NEED  BASED  MEDICAL  EDUCATION

Prof  B M Hegde

This is an attempt to look at our present day medical education from within, after nearly four decades of, I hope, fecund involvement. This is my attempt to think aloud and share my anguish with the reader.  Modern medical education in India goes back to the year 1857, when the East India Company started three medical colleges in Madras, Bombay, and Calcutta. The initial syllabus was brought from the London University. It has, of course, changed a bit here and there, but there has never been an attempt to really do some introspection for nearly one-century and a half.

There has never been an attempt to see if our hoary past, with its wonderful medical knowledge, could, at least, be amalgamated with the western thoughts brought from outside, with benefit to the suffering humanity. Most of us inside the system have a holier-than-thou attitude towards anything Indian that has not been certified to be scientific by the West. I think time has come now to think of all that, as the West itself is looking to the East for inspiration in this field with the top heavy, hi-tech western medicine having become prohibitively expensive. Sizeable percentage of the populace there are opting out of the system for various reasons, not the least is cost in a fee-for-service system.  The London Royal College of Physicians, recently brought out a manual, following a symposium on The Science of Alternative Medicine, highlighting the positive aspects of the latter and also bringing out a lot of good scientific material in them.  It is time now for us to take a fresh look.

Be that as it may, we should also look to see if the present system of teaching and learning are relevant to the scenario obtaining in the world today. There are many questions to be asked and then answered in this area and I shall attempt to do just that. I shall leave the reader to draw his/her own conclusions.

What is wrong with the present system?

On the surface everything looks good. Many would want to know that if it was good enough for us why not continue it for the next generation. How good is good? Modern hi-tech medicine, sold all over as very scientific has a very shaky foundation. “For all its breathtaking progress, modern medicine, like the tower of Pisa, is slightly off balance,” was the feeling of the outside world, very well represented by Prince Charles, the heir to the British throne, in one of the meetings recently. David Eddy, a former associate professor of cardiovascular surgery at the Stanford, after very extensive research, wrote that 85% of what doctors do is based on very soft data, while only 15% is based on hard unequivocal data. That much for its scientific validity.

The recent UNIDO report showed that about 80% of the world’s population today does not have the benefit of modern medicine. Many studies have very clearly shown that the most important risk factor for all diseases, from common cold to cancer, is poverty. Poverty and ignorance begin to have their ill effects on the future man right from the first trimester of pregnancy inside his mother’s womb and bothers him chasing him to the tomb! Studies in the West have shown that whereas the diseases are in plenty in the far-flung villages, surplus of doctors are in the cities and metropolises. This inverse-care law, propounded by a family doctor, Tudor Edward Hart, working in a Welsh mining village, speaks volumes about what happens in the third world countries.

The art of medicine, that which makes the patient’s day, is not being taught enough in the medical schools. Even when passing remarks are made by some teachers about the art of medicine, most of it gets drowned in the sea of awe-inspiring technology. There is a lot we could do in this field, as shown very well by an Oxford professor, David Weatherall, in his book The Science of Medicine and its Quiet Art, and by Shervin B. Nuland, Stanford professor of clinical surgery, in his book Wisdom of the Body. The art of listening, which many times gives the doctor a clue to the diagnosis and management, is forgotten these days in our teaching. Most young men and women in the medical schools feel that it is a waste of time to listen to patients. This has been proved wrong by a very scientific study by a group of professors of medicine in England published in the BMJ. Professor Calnan’s book Talking with Patients brings out the anguish of a thinking teacher at the Hammersmith hospital, London.

Too much of technology and teaching subtleties to undergraduates was shown to be counter- productive in a study by three generations of teachers in the department of cardiology at the St. Andrews University, Dundee.

Our replicative evaluation system is another curse for proper learning. The student gets lost in memorizing data for the sake of the examination and thus loses sight of the woods while counting the trees.  At the end of the day, what with all the memorizing, the new doctor is not capable of coherently communicating with the sick and their near and dear ones. Bereavement is an integral part of a doctor’s life! Very little input is given in this direction to students to cope with it. Memorizing the subject has another dangerous consequence in that the student just before the examination, and if he passes the examination for ever after, deludes himself with the idea that he knows everything that is to be known. This feeling of “knowing” is suicidal in this field. One should aim at making the student realize genuinely that he does not know! That is where curiosity starts and wisdom begins. Our present system breeds paternalism in medical care, whereas partnership should be the better word in dealing with patients.

I hope, by now, I have been able to convert, at least, a few of the readers to think that there may be room for improvement in this field where, earlier, there was no need to have a re-look at medical education. Another very important reason why medical education has become irrelevant to the present day needs is the craze for trying to do good to the apparently healthy in society in the name of health screening and predicting the unpredictable. Both these have been highlighted by the BMJ recently. Whereas screening is a very good business proposition for the hospitals and equipment and drug manufacturers, it may not do much good (may even be dangerous) to the population! The reasons are not far to seek.

Predicting the future of any organism in this dynamic universe needs the knowledge of the total initial state of the organism, which is impossible today since we have no clue about the genotype of man and his consciousness! In addition, the linear thinking that if one were to change the initial states from abnormal to normal there is no guarantee that this change holds good as time evolves. Time evolution in a dynamic system does not follow this rule. Long term studies have shown the futility of this kind of exercise. Doctors have been predicting the unpredictable was the judgement of a physicist, professor Firth, in his enlightening article in the BMJ in 1991. The same is again highlighted in a good book Who Has Seen a Blood Sugar, by an American professor and diabetologist, Frank Davidoff. Most students do not have an idea of the type of science that is being used in medicine!

What could be done to rectify this?

This could be discussed under three heads, viz. Changes in the content, methods, and evaluation in the medical school to make medical education relevant to the societal needs.

Content and Methodology : -

The syllabus is already overburdened. It can not and should not be expanded; instead it could be profitably cut short, without affecting the quality-nay even enhancing the quality of education. Problem-based learning, where the student and the tutor are both curious to learn, would be a better method. More time should be given to the students to think for themselves, in place of all the didactic teaching of facts. Facts keep changing everyday, what with the new information pouring in at a phenomenal pace of seven per cent per month. The correct method of obtaining the data from many sources today is to be taught in place of teaching facts.

The student should be provided with all the opportunities to learn for himself, like a delivering mother who needs care, compassion, love, empathy, and assistance, but the delivering has to be done by the mother herself. Similarly the student should be given all the above but, the learning has to be done by him. A good teacher, who shows by his example, that learning is not an easy process and that it is a never ending process, would be the ideal example to motivate the student. Longer and prolonged contact between the teacher and the taught, as was done in our ancient gurukula system, would be more beneficial.

Didactic lectures could be cut to the bare minimum. Even those should be more of a deliberation on a topic rather than custom-made time bound lecture. The attendance in those lectures must be purely optional to make them more effective. Studies have shown that an unprepared mind absorbs less than five per cent of what is told in a lecture class. That could come down still further if the student has a hostile attitude!

Clinical clerkships must take more of the student’s time. There again the ritualistic bedside clinics should give place to collective effort between the teacher and the taught to arrive at the diagnosis and management strategies for every patient under their charge. Then and then only does the student realize the most important lesson in medicine that diagnoses and management are basically full of uncertainty. The only certainty in medicine is uncertainty. The gray zone in medicine is expanding every day and the student should be aware of that as much as the teacher.

Medical education should be a collective effort at learning between the two parties, the teacher and the taught. The conventional teaching by humiliation should give place to learning with pleasure with a footing of equality. On the bedside the student learns by observing the teacher, in all its ramifications, viz. manners, ready wit, compassion, understanding, human dignity, patient leeway, frustrations, anxieties, and what have you. This would give the student the courage to keep learning. The process could be assisted by the thought in the student’s mind that even his teacher, under certain special circumstances, lacks total knowledge! To know that the emperor also could be without his robes is a very good stimulus to learn.

Specialists Vs Generalists:

There was a craze for specialization in the West for more than two decades now. There were so many specialties and subspecialties that they have now realized the bad effects of these both on the recipient, the patient, and also on the system. This kind of fragmentation is doomed to fail as per the 1^st Law of Thermodynamics!  In anything new the Americans lead the way, basically based on the business interest in any field. Medical specialties grew directly proportionate to the growth of technology. The result is that technology has become top heavy and the hospitals have become prohibitively expensive even for the middle class Americans. The trend is reversing now with Universities looking to go back to their old ways.

The University of Minneapolis has started the system of having three major specialties in clinical medicine: general surgery, general medicine and midwifery. They have appointed Professors of general medicine and surgery who oversee the diagnoses and management of most, if not all outpatients. Only when there is a definite indication for any type of intervention does the patient get referred to the particular specialist. Similar trend is coming to the UK also. There are demands for decreasing the cardiac specialty centres even there.

Of course, we Indians believe in the dictum that we have to make the mistakes ourselves before we learn from them. We are wise enough not to learn from other’s mistakes. We are where Americans were twenty years ago, starting more and more specialties and corporate hospitals. We would be committing the same mistakes in future. The UK had even earlier a special system where the specialist also had sufficient training in his major branch that he could manage all patients at the first contact.

A large country like ours where more than 80% of our patients are spread over the 5,75,000 odd villages, we would have to, per force, have more generalists. In addition, our present day medical training for a graduate is not conducive to send him to a village to manage alone. He would be a fish out of water there, as the ground realities in the community incidence of illnesses is not represented in the teaching hospitals. This is one of the main reasons why doctors do not want to go to the village. New doctors are not comfortable with their clinical abilities sans the hi-tech that they are used to in their medical school hospitals. If every headache patient in the village has to be CAT scanned, the country would go down the drain! But the new graduate would not be comfortable unless he ruled out a very rare small malignant lesion in the brain in a rare patient with headache.

The same holds good for all other patients. Our graduates are good for working as junior doctors in larger corporate hospitals to order all the tests for every one who comes there for the boss to review when he arrives. Left alone in a village he would be helpless. We need to reorient our training to meet this dire need in our villages.

Evaluation:-

This is the real pain in the neck for both teachers and students alike. I know of no foolproof method of evaluation. The present system that we follow, which has been followed since the beginning of medical education in India is far from satisfactory. Even though the best is yet to be thought off we could try and make it more effective.

The end of term, one time examination should be replaced by continuous on the job evaluation. This could be split into teacher evaluation and peer evaluation. The latter could bring out the weaknesses and strengths of a candidate much more candidly. The teacher evaluation should be a long drawn observation in place of the short, anxiety generating, incomplete assessment. The debate about the type of theory examination is a never-ending one. The West went into the multiple choice objective theory tests, only to go back now to the time-tested essay type examination. However, both of them test the memory power of the examinee and not his total ability. In their place a novel creative type of theory examination could be held. The student is posed a real life problem and is given enough time to write a critical answer on the lines of his future work outside. He could consult books if he wants in the examination hall. The question must be such that the student would not be able to copy the whole answer from any book!

No one could be expected to keep all the information in his head these days of explosive knowledge in every field. Even in day-today work one will have to consult medical literature when in doubt. The student must be adept at consulting these sources and, if he is found to be good enough, he should be let loose on the gullible public. Parrot repeating a textbook would not stand him in good stead in real life situations. A critical appraisal of the problem should be able to give the candidate the capacity to learn the communication skills also in later life.

Practical and clinical examinations should mimic the real life situation. They should aim to assess the candidate’s ability to listen to his patient, his compassion and human understanding, his knowledge of the clinical methods of eliciting the signs of disease, his interpersonal relations, his ability to get on with colleagues, his temperament as a doctor, and his mastery of the diagnostic skills and management strategies. To test his ability to communicate could be assessed by asking him to write a discharge letter to the patient’s family physician about the patient’s clinical status.

Viva-Voce examination is an opportunity to check the student’s thinking capacity, instead of once again assessing his memory recall. This could be utilized to find out what kind of a doctor he would make in real life, his interest in furthering his skills and knowledge, his capacity to look at the same thing from different angles and also to fathom his reasoning power.

Examiners should have a check on them. All the markings should be in the close-marking method, where each part of the examination (short and long case etc.) should be marked out of ten. Five out of ten or four and six are okay; but if the mark is below 4 out of ten or more than six out of ten the examiner should give in writing the reasons for that particular mark. The positive and negative aspects of the student’s abilities should be noted down for the future guidance of the candidate should he fail to make the grade. The examiners’ performance should be computerized to assess them as examiners. Erring people should be blacklisted and their names sent to all the examining bodies with valid explanations. They could be reassessed after the lapse of a particular number of years!

Beyond the Four Walls of the Class Room :-

Doctoring needs more skills than all that is written above. There are important areas not covered by the conventional teaching methods. One area that needs wider knowledge of human affairs is the capacity of the doctor to handle the only certain thing in life, that is death. One of the questions asked is “why” did a patient get a particular disease or why did he die? These two questions could never be answered in biology. One needs to know a bit of teleology and also philosophy. Positive sciences answer the question “how” or “how much”, but not the question “why.” One needs special skills of compassion and understanding to manage bereavement and separation.

The bane of modern medicine today is its cost. Every doctor must have an exposure to pharmaco-economics. It is one thing to read a book and write the medicine or order an operation, but the crux of the matter is if the recipient is able to afford that and if not what are the alternatives. Many doctors today simply follow the rule of the thumb that they have studied in the medical school and leave it at that. That leaves the much-harried patient in a worse state. One has to have knowledge of the alternatives available and their scientific validity. Patients have more extensive knowledge of the alternative systems of medicine today than the doctors do. One should be aware of their role in disease control.

The mind of man is known to be the most important part of the whole gamut of health and disease and the modern doctor should be able to unravel the depths of human mind, with a reasonable knowledge of human psychology, local customs, taboo, fears, anxieties and even superstitious beliefs. An assessment of the patient’s surroundings, his worries, his anxieties, his near and dear ones, and his social ties would all have to be taken care of in some special situations.

The medical course being long and arduous one could not squeeze all these into the curriculum, but they need be taught all the same and the students should be exposed to these situations during their tenure in the medical school. Special guest lectures, workshops, and also group discussions could be encouraged.

Knowledge advances by refuting false dogmas. Genuine research demands that doctors keep an open mind on all aspects of their learning and try and get the dogmas demolished to the extent possible. This requires the capacity to keep meticulous records of all our dealings with patients sincerely and honestly. Documentation should be taught to students from day one in their routine work as well. Research is not repeating others’ work in your laboratory. Clinical medical research is “having a question on the bedside and trying to go as far away from the bed as one could to get an answer.”

In this context the new doctor should be trained in the methods of collecting data from the medical literature. The latter could be compared to a jungle full of dead wood. There are occasional rose wood and teak inside, but a novice who gets in there without proper guidance may not reach the rose wood, and might even be bitten by a snake or eaten by a tiger. Medical technology and the drug industry would want to twist the research data to suit their business interests and the reader of the medical literature should be trained to pick the wheat from the chaff. This is an ongoing process and one has to keep on learning daily!

In short, medical education is an education for life. The right kind of education would bring out the best in every doctor who becomes patient friendly and would be able to most good to most people most of the time. He is ideally one who knows not but, knows he knows not. May his tribe increase!

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