Supe, Avinash MBBS, MS; Burdick, William P. MD, MSEd
The medical education system in India is one of the largest in the world. It consists of 258 medical schools, each associated with a university, producing 27,676 doctors each year.1 One third of these doctors leave India every year for residency training and/or practice abroad, with around 1,500 medical graduates emigrating to the United States each year to enter residency training2. The quality of Indian medical education and of the physicians it produces therefore has implications for the United States and the entire world. With 0.5 doctors per 1,000 people (compared with 2.3 per 1,000 in the United States),3 the capacity of health professional education in India also has significant ramifications for health care in India, where the need is extreme (see the sidebar entitled “Health and Health Care in India”). In this article, we describe the main issues facing Indian medical education today, and we offer suggestions for addressing these issues.
A number of high-profile issues confront undergraduate medical education in India, a country with a long history of medicine (see the sidebar entitled “Medicine in India: A Historical Perspective”). They include curriculum reform (including the structure of the internship year, which constitutes the last year of medical school), proliferation of new medical schools, accreditation standards for all medical schools, selection of medical students, and faculty development. Below, we discuss each of these issues and offer suggestions for addressing them.
Calls for reform.
The first issue confronting medical education in India is curriculum reform, with many calls for curriculum change having been made in the last 30 years. In the mid-1970s, the Srivastav Committee, a group of educators commissioned by the Indian government, advocated reorientation of medical education in accordance with national needs and priorities and recommended establishing a medical education commission to implement reforms. In 1986, the Bajaj Committee, another group commissioned by the government, repeated the call for an educational commission for health sciences and noted that although medical school faculty were effective in their clinical specialties, they were deficient as educators.4 Linkage between curricular goals and the actual curriculum was stressed in 1993 by Kacker and Adkoli,5 who advocated updated course content, revisions in student assessment, and innovative teaching methodologies. To implement these changes, they suggested improving faculty development, establishing medical education units, making educational funding more transparent. These recommendations were reiterated in 2004 by Majumder6 in a government-commissioned report in which he emphasized the need for political commitment and leadership to achieve relevant, evidence-based medical education.
Curriculum structure and recent reforms.
Any significant reforms to the bachelor of medicine and bachelor of surgery (MBBS) curricula must ultimately be approved by the Medical Council of India (MCI), a governmental agency under the Ministry of Health and Family Welfare established in 1934. The MCI stipulates, in significant detail, the rules for medical school curriculum structure and content. These rules start with the three-phase framework of preclinical, or first MBBS (12 months); paraclinical, or second MBBS (18 months); and clinical, or third MBBS (24 months) plus internship (12 months), a period devoted to rotating clinical experiences. Mandated summative assessment for each MBBS phase is composed of external, or university-based, examinations uniformly required for all medical colleges of the parent university (as many as 37 medical colleges in the case of Maharashtra University of the Health Sciences), as well as a small percent of internal, or medical school–based, assessment. The assessments consist of multiple-choice questions, modified essay questions, and oral examinations. Successful completion of each MBBS examination is required for advancement to the next phase of study. Passing standards for internal assessments are controlled by regulations of the parent university.
In addition, the MCI regulates allocation of time among disciplines, percentage of lecture time, required percentage of class attendance, types of electives and their duration, time distribution of internship components, and even duration of the lunch break. These regulations for medical school curricula were substantially revised in 1997 in an attempt to promote small-group learning, greater emphasis on health and community, problem-based learning approaches, and horizontal and vertical integration.7 Although vertical and horizontal integration is advocated by the MCI regulations, discipline-based teaching remains the predominant mode of education.
Medical education programs were increased from 4.5 to 5.5 years with the addition of an internship year in the 1960s, but the success of this innovation has been questioned.8 The addition of an internship year was partly a response to rising awareness of the need for resources devoted to community health, and it has a mandated 3-month community medicine block (half rural, half urban). Interns must also spend 2 months each in medicine, surgery (including orthopedics), and obstetrics and gynecology; 1 month in casualty (the emergency department); and a half month each in family welfare planning, pediatrics, ophthalmology, and otolaryngology. Interns must also take two half-month periods of electives.
Unfortunately, the structure of the assessment and examination system has undermined the usefulness of the internship year. Internship begins after the conclusion of the third MBBS examinations. Extremely competitive “pre-postgraduate” examinations for admission to the limited number of residency positions in India are given toward the end of the internship. Because assessment and, often, supervision during internship is perfunctory, and a high score on the pre-postgraduate examination is essential to obtain a residency position, students devote little effort to achieving the goals of the internship experience, instead spending most of their time preparing for the examination. Only 29% of medical school graduates (approximately 8,100) are able to enter postgraduate education positions in a clinical specialty in India, with another 10% qualifying for postgraduate education positions in nonclinical specialties such as anatomy, pharmacology, microbiology, pathology, or hospital administration.9 The remainder enter directly into general medical practice or emigrate to another country.
Growth of medical schools
A second key challenge is the increasing number of medical schools in India. The 1960s witnessed a dramatic growth in the number of medical colleges in India, and in the past 25 years the number has doubled, for a total of 258 “recognized” or “permitted” schools in 2006 (Table 1). The number of schools continues to increase, and the latest totals are likely to be higher. New private colleges account for most of the growth in the number of schools. More than half of the new schools have been created in four states out of India's 28, namely, Maharashtra, Andhra Pradesh, Tamil Nadu, and Karnataka. Although these states rank second, fifth, sixth, and ninth, respectively, in population, they already have ratios of medical school admissions to population well above the median (Table 1). The considerable political strength of these states may be a factor in the disproportionate growth of medical schools there. The states and the MCI regulate the number of public and private schools, which may have led to some of the state variations in the growth of private medical schools.10 The sudden growth of medical schools in the country has also resulted in an increased need for medical teachers, with vacant faculty positions in many medical colleges.
Lack of effective government oversight of private medical education and the private health sector in general has led to many problems, including maldistribution of resources that favors urban areas, and even irrational use of medical equipment and services. Recently, a report on privatization indicated that “oversupply of doctors in the private health sector has also created unhealthy competition that has led to unnecessary or excessive medication of otherwise healthy people.”11 Medical schools in India must be linked to hospitals treating specified numbers of patients, with privately owned schools attached to private hospitals. It is often difficult to fill these private hospital beds, which affects a school's ability to comply with MCI regulations. Government-owned medical schools, which are attached to public hospitals, face no shortage of patients, because charges, all borne exclusively by the patients, are significantly lower than at private hospitals, and demand often far exceeds capacity. The proliferation of private medical colleges also may be aimed at an export-oriented market, and the large rise in the number of medical schools may be motivated by the financial rewards offered by the high demand for medical education coupled with high tuition fees. Demand for medical education is so high that Indian citizens are attending medical school in Russia and, more recently, China.
Related to the increase in number of medical schools is the issue of their accreditation. Modest accreditation standards may have also facilitated the rapid growth in the number of schools. Accreditation of medical colleges by the MCI is compulsory, but the requested information emphasizes documentation of infrastructure and human resources rather than measures of the quality of medical education and outcomes.12 Information comes solely from the medical school administration; information from other sources, such as faculty, students, or patients, is not used in the accreditation process. Brief site visits have recently been added to the process.
In addition to accreditation by the MCI, voluntary accreditation is offered by the National Assessment and Accreditation Council (NAAC) to provide schools with an opportunity for additional recognition and status.13 NAAC is an autonomous body established by the University Grants Commission of India to assess and accredit institutions of higher education in the country. The process of NAAC institutional assessment includes submission of a self-study report and a site visit by the peer-evaluation team. Less than 10% of medical schools, however, have been accredited by NAAC.
Selection of medical students
A fourth challenge in Indian medical education is how to select students for entry. Selection of students for state-owned medical schools in India is based almost entirely on scholastic merits. The premedical test (PMT), a set of one to four multiple-choice examinations covering physics, biology, and chemistry that takes place once a year after high school graduation examinations, is offered by each state to its residents. A national examination is also offered to allow students from one state to apply for admission in another. Passing grades required for consideration of admission are stipulated by MCI regulations.14
Admission is based almost entirely on the PMT score. Interviews are rarely used in the selection process, and other candidate traits are not significantly considered by most schools. Some points in the scoring system for admission may be awarded for community service, sports, and military service. Preparation for the PMT often involves private coaching classes and disruption of other formal education activities. Individuals from “socially backward” groups are admitted with a lower cut score on the admission examination to increase their representation. Students are accepted to their preferred medical school based on their PMT ranking and availability of seats in the school. Medical educators in India have questioned the validity of selecting students solely on the basis of a single multiple-choice examination.15
Private medical schools are required to have a government-determined proportion of “merit seats,” for which students are charged about $400 per year for the first 4 years of medical school, as well as a proportion of “payment seats,” for which students pay substantially higher tuition (about $3,000–$6000 per year).16 Both “merit” and “payment” students in private schools pay the same for the last two years (about $4,000–$7000). Tuition levels for payments seats are determined by the state and are based on education costs reported by the medical school. In addition, higher fees may be allowed for nonresident Indians. The complicated nature of tuition and selection regulations has resulted in frequent litigation.17
A final critical issue is that of strengthening the capacity of the faculty in Indian medical schools. National teacher training centers (NTTC) were established in 1974 at medical colleges throughout India, including Jawaharial Institute of Post Graduate Medical Education (JIPMER) in Pondicherry, the Post Graduate Institute in Chandigarh, and Maulana Azad Medical College in New Delhi. They were funded by the World Health Organization until 1984, and from then they were funded by the government of India until 1999, when funding authorization was not renewed, presumably because of national spending constraints. NTTC activities included six- to ten-day programs for medical educators and included topics on education objectives, curriculum design, teaching methods, and assessment. Faculty-training courses facilitated the introduction of some innovations in various medical colleges in India and fostered the development of medical education units in other colleges. After 1999, only the NTTC at JIPMER continued to function.
The Foundation for Advancement of International Medical Education and Research (FAIMER) is also supporting faculty development in India. The FAIMER Institute,18,19 which offers a two-year part-time fellowship, teaches education methodology and leadership skills to faculty from developing countries from around the world, with an emphasis on faculty from South Asia. FAIMER Regional Institutes have been created in Mumbai and Ludhiana, and others are anticipated in the next several years. FAIMER has invested about $2 million since 2001, supporting over 80 medical school faculty from South Asia who have participated in the FAIMER Institute or FAIMER Regional Institutes.
Challenges and Recommendations
The challenges in medical education in India include the rapid, uneven growth of medical schools, the questionable validity of student-selection policies, curriculum goals that are weakly focused on health care needs with significant deficiency in the internship year, and a lack of faculty development to meet the needs of the expanding number of medical schools. We believe that constraints created by detailed national regulations from the MCI as well as state regulations from individual states, examination requirements of the parent university, and the preresidency examination make reform of medical education difficult, despite the changes advocated by the revised 1997 MCI regulations.
However, although structural changes in national and state assessment and accreditation are needed to make improvements in medical education, reforms at the medical school level are still possible. Our experience leads us to recommend that curriculum redesign should emphasize social and clinical context, including a greater focus on bedside teaching. Improved vertical integration through problem-based organ system design of the curriculum can also help address this issue. Formative student assessment should be added to the predominantly summative examinations. Objective, structured practical and clinical examinations, with criterion-referenced standards, should augment the current multiple choice–dominated assessment design. Internships must be used for skill-oriented training and should include meaningful supervision and assessment. If the internship is truly considered part of the medical school experience, this may be accomplished by revising and moving the last medical school examination to the end of the internship. It may also be accomplished by modifying the selection method for postgraduate (i.e., residency) training or by expanding those positions.
In our opinion, a more valid and uniformly applied approach to measuring the quality of Indian medical schools is also essential. Dialogue between the MCI and medical educators must strive to continuously update MCI regulations based on evidence generated by education research. Greater, if not total, inclusion of schools under the NAAC accreditation process may be desirable.
Faculty-development programs like those of the NTTC have been constrained by lack of regular funding. Incentives for participation in training programs should include the opportunity for professional advancement based on education scholarship. A medical education unit capable of promoting this should be developed in all colleges, and it should have the requisite resources for faculty development, research in medical education, curriculum design and implementation, student assessment, and program evaluation of institutional educational policies and programs.
In summary, medical education in India faces significant challenges. We believe that reforms should be based on sound educational research, with government agencies held accountable for evidence-based regulations. Where no current evidence exists, experimentation should be encouraged. If reforms are successful, the impact of improving Indian medical education will be felt around the world.
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