June 14, 2019, 2:00 AM IST Devi Shetty in TOI Edit Page | Edit Page, India | TOI
The WHO ranking of global health systems ranks India at a shameful 112th position, below Iraq and Venezuela, mainly due to the shortage of doctors. Converting taluka and district hospitals to medical colleges is logical but not practical. It costs about Rs 450 crore and five years to build a government medical college, and thereafter costs about Rs 150 crore for annual maintenance. Many state governments cannot afford to spend that amount.
Rigid regulations on definition of a “teacher” makes the matter worse. However, today we have an affordable solution to transform medical education by simply copying what the Americans and British did to transform their medical education. We must embrace modern pedagogy such as problem based learning (PBL), which produces outstanding doctors in a frugal, readily available infrastructure.
There are 330 private/ trust hospitals in India with 300 to 800 beds conducting postgraduate training under the National Board of Examinations (NBE). They have more caseloads than some of the best medical colleges and some of the best doctors work and teach here. By introducing undergraduate medical education (MBBS) in these hospitals with 100 seats per hospital, we can add over 30,000 MBBS seats in less than a year, at no cost to government.
The most attractive part of this project is that all the 30,000 medical seats are owned by the government with no management quota and the tuition fee is fixed by the government. Essentially, our government can produce 30,000 passionate doctors from poor families annually, without spending a penny.
Illustration: Chad Crowe
PBL in American medical education amounts to one of the most significant changes since the Flexner report motivated university affiliation. In PBL, the role of the tutor is to facilitate learning by supporting, guiding and monitoring the learning process rather than lecturing. Prestigious medical schools like Harvard shifted exclusively towards PBL preclinical curriculum, doing away with almost all lectures.
About 70% of medical schools in the United States now have some form of problem based learning in their programmes. Maastricht and Saint Georges University of London offers its whole programme in PBL format only. The advantage of PBL is the early exposure of students to clinical settings and patients, which makes them better doctors.
Large hospitals with over 300 beds, conducting postgraduate training programme under the NBE, can have an annual intake of 100 medical students. All they need is a few academic discussion rooms. Staff and students can find affordable accommodation in most cities. All the practising doctors with over eight years of clinical practice should be recognised as teachers, after going through a “train the trainer” programme to ensure quality.
A committee nominated by the government can prescribe the course fees in consultation with the medical college management. A 5½+1 years MBBS course should cost approximately Rs 25 lakh. The government spends Rs 1.5 crore in AIIMS and Rs 48 lakh in army medical colleges to train just one doctor. All the students should avail educational loans with an undertaking that when they get employed 10% of their salary will be deducted at the source to pay back the loan. Neither the parents nor the government should be responsible for the loan.
New model medical schools are not recognised by MCI. Students graduating with MBBS degrees can get MCI recognition only after passing the exit exam conducted by MCI for students graduating from foreign medical universities. New model medical schools also tutor the students to pass both USMLE and PLAB – the entry tests for the US and UK – during their undergraduate days to broaden their opportunities.
Why do we need two parallel streams for medical education? Since the entry and exit tests are based purely on merit, especially exit exam conducted by MCI, only the supremely confident students who have the passion and knack to crack any competitive exams will join. In fact, it will become an elite force like the US marines, or IIT and IIM graduates.
Persons like me can never top these ultra-competitive tests, competing with a few lakh of the brightest minds. I was never a topper in my class, just an above average eccentric student whose only passion was cardiac surgery. The healthcare system also needs many doctors like me. Traditional MCI affiliated colleges can provide bulk of the doctors like me. Of course, after graduation both streams are treated equally.
None of the innovations suggested here are our own ideas. They are the standard and norm in most parts of world. PBL curriculum was introduced in McMaster medical school in 1969. Today most medical schools in the US, Europe and Asia (except India) have adopted it.
Many years ago when Malaysia was facing a shortage of doctors, a Malaysian university started a medical school for clinical subjects in Bengaluru – at the prestigious Baptist hospital which has a huge patient load and excellent infrastructure. Only Malaysian nationals could enrol and after graduating they went back to Malaysia. If the Bengaluru Baptist hospital can train doctors for the Malaysian government, i am sure they wouldn’t mind training doctors for the Indian government.
Ramakrishna Mission hospital in Kolkata – with close to 1,000 beds, fantastic doctors and great infrastructure – can compete with AIIMS. In fact, almost all prestigious medical colleges in the West are built on this model. At $8.2 trillion, global healthcare is the largest industry. And is fuelled by doctors. By producing passionate doctors, India can dominate the world’s largest industry.
DISCLAIMER : Views expressed above are the author’s own.
Devi Shetty is a cardiac surgeon and Chairman and Founder, Narayana Health