INDIA: Major revamp of medical education sector

India's undergraduate medical education, or the MBBS degree, is to be revamped to cater more closely to the health needs of the country, produce more doctors and include clinical training at an earlier stage. With 330 medical colleges and an intake of 35,000 students annually, India's medical education sector is one of the largest in the world.

Despite this the current ratio of doctors to the population in India is just 0.7 doctors per 1,000 people compared to a world average of 1.5 doctors per 1,000.

This is exacerbated by the emigration of doctors, with almost 5% of the medical workforce migrating to richer countries, according to India's Planning Commission. It puts the number of Indian doctors in the US, Britain, Canada and Australia at around 60,000, with many more in the Middle East.

The Medical Council of India (MCI), the apex body overseeing medical education, released a reform document in January to improve the ratio to one doctor per 1,000 by 2031. To reach that target India needs to double the current intake of medical students, it said.

Although India's medical education is of high quality by international standards, many critics say it does not respond to the needs of society.

The MCI document highlighted the gap in health care provision for the poor and disadvantaged. It said medical graduates do not feel they have adequate training in primary health care, reflected in the lack doctors in rural areas and in primary health centres.

"While there is a need to expand quantitatively, we cannot forget qualitative improvements. While producing more doctors we need to keep in mind the health needs of the country and ensure that doctors are equipped to handle them," said Vinay Agarwal, President of the Indian Medical Association, the largest lobby group of Indian doctors.

At the same time, while hospitals have updated laboratory techniques, medical education in India has not kept pace with developments in medical technology.

"These changes are welcome. Over the years the MBBS course, set in tertiary care institutions which often deal with exotic and rare disorders, has not equipped students to deal with the health needs of local communities," said the medical faculty of the Christian Medical College, Vellore, in a discussion document on the proposals.

"The explosion in medical knowledge has resulted in the introduction of new specialties. But there has been a marked reduction in the time spent for training in each subject and for acquiring practical skills during internship. This pattern has made [medical students] less skilled and much less capable of managing basic conditions," they said.

The expert committee that drew up the MCI report recommended reducing undergraduate training from 4.5 years plus a year internship to four years and one year of internship.

"No one is suggesting that medical students be taught less. What the committee has proposed is doing away with a lot of redundant material in the curriculum and making it more relevant," said a committee member who did not want to be named.

"Moreover, the introduction of new teaching techniques such as simulation and skill labs and smart classrooms will not only save time, but also make learning more fun for students."

The committee also recommended clinical exposure from the first year of undergraduate medical education instead of at the end of the third year.

Under the proposed changes, each medical college would be linked to the local health system including community health centres and primary health care centres that can be used as training bases for medical students. The committee has also introduced a student clerkship, in which a medical student serves in a department as a clerk or sub-intern (below the level of intern).

"Certain areas such as early clinical exposure, clerkships and mandatory certification of skills before doctors can practice will go a long way in improving the quality of graduates. But other areas, like decreasing the course from 4.5 to four years, need broader discussion," said Agarwal of the Indian Medical Association.

One radical proposal that has caused controversy is doing away with examinations in the first three years in favour of continuous assessment, to move away from an overemphasis on rote learning. If implemented, students may have to take examinations only at the end of four years of undergraduate educations and another after the completion of a one-year internship.

"The reforms need to be widely debated before they are implemented. The suggestion to do away with examinations in the first three years should also be accompanied by alternative patterns of testing," said Dr Ravi Rananavare, dean of Nair Hospital in Mumbai.

While there is no timeframe for publication of the final revised curriculum, the MCI is currently consulting widely on the reform proposals.