Medical education is an ongoing process and can be divided into three phases, the undergraduate, the post-graduate and continuing medical education, designed to ensure that the practitioner stays updated. It can further be divided into the public and private sector.
Successive governments have abdicated their responsibilities and neglected medical education for years, allowing it to drift into the hands of private enterprise. Hence the 72% increase in the medical seats in the private sector came at a price. The problems of inequity, quality, cost of education and geographical skew were never anticipated, and it is only recently that any attempt has been made to address them. Private medical colleges were less transparent and difficult to regulate. The fact that many are owned by political heavyweights did not help. Unfair practices are so rampant that we now require a dedicated law “The Prohibition of Unfair Practices in Technical Educational Institutions, Medical Educational Institutions and University Bill, 2010”. Meanwhile the neglect resulted in a shortfall of doctors with no resolution in sight for at least the next 20 years.
Efforts are now being made to standardise both the entrance to and graduation for the MB, BS courses with the NEET an Exit examinations. This welcome step will establish a level playing field and tackle regional discrepancies in standards. However the private sector still remains a problem. Even though courts have declared capitation fees illegal, it is still a rampant practice. A recently deemed university in a neighbouring state quotes a fee of Rs 50 lakhs even with a score of 60% in the entrance tests. And this is just the beginning. During the course, even a genuine sick note for a student is accepted for “a price”. Thus the total cash outflow from entrance to exit can easily cross one crore for an MB, BS degree. How the average middle class copes with such expenses is beyond me; it is only possible with black money or crippling loans. With the government removing the cap on fee structure in private colleges and permitting profiteering, the problem can only get worse. It must be stated however that the rules for capping fees and profits produced their own problems. Maintaining standards was quite impossible because inviting world class faculty, and driving research costs money. This spawned the concept of “ghost faculty”.
Having spent such sums of money, what sort of a world does the fresh medical graduate face?
All normal human milestones are delayed; doctors start earning, get married, and settle down much later than in any other profession. The only advantage may lie in an enhanced price tag in the marriage market. The primary concern is the recovery of the investment in medical education and returns. Average starting incomes makes this extremely difficult unless one resorts to supplementing ones income by “other means”.“Revenue maximisation” now enters the equation. This in my opinion lies at the heart of “unethical practice” and the whole concept of commercialization of the profession that we hear so much about. Accusations of unnecessary surgeries, unwarranted investigations and cut practice abound. The same pressures apply to investments in expensive equipment. Having paid a fistful of crores for sophisticated scanners, “revenue maximization” becomes a priority. Mahawar in his book “The Ethical Doctor” makes the point that it is quite impossible to work ethically in today’s environment.
To add to this piquant situation, the government in its efforts to tackle the shortage of doctors, particularly in the rural areas plans to permit practitioners of Indian systems of medicine to practice allopathy, with the stamp of approval from the National Medical Commission (due to replace the MCI). Which begs the question; why go through this trial by fire of getting a medical degree when such “short cuts” are available?
The second phase of medical education, is post-graduation, a much sought after option. The same exercise is repeated, on a larger scale. The cost of entry now goes into crores with recovery becoming that much more difficult. Reports of admission scams and harassment of students are common and add to the nightmare. Examiners have been apprehended with unaccounted cash and got away on legal technicalities. And all the while one has to live with the reality of a government promoted system of quackery permitting cross practice and the concept of “doctors” produced by crash courses. Add to this the ever present threats of litigation or assault and the dismal picture is complete.
The third stage of medical education is the Continuing Medical Education or CME program. A fairly new concept in medical practice, it has been the norm in many other professions in India like master mariners and pilots. Keeping yourself updated and renewing the licence to practice with certificates of attendance at CME programs is standard practice in many countries. In fact, in the USA merely attending a conference does not earn CME credit points. After the conference one is expected to go online and answer a questionnaire based on the lectures attended, and only if this is satisfactory does one earn the credits. Attempts to introduce compulsory renewal of registration based on CME credits has met with considerable resistance. Attendance is fudged, and false certificates claiming credit awards issued. At a recent conference in Delhi, entry and exit at the lecture hall was recorded electronically with the identity tag provided at the time of registration and credit points awarded based on this. Such gross methods of policing should never be required in a community that occupies such a distinguished place in society.
Problems are always easy to identify; what eludes us are solutions. If we are to effectively deal with this catastrophe in healthcare, the first thing that has to happen is an increased allocation in government funding from the measly 0.9% of GDP and more attention paid to medical education so that students are not held to ransom in this way.
(Dr Gladstone D’Costa is the Chairman, Accreditation Committee and member, Executive Committee, Goa Medical Council).
