time and energy spent to keep the public health would lessen the need for expensive quick fixes in the long run. In addition, the quick fix methods do not have long term good effects. Most of them might do more harm than good in reality. Our medical education does not stress on public health. The new name, community medicine, excludes hospital medicine. Public health is an all encompassing word and is a very good word for doctors to know and have as their life’s motto. In India all that we need to do are the following low tech methods to lessen our large disease burden.

* Clean drinking water for every citizen.

* Three clean and nutritious meals uncontaminated by human and/or animal excreta.

* Cooking smoke free houses in the villages to avoid cancer and heart attack deaths in women and pneumonic deaths in children below the age of five years.

* A damp proof house to avoid bacterial infections.

* Toilets for every house and even for the slums to avoid the rampant hookworm infestation in our population making them lose their blood to the crafty hookworms.

* Economic empowerment and education of women to improve infant and maternal mortality.

* Judicious use of Vaccination universally.



If we bother to attend to the above needs of health care, the need for expensive medical care, using quick fix methods, would diminish remarkably. Our doctors do not have anything to do with any of the above mentioned needs of the common man. How could they be the guardians of human health and wellness?



Who is a well man/woman?



In the hi-tech modern medical jargon the only well man/woman is the one who has not had the total body scanning done. If one goes through the present gadgetry to have a check up (routine screening) every one of us (one hundred per cent of us) would have to be declared abnormal. Improvement in human well being has been brought on, even in the west, by the change of mode of living, better food, greater awareness of the need to regularly exercise to keep oneself fit, better living standards and better education. Very small part was played by the hi-tech gadgetry in this game of human health and wellbeing. This fact has been time and again learnt from studies in the west, especially America. We are waiting to commit all the mistakes that the west had to commit in the last half a century to learn our lessons. We are still in the business of aping the west, a good two decades behind them, in their progress in the arena. Time has come to change our medical education and supplement the western knowledge with Indian wisdom of yore in Ayurveda and other systems of medical care to do most good to most people most of the time.



Conclusions: What should be the future Indian medical education like?



We need a cadre of basic doctors to man our family medicine facilities in towns as well as in our far flung villages. We also need a small number of specialists and sub-specialists to man our hi-tech set ups. Of course, there will be the private five-star medical care delivery systems in place for a very long time to come. The corporate world has already tasted blood. The drug and technology lobbies would not want to loosen their grip on this milch cow that is yielding them good returns without the hassles of raw material and labour problems. They are aiming at big money in medicine and people are already talking about billion dollar business in Medicare. It would be a sad day for the common man, though.



However, our country’s needs are to be met first by training basic doctors who would be at home to practice clinical medicine on the bedside with scientific accuracy. The whole course of study, from day one, should be patient centred and community based. Class room teaching should be minimum and an occasional didactic lecture could clarify some theoretical points. The basic problem based learning by the students and teachers together in groups should go on for the 156 weeks of the three years; each week for a new human problem vis-à-vis health and illness. The curriculum should be drawn to stress on our common illnesses and also on the minor illness syndromes. All the basic sciences are taught along side all through the three years. The grading system of evaluation with semester credits should be the foundation of evaluation. Keen bedside observation and trying to unravel some of the clinical mysteries should form the basis of clinical research in medicine. Repetitive research of the western type is of no use. Refutative research to demolish many myths in medicine is the need of the hour.



This should be followed by two years of internship, one year of which should be following the footsteps of a successful practitioner in the community. He could be an LIM, LMP, GCIM or any other regular system of Medicare. The student should live and work with the practitioner. The last year could be a rotation in the teaching hospital set up. For the exceptionally brilliant students there should be provision for postgraduate training after a gap of three to five years of family medicine. The PG training could last between three and seven years depending on the subspecialty chosen. These could manage the hi-tech set ups in future. Care should be taken to see that the basic doctor is not financially inferior to the sub-specialist. This is one of the reasons why our young doctors despise family medicine. The house keeping details could be worked out after a national debate.

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