white paper on medical education by dr.DEVI SHETTY

Contents

Page No.

Executive Summary ……………….. 02

1. Preamble ……………….. 04
2. Current scenario ……………….. 05
3. Challenges faced ……………….. 06
4. Initiatives in the past by MCI ……………….. 08
5. Recommended actions ……………….. 09
6. Outcome and Benefits ……………….. 11

Executive Summary

Preventing and treating NON-COMMUNICABLE DISEASES(NCD) is going to be the greatest challenge in managing healthcare delivery in our nation. Unfortunately an MBBS doctor is just not trained or empowered to treat any of the NCDs.

An MBBS doctor is again not trained or empowered to treat any of the top ten causes of death in India other than diarrheal diseases.

An MBBS doctor cannot reduce the Maternal Mortality Rate (MMR). Approximately 15-20% of pregnancies end up requiring Caesarian section. Badly managing these pregnancies results in high MMR. For a successful childbirth with caesarian section we need a radiologist to perform ultrasound scan to predict complications during childbirth, an anesthesiologist to safely anesthetize the pregnant lady, a gynecologist to conduct the caesarian section and a pediatrician to resuscitate the baby. Any doctor with just an MBBS is not trained or empowered to do these tasks. Normal delivery is a physiological process that does not require any intervention by the doctor or the nurse. Only a doctor with post graduation degree can reduce MMR.

Due to lack of doctors with post-graduate training in tier 2 and tier 3 cities every ten minutes a young lady dies during childbirth, 3 lakh children die every year the day they are born.

For effective delivery of healthcare in USA, they created 19,000 UG seats and 32,000 PG seats. In India we have 47,688 UG seats and 14,500 PG seats in clinical subjects.

To address the disparity and improve delivery of healthcare especially for NCDs, MCI came up with major reforms in post-graduate training programme. Just by implementing the changes suggested by MCI, without diluting any standards of education and without bringing about any new regulatory changes, the number of post-graduate seats in clinical subjects can be increased from current 14,500 upto 38,500.

Ministry of Health and Family Welfare is only expected to monitor the implementation of suggestions by the MCI.

State and Central Government will control 100% of the total seats in postgraduate medical education in government colleges. 75% of the seats in private medical colleges in Karnataka and 60-75% of seats in private medical colleges of other states will be at government’s disposal to allot for meritorious students.

38,500 PG seats can be made available in both government and private medical colleges for the next academic year without incurring any extra expense by the government.

With increased number of PG seats available to the private medical colleges (25% of the total number of PG seats) the cost of education per doctor will come down significantly.

By increasing the number of post-graduation seats ‘brain drain’ will come down drastically, thereby increasing the availability of doctors to serve the underserved regions of India. Today there are 29,451 Indian doctors serving in UK and about 60,000 Indian doctors in USA, UK, Canada and Australia put together. These doctors moved abroad mainly due to lack of higher medical education opportunities in India. Their retention would have made a tremendous difference to healthcare in India.

By increasing the number PG seats, 2 lakh doctors who are currently spending time in coaching classes will be joining the mainstream of health care delivery by treating patients as Postgraduate students in one of the 381 Medical colleges.

1. Preamble

Listed below are the top ten causes of death in India:

1	Diseases of Heart	6	Tuberculosis
2	Diarrheal disease	7	Lower birth weight
3	Chronic lower respiratory diseases	8	Mental diseases leading to Suicide
4	Cerebro-vascular diseases (Stroke)	9	Liver diseases
5	Influenza and Pneumonia	10	Accidents

(Source: WHO Data)

An MBBS doctor is not trained and empowered to treat any of the top 10 causes of death other than diarrheal diseases.

The greatest challenge in delivering healthcare is going to be preventing and treating NCDs. 62% of the disease burdenin India are related to NCDs. A doctor with just an MBBS degree is not trained and empowered to treat any of the NCDs. Following are the major NCDs prevalent in India and the disease burden:

Cardio-vascular diseases	20%
Accidents and Injuries	20%
Neuro-psychiatric (mental health)	19%
Respiratory diseases	7%
Cancer	6%
Diabetes	2%
Stroke and other causes	26%

(Source: WHO – Global Burden of Diseases)

We are becoming the diabetic capital of the world. Uncontrolled diabetes leads to kidney failure, heart failure, stroke, gangrene of the foot and responsible for most of the premature deaths. USA trains more than 250 Endocrinologists to treat diabetes whereas India has 50 PG seats.

With the rapid spread of micro-health insurance, which is currently covering about 20% of the population,healthcare will reach over 50% of the population in the near future. India is short of nearly 2 million beds. We have 100 towns in India with a population of half a million to one million. Most of these towns do not have a hospital forsecondary and tertiary healthcare. Each district head quarter hospitals must be converted as secondary or tertiary level hospital. We need to train thousands of doctors as Anesthetists, Gynecologists, Pediatricians, Radiologists and Psychiatrists to offer at least secondary level care in Taluk level government hospitals.To create this massive infrastructure to deliver healthcare we need to train thousands of medical specialists.

2. Current Scenario

Under-graduate (UG) and Post-graduate (PG) seats in India and USA:

	India	USA
Under-graduate seats	47,688	19,000
Post-graduate seats	14,500 (in clinical subjects)	32,000

Select specialty training positions in India and USA:

	Discipline	India	USA
1	Cardiology	250	781
2	Diabetology / Endocrinology	50	251
3	Gastroenterology	93	433
4	Haematology	13	523
5	Nephrology	84	416
6	Neurology	159	592
7	Oncology	48	508

(Source: MCI, India and National Resident Match Program, USA)

Latest MCI update shows that there are 381 medical colleges in the country imparting medical education through MBBS degree to 47,688 students annually.The number of PG seats in clinical disciplines is only 14,500. These figures clearly point out the big gap existing between UG and PG seats. It is to be noted here that in the last NEET exam for PG admissions, the total number of applicants were about 90,000 and the available seats for disposal was 14,500 clinical seats.

Due to the acute shortage about 1 to 2 lakh doctors spend one year to five years attending coaching classes away from patients. This results in massive disruption of healthcare delivery across the country.

Brain drain with large number of doctors going overseas is directly related to lack of opportunity in higher medical education. Once a doctor migrates to first world countries for training, he/she is lost for good to serve our country.

Cost incurred by the government:

a.to train a doctor anywhere in India – Rs. 25 lakhs

b. to train a doctor at AIIMS, Delhi – Rs. 1.7 crores

(Source: Determination of the cost of training of MBBS student at AIIMS by Dr. Shakti Gupta, HoD, Dept. of Hospital Administration, AIIMS)

Percentage of AIIMS doctors from 1956-1997 batches who immigrated overseas – 53%

(Source: Media Study Group, New Delhi, Dec.2006)

3. Challenges faced

It is a fact that 70% of the population lives in rural areas and is deprived of specialized health care facilities. Secondary and tertiary healthcare have become a city-centred phenomenon. Unless the cities get super saturated with medical specialists, doctors with PG degrees will not consider serving the rural population. Similarly, there is a lot of regional disparity of specialized doctors. There are more neuro-surgeons in Chennai than whole of eastern India. The present rate of rise in the population demands similar rise in the super specialty services. The burden of managing these NCD services will be stupendous in the coming years. Our district / taluk level hospitals hardly have any facilities to treat NCD cases.

In its NCD Policy Brief – India, The World Bank Study published in Feb 2011 states “The NCD burden in India will significantly worsen in future; NCDs are more common among older population; it is estimated that the people with diabetes will increase from 40.9 million to 69.9 million by 2025; and obesity which is associated with hypertenison, CVD, diabetes and some cancers, will affect 52.1 million by 2030. CVD is expected to be the main cause of death (37%) by 2030. Finally, road traffic injuries are projected to cause 185,000 deaths and 3.6 million hospitalizations by 2015”

Potentially Productive Years of Life Lost (PPYLL) due to Cardio-vascular Diseases in the age group of 35-64 would be 17.9 million years by 2030. The national income lost due to premature deaths is estimated at US$ 237 million during 2005-15.

(Non communicable diseases: New Public Health Challenge – Prof K Srinath Reddy, President, Public Health Foundation of India; World Health Organisation)

The NCDs are costly in terms of both human suffering and economics. A study by David Bloom and Elizabeth Cafiero, both of Harvard School of Public Health (HSPH), in conjunction with the World Economic Forum, indicates that these diseases will cost India 126 trillion rupees (roughly 2.3 trillion U.S. dollars) from now through 2030 – an amount that is 1.5 times India’s annual aggregate income and almost 35 times India’s total annual health spending.

“Through a judicious blend of technological innovation to generate new knowledge, institutional innovation to promote the efficiency and equity of health provision and public finance, and increased funding to close knowledge-action gaps, India will be able to ameliorate the human and economic fury of NCDs,” wrote Bloom, Clarence James Gamble Professor of Economics and Demography, and Cafiero, research analyst in the Department of Global Health and Population, in a November 7, 2012 World Economic Forum blog. “One thing is clear: when it comes to NCDs, inaction is not an option.”

Unlike in western countries where medical graduation is devised to acquire a specialty aligning with healthcare delivery needs, our system does not assure academic progression and qualification to treat NCDs. The system of distribution of UG / PG seats – unless revised properly – will result in doctors remaining redundant and unemployed besides resulting in improper management of diseases.

Connecting the high maternal mortality rates to lack of healthcare accessibility, Hon’ble Union Minister for Health and Family Welfare, Mr. GhulamNabi Azad has said that it is important to end the shortage of medical and para-medical human resources in the country. “There are 28 million pregnancies every year, but we see 56,000 maternal deaths,” Mr.Azad said while inaugurating the 56th All India Congress of Obstetrics and Gynecology (AICOG) in January 2013.

A Media Study Group tracked 2,129 students who passed MBBS from AIIMS during 1956-1997. The study found that 53% of them to be working abroad. There are 29,451 doctors of Indian origin currently serving in UK.

(Source: List of Registered Medical Practitioners, General Medical Council, UK. Updated 5^th July 2013)

The Wall Street Journal in its April 25, 2012 edition has stated that there are an estimated 60,000 physicians from India working in the US, the UK, Canada and Australia. In total they account for 5% or more of medical professionals in the developed world.

Within the country too there is a lot of disparity in the availability of UG and PG seats.Delhi has 1111 PG seats against 950 UG seats(MCI website), which provides a valid case to replicate higher number of PG seats in other states.

4. Initiatives by MCI in the past

MCI with its prestigious project of Vision 2015 foresaw this problem of improper availability of UG and PG seats and amended the PG Medical Education Regulations vide Amendment dated 21.07.2009 with the avowed view of increasing the number of PG seats. Subsequently the regulations were amended in 2012 to replace “Medical Education Regulations 2011” clause 12(1)to read as:

“The ratio of recognized postgraduate teacher to the number of students to be admitted for the degree course where diploma is not prescribed shall be 1:2 for a Professor and 1:1 for other cadre covered by the general note following this rule in each unit per year subject to a maximum of 5 PG seats for the degree per unit per academic year provided a complement of 10 teaching beds is added to the prescribed bed strength of 30 for the unit for broad specialties.

Further in case of Anesthesiology, Forensic Medicine and Radiotherapy where the ratio of recognized postgraduate teacher to the number of students to be admitted for the degree course where diploma is not prescribed shall be 1:3 for a Professor and 1:1 for other cadre covered by the general note following this rule subject to a maximum of 6 PG seats for the degree per academic year.”

The MCI also amended the PG Medical Education (Amendment) Regulation 2012 in respect of some super speciality courses wherein the departments of Medical Oncology and Surgical Oncology have been given a special status by increasing teacher-student ratio as follows:

“The ratio of PG teacher to the number of studentsto be admitted for super specialties course shall be 1:2 for Professor / Associate Professor and 1:1 for remaining cadre covered by the general note following this rule in each unit per year subject to a maximum of 5 PG seats for the course per unit per academic year provided, the complement of 10 teaching beds per seat is added to the prescribed bed strength of 20 for the unit. Further in case of full fledged dedicated departments of medical oncology and surgical oncology the ratio of PG teacher to the number of students to be admitted shall be 1:3 for Professor, 1:2 for Associate Professor and 1:1 for remaining cadre covered by the general note following this rule in each unit per year subject to a maximum of 6 PG seats for the degree per unit per academic year provided a bed strength of 30 for the unit for super specialties.”

5. Recommended actions

“Minimum Standard Requirements for Medical Colleges for Annual UG admissions Regulations 1999” defines the MCI norms of number of beds and units for different departments against specific number of UG admissions:

Sl. No.	Departments	50 Intake		100 Intake		150 Intake		200 Intake		250 Intake
Sl. No.	Departments	Beds	Units	Beds	Units	Beds	Units	Beds	Units	Beds	Units
1	General Medicine	72	03	120	04	150	06	210	07	240	08
2	Paediatrics	24	02	60	02	90	03	120	04	120	04
3	TB & Respiratory diseases	08	01	20	01	30	01	30	01	50	02
4	Dermatology	08	01	10	01	15	01	15	01	30	01
5	Psychiatry	08	01	10	01	15	01	15	01	30	01
6	General Surgery	90	03	120	04	150	06	210	07	240	08
7	Orthopaedics	30	02	60	02	90	03	120	04	150	05
8	Ophthalmology	10	01	20	01	30	01	40	02	60	02
9	ENT	10	01	20	01	30	01	20	01	30	01
10	OBG	40	02	60	02	100	03	120	04	150	05
	Total	300	17	500	19	700	26	900	32	1100	37

Here is an illustration on how, by complying with the teacher-student ratio and PG seats per unitas per MCI guidelines the UG and PG seats can be equalized.

Anexample from a medical college with 150 UG admissions is enumerated below with the total number of clinical units available:

Departments	Units
General Medicine	6
TB and Chest	1
Dermatology, Venerology and Leprosy	1
Psychiatry	1
Pediatrics	3
General Surgery	6
Orthopedics	3
Otorhinolaryngology	1
Ophthalmology	1
OBG	3
Total	26

Going by the PG admission norms of MCI amended in 2012, if the new ratio of teacher-student is strictly enforced, the total number of PG seats for 26 units would be 130 (at 5 seats per unit including Diploma). To this, add 30 PG seats of non-unit departments like Radiology and Anesthesiology,the total number of PG seats available would be 160.

MCI data for August 2013 shows there are 268 medical colleges in the country as PG trainingcentres. Clinical specialty seats are 14,500 in number of which 65% seats are in government colleges. With implementation of 5 students per unit and adding non-unit department seats, the clinical specialty seats will go up to 38,390. Government colleges will continue to have the major share of 24,953 (65%) clinical seats.

6. Outcome and benefits

The outcome of implementation of this White Paper will be:

To remove the prevailing disparity between availability of UG and PG seats;
To provide opportunities to medical undergraduates to go for higher / specialized training in their chosen disciplines;
To remove the rural – urban disparity of medical facilities;
To make higher medical education affordable and attractive to aspirants, and;
To harmonize regional imbalances.

Government will control 100% of the total seats in postgraduate medical education in government colleges. 75% of total seats in private medical colleges in Karnataka state and 60 – 75% of total seats in private medical colleges in other states will be at the disposal of government to allot for meritorious students.

By just implementing the changes suggested by MCI, without diluting any standards of education and without bringing about any new regulatory changes, the number of post-graduate seats in clinical subjects can be increased from current 14,500 up to 38,500.

38,500 PG seats can be made available in both government and private medical colleges for the next academic year without government incurring any extra expense.

By doubling the number of Diplomate National Board (DNB) seats under National Board of Examinations (NBE) from 5,000 to 10,000 the availability of PG medical seats will increase significantly.

By increasing the number of post-graduation seats ‘brain drain’ will come down drastically, thereby increasing the availability of doctors to serve in the underserved regions of India. Today there are 29,451 Indian doctors serving in UK and about 60,000 Indian doctors in USA, UK, Canada and Australia put together. These doctors moved abroad mainly due to lack of higher medical education opportunities in India. Their retention would have made a tremendous difference to healthcare in India.

With increase in number of PG seats, of higher medical education will cost less,remaining affordable and attractive to aspiring students.

It is imperative that the government takes a landmark decision to increase PG seats sooner since the impact of the decision will be seen only a decade later.