The Pathophysiology Of Declining Medical Education In India

Picture this. You’re in school, preparing for the medical entrance examination. There are only a few colleges that are on everyone’s lips as places you must strive to get into – excellent education, great infrastructure, and the like. There you are, slogging it out to clinch the coveted seat, in the hope of becoming a ‘good doctor’ (and not just watching it on TV!). When I did get into one, little did I know that I would be met with quite the opposite, a deep look into the rotting heart of our medical education system. 

What is wrong with medical education in India?

Medical education depends very heavily on the ecosystem created by institutions, which in my opinion, is an aggregate of the contributions made by three stakeholders: the faculty, the students, and the college administration. Faltering of even one of them can destabilize this tripod, which further impacts the quality of education. What I am witnessing currently is a breakdown of all three pillars. 

When you think about it, the very first step of medical education - enrollment into a college - is flawed. How is one test administered over three hours on a single day of the year supposed to determine the capability of candidates? How is it a good test of attitude and personality? What we’re seeing is an influx of misguided students straight out of school who have no idea of the sheer hard work, kindness, empathy, and astuteness it takes to be a good clinician. Even while at college, very rarely have I seen students going beyond the pages of their textbooks - well, these days it is coaching notes - to acquire any soft skills. 

Platforms offering coaching for postgraduate medical entrance examinations (as if coaching for undergraduate entrances wasn’t enough!) are probably the only entities benefiting from this mess. Heavy reliance on their highly distilled notes has also destroyed the ability of most students to read standard, high-quality study material in any capacity. 

The culture of treating MBBS as a mere stepping stone for postgraduate specialization is rampant, and is already proving to be a roadblock in acquiring a solid foundation and vital clinical skills. Skipping clinical postings to watch coaching videos is quite normal, and the number of modules completed is now a matter of pride. 

Speaking of clinical postings brings me to inadequacies on the part of educators. The lack of initiative to teach the remaining students who did manage to undertake the journey to the clinics fosters dissatisfaction and disappointment, deterring them from going back and making them resort to coaching from the comfort of their rooms. Evidently, this is a vicious cycle. 

Not just this, it is commonplace to find a lecture theatre full of students, but without any teacher, because they either forgot or weren’t informed that they have a class. Even when the lecture is taken, the quality is often subpar and entails reading out a bunch of slides downloaded from SlideShare. Ambitious, well-made lecture and demonstration schedules don’t translate into reality, and practical demonstrations are frequently held haphazardly with disintegrating specimens, broken instruments, or maybe nothing at all. 

If not for compulsory attendance and the occasional good lecture, I doubt anybody would want to attend such classes. It also doesn’t help when the blame for the falling standards of education of the institution is then repeatedly pinned on the students and their laziness. 

‘Lazy’, however, is a word best reserved for the college administration. They sure do know how to keep everyone on their toes, making them volley back and forth between multiple offices to accomplish the simplest of tasks. Letters and documents get lost in the commotion, which makes me wonder why the push for digital India seems to have evaded medical colleges. The internal functioning of institutions is still stuck in the Stone Age. The idea of “if it ain’t broke, don’t fix it” is dangerously treading towards “if it ain’t collapsed, decimated, destroyed beyond recognition, don’t fix it”, exacerbated by a non-existent mechanism for redressal of complaints. 

The lack of college support for venturing beyond the mundane, and taking time to explore other fields, like taking up research opportunities, or acquiring work experience at other institutions, will produce an army of doctors with little to no exposure to the world outside of lecture halls of medical college. The stagnant academic and administrative atmosphere only breeds mediocrity, and mediocrity is protected and propagated by guaranteed pay and promotions regardless of quality. I suppose that is one of the charms of working in the government. 

While our colleges are marred by problems, I truly believe that they are victims and not the direct perpetrators. The ever-increasing number of MBBS seats, without proportional expansion of infrastructure, is adding to the pressure on colleges already strained by a lack of resources. Not only that, overcrowded colleges are unable to cater to the needs of students and faculty effectively. It becomes impossible to learn when a giant group of twenty is hovering over a single patient to take a history. 

Colleges have suffered under decades of poor and restrictive policies, hampering their autonomy, and forcing them to follow protocols that are nonsensical and obsolete, to say the least.

What is the treatment for this affliction? 

I believe that medical education truly needs to be reimagined - not just papering over the cracks. The dysfunction is too vast and too deeply rooted to be simply glossed over with half-hearted interventions. 

In an ideal world, the process of enrollment of students needs to change. The path towards securing admission in a medical college should involve a more holistic evaluation of the student, not relying solely on a rank, and making sure that aspirants are aware of what they are signing up for. 

Practically, one could start by creating an encouraging atmosphere for students once they are in college. While coaching may be considered essential to secure a good rank in the postgraduate entrance examinations, the heavy dependence on coaching material throughout MBBS, with little exposure to other resources for learning, is dangerous. 

Effective utilization of the time devoted to lectures and postings, with greater involvement of faculty in the teaching process, will prevent students from relying solely on coaching for their education, and will ensure that they acquire essential clinical skills. It will be a win-win situation for everyone - satisfied students, who believe that attending college is fruitful, and satisfied faculty, no longer troubled by the declining clinical acumen of students. 

Students need to be sensitized to the health requirements of communities by providing them exposure to field work, encouraging them to work with nurses, auxiliary health workers and community health care providers. They may also be encouraged to participate in sensitization programs run by numerous organisations working for the cause (like Yumetta foundation’s sensitization programs, Tribal Health Initiative’s Rural Sensitization Program, SEARCH’s Nirman program). The Family Adoption Program is a good move in this direction, but only on paper. The implementation of this program is abysmal which is further forcing students to lose interest. The idea is to move beyond statistics and paragraphs given in textbooks, and gain firsthand insights into the applications of medicine, to create well-rounded doctors. 

Additionally, it is the age of breaking down silos, and colleges need to provide flexibility to students who wish to pursue interests beyond medicine, to keep up with the times. It could be something as simple as provision of a channel for faster processing of paperwork to conduct research, or maybe even fostering a culture of interdisciplinarity by promoting collaborations, within and outside the college. 

Improving coordination and communication within colleges, by promoting a shift to digital platforms for ease of storage and dissemination of information will save the numerous days lost while letters and registers are in transit from one room to the other, and simplify administrative processes. For example, most colleges do not have digital attendance records, and attendance is tabulated manually at the end of the academic year, which can be a source of great anxiety for students. Arguably, the greatest benefit of digitization will be reaped by the administrative departments, which are currently drowning under piles of papers. Faster channels of communication can be utilised to hasten administrative work. The digital shift will undoubtedly improve the efficiency of students, faculty, and the administration.

It is imperative to ensure that educators stay abreast of the most effective and innovative methods of teaching, and they need to be held accountable for the education they impart. Frequent audits and training sessions could be a step in the right direction. At some point, the vicious cycle I mentioned earlier needs to be broken. It can only happen when both the educators and learners stop deflecting blame, and collectively realize that medical education is a two-way street - the faculty needs to take teaching seriously, and the students need to take their course seriously.

Edited by Parth Sharma.

Image by Janvi Bokoliya.