For better medical facilities there is an urgent need to train more teachers and improve doctor-patient ratio in teaching institutes, says Dr Rajeev Sudan
Medicine is one of the most challenging, yet so fulfilling a profession. The early inspiration for most doctors comes from either the family or interaction with a pleasant mannered, warm hearted paediatrician. Some of course get inspired by rich fruits of hard labour. They start preparing for the entrance exams as early as tenth standard and few thousand manage to get through the barrier, to a medical school. The medical college for the most comes as a shocker. The basic subjects of anatomy, physiology and biochemistry seem so disinteresting, taught by a demotivated faculty, low on creativity and inspiration, at least in most colleges in India. The same happens later in clinical subjects. The conditions are worst in most private medical colleges. They not only lack good faculty but a good hospital infrastructure as well. Most of them are located in relatively remote areas and do not attract many indoor patients. Many of them employ ghost faculty, to be showcased during medical council inspections only. The bedside teaching and clinical skills, the bedrock of medical practice is left to senior resident or junior faculty. In absence of adequate indoor patients and lack of good clinical teachers, the skillset of graduates passing out of these colleges is anybody’s guess..
There has been a rapid expansion of medical education infrastructure in last decade, more so in the private sector. The Government is planning to upgrade district hospitals to teaching medical colleges in many states, increasing the number of graduation seats. Similarly, many AIIMS- like tertiary centres have been started with eye at training both graduates and post graduates.
The issues of facilities and infrastructure though linger on. The most serious issues facing medical education in India is lack of teaching faculty. A parliamentary panel report on six new AIIMS has indicated a vast shortage faculty . About 48 per cent of faculty pots are lying vacant and some of them don’t have a single teacher in super speciality services like neonatology, surgical gastroenterology and trauma management. The non-faculty positions are understaffed as well, 60 per cent of the sanctioned non faculty posts are vacant. The doctors have to work under huge stress because of skewed doctor patient ratio, affecting both the clinical services as well as medical education. These institutions are created for an excellence in patient care, teaching and research. If they are in such a condition, the plight of state medical colleges is anybody’s guess!
Since the expansion of corporate hospitals, most of the talented doctors opt for financially lucrative private sector or leave the country. The medical colleges especially the private ones don’t get the best talent for teaching. Most of them employ retired medical faculty for heading departments and are most often have a notional presence. The medical faculty in clinical departments in Government medical colleges are overburdened with patients and also have busy parallel private practice to manage.
Since time for them is a constraint, teaching suffers in the end. The traditional clinical skills of history taking and thorough clinical examinations is taking a back seat. There is more emphasis on diagnostic investigations. The graduates are tested more for their rote skills in examinations than clinical acumen. The one year internship is mostly used for preparing for post graduate exam, than learning art of conversation with patients or honing clinical skills. Most of them join postgraduate courses or state services, hyposkilled. The training in post-graduation is no different, barring a handful of institutions. The clinical learning in medicine is by apprenticeship. The young ones learn when the old cock crows.
When the old cock has come up the heirarchy on considerations other than teaching skill, the skill transfer to students get compromised Unfortunately, political patronisation of medical teachers is playing havoc like in all other fields. Eventually, a generation of specialist and primary physicians enters medical services without requisite skills, heavily dependent on clinical investigations for diagnosis and management of patients, driving up the cost of medical services.
Medicine is not only a science but a skill and philosophy as well. The art of medicine is the history taking, a thorough physical examination and ordering minimal relevant test for confirmation of diagnosis. Prescribing plethora of tests without a diagnosis is antithesis of art of medicine. The practice patterns must suit the socio-economic conditions of the country and must not be aped form the costly models of the West. Unfortunately, the so called latest technology is being increasingly adopted to boost earnings. The optional is being pushed as necessary. The case in point is a marketing of Femto cataract as vastly superior technology. The technology has its few advantages in a few steps of surgery but is driving up the costs to two and half times, compared to safe and tested phacoemulsification. I do not want to sound like a Luddite but a thorough cost benefit analysis is to made before adopting a technology, profiteering can not be the sole motive!
The low clinical skills of doctors and over reliance on investigations come handy for corporate hospitals. Most corporate hospitals and nursing homes employ doctors on “fee sharing basis” or on “percentage on earning”. This fuels unnecessary investigations and needless surgeries. The economic benefits seem to justify and incentivise poor clinical skills. Eventually, the doctors with good skills also tend to adopt such dubious practices. The ethical practice in medicine is also a learnt trait, learned from the honest and hard working teachers. The ethical code gets passively transferred to a student.
The general fall in ethics in a material driven world has affected everyone including the medical faculty, adversely affecting the ethical fibre of students.
There is an increasing trend of in-house pharmacies in hospitals and clinics. It provides ease to the patient in having all facilities under one roof, saves time and ensure quality of medicine. Unfortunately, it raises issues of ethics and propriety. The prescription behavior can get influenced, with profiteering as motive for prescribing unnecessary and costlier medicines, without understanding the impropriety of the act.
The medical profession needs a serious introspection about training and skilling. There is an urgent need to train more teachers, improve doctor-patient ratio in teaching institutions, allow lateral entry for the talented ones and improve the remuneration and housing of teaching faculty. The motivation to teach and quest for excellence should be the only criterion for selection. Political patronisation in selection of medical faculty must stop. The “deadwood” amongst teaching faculty, the ones playing politics and vitiating the whole learning environment must be removed. An internal audit is urgently needed. The young residents with knack for “skill transfer” must be groomed and mentored as future teachers. The future of a quality medical healthcare delivery of India lies in their hands.
In the absence of good teachers, expanding the medical graduation seats can be counter-productive. The quality of services will get severely compromised if the doctors lack clinical skills and their over dependence on diagnostic tests will escalate the health costs. No country can afford an extravagant health care system. An exit test or a licensing exam for doctors both theoretical and a practical clinical assessment is a good idea to maintain an uniformity in teaching and minimal requisite clinical skills.