The Precarious State of Indian Medical Education
Part II: How did medical education change after 2019? Did it?
“50 years ago, brilliant doctors compensated for unsophisticated technology.
Today, brilliant technology compensates for unsophisticated doctors.”
Many veterans in medicine have an overt distaste for undergraduate students, they don’t spare an opportunity to tell us that we’re going to become subpar doctors, incapable of thriving without modern investigations. Older examiners are a nightmare in viva exams, they will ask the quirkiest questions and rip you off any self confidence that you’ve managed to muster before the exams; there’s no pleasing them. Old timers love to reminisce about the glorious past, the grit and the greatness of the men in their time; perhaps the memories of simpler times are comforting.
Medicine has become dramatically more competitive in the last few decades. Undergrad students have to stick their heads in books and coaching modules to crack entrance exams, instead of spending more time in the wards, like the professors would want them to. The attention span of this generation is comically tiny; combine this with somnolent college lectures and you have an entire class that can doze off any moment. Naturally, it has created friction between students and teachers, tarnishing the sacred mentor-mentee relationship. Students are under too much pressure to perform well in exams which fail to replicate the real-life clinical scenario, while professors have adapted to an uninterested lot and stopped going out of their way to teach like their mentors did; it is a sad state of affairs. In this post we’ll look at some attempts, half-baked and confusing but nevertheless, good attempts, to restore the sanctity of medical education.
In 2019, after years of negligence, the Indian state decided to overcompensate for its absence like an estranged parent. They not only opened new medical colleges and increased the number of seats but also realized that something needs to be done to produce more competent doctors.
Simple problems demand simple solutions. They must’ve thought, “If we need competent doctors, what better than to introduce a Competency Based Medical Education (CBME) curriculum.” CBME is an outcome-based teaching method, where students learn competencies and gain early clinical exposure to improve their skills. It is a more holistic teaching program designed to equip medical students with the skillset and knowledge they’d need to be at par with international medical graduates. CBME was a well-intentioned idea, but something was amiss about the way it was implemented. The flurry of changes was introduced without conducting prior teacher training programs, which did not allow professors to acquaint themselves with the larger idea of the policy. A list of competencies was handed down and interpreting it was left to the teachers’ discretion. Yes, the National Medical Council (NMC) does say that CBME is an outcome-based curriculum and does not outline specific teaching strategies but what incentives would professors have to adapt these ‘competencies’ into their teaching repertoires? There is neither incentive nor accountability, only intrinsic motivation. And when something banks on the intrinsic motivation of government employees, it warrants skepticism.
To their credit, many first-year professors attempted rather well to deliver more clinically integrated lectures. Small group discussions were held to foster rapport building, some lecturers added clinical vignettes to their 19th century presentations and there was some emphasis on application-based learning. The lazy ones did not bat an eye, but it gave the better teachers an opportunity to shake things up. They also introduced something called a ‘Foundation Course’, where no lectures are held for the first few weeks of college, it’s all about mingling and orientation. Group activities stressing on intermingling of local and outstation students, ice breaking and AETCOM (Attitude, Ethics, and Communication) were enthusiastically conducted. AETCOM is the poster child of CBME, it was added to the syllabus in the light of frequent instances of violence against doctors. We were taught medical ethics, empathy, delivering bad news, the role of a doctor in society and the likes. I think it’s very wise of them to address the supply side of the issue at least and create a sense of responsibility among future doctors, but tomorrow when I’m worn down by a 36-hour shift, sleep deprived and functioning on primal instincts, are these AETCOM lessons going to come back to me and make me want to be nicer to my patients? Is that humanly possible? Nevertheless, it was a step in the right direction. The new curriculum was definitely better than the traditional teaching schedule in some ways, but the big picture dissipated very soon. Every professor in every nook and cranny of the country was not able to envisage what the guys at NMC wanted. As we got promoted, things started going back to the way they were.
When a program is outcome based, results have to be evaluated to see if it’s working. Following a change in the curriculum, a new university exam pattern was devised. We would have to answer long form, clinically oriented questions worth more marks than the previous batches (200 vs 80). They also introduced the Objective Structured Clinical Exam (OSCE) (like how they do it in the UK) and a more comprehensive practical assessment. Owing to the new exam pattern, irrespective of whether we were taught more in college or not, we have had to study a lot more than our seniors to pass these exams; thus, receding to the library instead of ward rooms, which is one of the things that professors detest the most anyway.
I can rant all I want but studies have shown that CBME has changed things for the better. Research has shown that the 2019 batch exhibited an overall reduced anxiety than the 2018 batch. Failure rates are significantly lower and perception of the environment among students is good. These are small scale studies, vulnerable to biases and confounding factors and only time will tell if there are any deeper implications. Largely, the effectiveness and permeability of CBME is debatable. It is exemplary of the discrepancy between what is envisioned at the top and what trickled down.
In my 3rd year of MBBS I’d applied for the ICMR student research grant. It is a government initiative to encourage research among medical students and foster critical thinking and problem solving. To make the grant more appealing, they raised the stipend from 20K to 50K the same year. After a lot of hassle and a few hiccups, my protocol got selected (it was a very random process, more like a lottery). Once the protocol was through, I was supposed to navigate the impossible business of getting an ethics approval for my study. The ineptness of the Indian bureaucracy deserves a separate post but after cursing the department every day for a month I finally got the approval (they made us write CDs and I spent an awful lot of time finding a system with a CD drive but never mind). We conducted the research and submitted the report to ICMR which got approved and after waiting for about 6 months, I got my stipend and a certificate. What surprised me was that when I applied to the ICMR journal to get the article published, they rejected it multiple times saying that it is not suitable. I was confused; why select a research study, approve the report and then shun it on the grounds of merit. The government did try to solve the huge research crisis in the country by throwing some money at it, but they failed miserably. The only thing it achieved was to make broke students like me happy. Instead, if professors are research oriented, getting an ethics approval isn’t so damn difficult and the culture in schools and colleges isn't so “let's just get it over with”, students need not be enticed by money to do student level research. When critical thinking and scientific application are the last things that cram schools want kids to learn, we cannot create an environment where people take up research just because they want to answer questions.
Talking about the quality of resources, no Indian textbook is known to be a “standard textbook” (except perhaps K.D. Tripathi for Pharmacology); textbooks published by Indian authors are meant to pass university exams and are full of discrepancies and controversial information. In fact, NEET-PG (the entrance exam for admissions to MD/MS courses) itself is a regressive exam; it is obsolete and irrelevant on the global stage. The US and the UK conduct the United States Medical Licensing Examination (USMLE) and Professional and Linguistic Assessments Board (PLAB) examination respectively for licensing doctors to practice medicine; each consisting of a MCQ paper followed by a clinical skills assessment. Residency programs gauge candidates based on their exam scores and interviews. We in India neither have a licensing exam nor interviews for admissions to post graduate courses. Of course, the United States has its own share of problems in terms of financial liabilities, and it isn’t necessarily the best model, but it does encourage undergrads to build a more dynamic approach to learning. Having prepared for both USMLE step 1 and NEET-PG, I for one can vouch that the former made me fall in love with medicine and the latter made me fall out of love. The preparatory resources that are available for the USMLE are considerably more innovative and engaging than those available for NEET-PG. In India, we’re still hung up on the chalk and board model of teaching where rote learning is upheld, while critical thinking and application are overtly compromised. This is symptomatic of the deeper lack of innovation in the Indian Education System. Not only is the exam poorly thought-out and subject to paper leaks but also the counselling process is confusing and heavily dependent on chance. A paper published in 2023 outlines the various fault lines in the counselling process of NEET-PG (anyone who wants to understand the process more deeply should definitely check this out).
Perhaps even the policy makers felt the palpable gap between Indian and International standards, which led them to reconsider the status quo and bring about some serious amendments. It was decided that NEET-PG is obsolete and needs to be scrapped. To replace it, the National Eligibility cum Exit Test (NEXT) was devised, which resembled the USMLE on paper. NEXT would be conducted for the first time in 2024, for the batch of 2019. It was one of the boldest steps taken by the government to reform medical education in a very long time; I was impressed. However, we were informed only 8 months in advance that we will be the first batch to appear for the new entrance. Unlike NEET-PG, it would be held right after final year and failing the exam would mean you’ll not be eligible for internship. It created widespread panic. The instructions were vague and half baked, dates weren’t clear, implications of taking a gap year weren’t mentioned and every clause was questionable. It was the definition of a hare-brained policy. We quit studying for university exams and started solving MCQs from day one. Every day, a new revelation made things harder to grasp and we didn’t know what to expect. Finally, a few months later NMC held an online conference to address the issue. In an hour-long meeting, they broke things down for us and made the idea a tad more palatable. We had no choice but to go back and study; resistance wasn’t going to change anything. But some petitions were signed, and meetings were held in the course of the next few weeks to pressure the authorities into reconsidering the exam. Some strings were pulled, politics was played and one day, just like that, NEXT was cancelled. The exam would now be held from 2028 onwards for the latest batch. It was hilarious. It reminded me of the mad capricious king Tughlaq of the Delhi sultanate who moved the capital from Delhi to Daulatabad on a whim and then back to Delhi again when things didn’t work out, killing many of his troops in the process.