The factors responsible for a dysfunctional healthcare system are many. Most of them, are in some way, related to bad habits, which plague any entrenched system. It is unfair to criticize the present Indian system, squarely and too rudely, as even, the far more evolved systems: such as the ones in the US and UK are facing existential questions.
The questions that need to be asked, to address our present issues, are pretty fundamental. They concern medical education and the way in which it is being delivered. Is medical education being delivered an an efficient loop? I call it a loop as I personally think it is a never-ending process. Similarly, are we efficient enough in selecting those candidates who are cognitively and socially equipped enough in becoming the leading: clinicians, academicians, and researchers of the future.
The present form involves free standing institutions, which are linked to a remote university or another healthcare university. At least this is the case with most of the colleges. If the said institution is well funded, staffed, and has experience of more than 30 years (as in AIIMS, or CMC(Vellore), or the PGIs), they would surely be efficient enough and successful in preparing the students for a clinical, academic, or research career. However, these are just a handful of institutions. The rest of the freestanding institutions are in a state of discomfort. Private institutions, which are primarily run like glorified corporate hospitals are bugged by an overt dependence on funds from the students.
The government institutions are a constant prey to the whims and fancies of the state or central government. The quality of staffing is again an issue, as the private institutions tend to compromise on it to save running costs while the government institution’s staffing is affected by nepotism, corruption and weird entities such as ‘reservation’! Ultimately the quality of medical education delivered is compromised to a ridiculous proportion. Yet, these institutions time and again deliver good and even great physicians. This is in spite of all the impediments and does not necessarily reflect the institution’s true potential.
I think there is a way out. This is possible by linking every free-standing medical university to a full-fledged university (which has all departments from the humanities to the sciences). A good instance would be to link madras medical college to madras university. Not only would this result in cooperation in the interdisciplinary fields such as genetics, bioinformatics, psychology etc. It would boost research output and that would bring in more funding. Moreover, universities are good at creating endowments out of donations and funding from national and international resources, this would help in investing on the infrastructure and hiring quality staffs. Even private institutions would be less dependent on the student’s tuition fee for their existence. Every institution, as a university, would be independent.
Is there a selection process necessary in the first place for medical college? The answer is yes. If there were n number of seats and n number of applying students, it would still be necessary to conduct an eligibility test. There are some basic cognitive and social traits, which are necessary for one to take up medicine. Having said that the present selection processes, be it the NEET or the other ‘entrance’ examinations, are mere extensions of the bad habits of our post-colonial mindset.
Another basic questions: ‘are the kids being asked the right question at the right age.’ The answer is a big ‘NO’. At 17, even for a kid who has been exposed to various aspect of medicine, there would be too many biases operating to make the right decision. At this pediatric age, when even the government doesn’t consider you mature enough to make a decision regarding one’s leader for a few years, how would he or she be able to make the decision of a lifetime. At this age, it would be sensible to go through a bachelor’s degree first, as the budding adult in the kid confronts his majors and minors, he/ she would be able to come to an informed decision. Then an abridged 3- or 4-years course could lead on to MBBS, post under-graduation.
The selection process per se leaves much to be desired. The ‘MCQs’ or the subjective questions (in the school graduation tests) tend to test the student’s ability of retention rather than the more sophisticated cognitive traits such as analysis, application, pattern recognition, abstraction etc. In other words, they hardly test those abilities which are essential to excel as a clinician, academician or researcher. Most importantly the breadth of knowledge seems to be given more significance rather than the depth. Thus, the student who is adept at scoring big, in these tests, voluntarily or involuntarily is involved in a task of shallow water fishing. Since a school’s or teacher’s success is measured in the number of pupils, they send to these ‘professional’ colleges, the system entrenches this type of learning into the minds of the pupils. Any selection process should include an interview in an OSCE format (to test social skills) and should also factor in the pupil’s cumulative performance in his school. Such an evaluation would be less primitive, up to date, and effective.
Any such testing system should have characteristics that make it immune to variables such as training i.e. irrespective of the training received by a student, he or she should not be in any way better equipped at taking a test. The tests should fulfil their primary objective of providing the test takers with an even playing field. The testing system needs a complete overhaul as it affects the basic way in which any pupil learns. By a complete overhaul, I mean from the primary school level to the post-graduate level.
The other day, while I was watching the news, one of the top guys in IMA was being interviewed regarding the mortality in the Muzaffarpur ‘epidemic’. While the question was regarding India’s poor infant mortality rate, this guy responded with an answer that was shocking to say the least. He started boasting about our multi-specialty hospitals and medical tourism scene. He was either totally unaware that IMR, as a variable, is not just dependent on the healthcare system but is also indirectly connected with the entire population’s well-being or was feigning ignorance. But that moment when a well-informed journalist made an ill- informed physician ill at ease was disappointing, we don’t need such doctors. There is a way to get rid of them and therein comes the Test.
One more bad habit applies to the qualified doctors. India is in dire need of the 5 yearly licensing renewal testing system. There have been a number of times when I have come across doctors who seem to be blissfully unaware of evidence-based algorithms. I have even heard them proudly quote their professor from 20 years ago, and they get away with it as it is an Indian thing to ‘respect elders’. Every patient in this country has a right to the best healthcare and I feel this policy is more important than any bigwig or elder.
Having commented about our own healthcare system it is important to mention that our system has produced many great: scientists, academicians and most importantly clinicians. All it needs is some tweaking. The last thing it needs is quacks being certified as clinicians. I leave you with a point to ponder on. Be it education or medicine, do you think any institution (not an individual) can deliver the aforementioned entity efficiently, if its intentions included financial profit?