The Covid-19 pandemic has laid bare the realities and weaknesses of India’s healthcare system. The sufferings of people during the pandemic need no elaboration. The need for reforming our medical care and medical education sectors can no longer be denied. Better medical infrastructure and more highly trained medical professionals are the need of the hour, if we are to ensure quality healthcare to our people.
Policy makers must now initiate all necessary steps to improve and strengthen our position, with particular emphasis on the rural areas. Since much has already been written and said about the state of our physical infrastructure, I present a more long-term view, and lay out some of the pressing areas of reform in relation to medical education.
Finding the talents
First and foremost, it is essential to realise that the medical profession is no longer a preferred destination for our brightest young minds. Being a doctor myself, it has been quite disheartening to witness, over the years, the increasing disinclination of bright young students to opt for the medical profession. As a society, we cannot afford to accept this trend. The cost of mediocrity, as someone wisely said, is disappointment; and in matters of life and death we cannot afford disappointment. The long training period, lack of commensurate remuneration and the shortage of adequate opportunities for professional growth are some of the apparent reasons for the decline in the popularity of the medical profession.
While some of these factors are unavoidable, given the very nature of the profession, all efforts must be made to remove the systemic bottlenecks and obstacles which frighten our youths away. We must tap the best and brightest, who are eager to serve and who long to achieve. The sheer nobility of the profession, coupled with the thrill of cracking hidden secrets and mysteries of science, has a magnetic pull for intelligent minds and idealistic hearts, and we must provide an adequate platform for talent to flourish.
The quality of medical training is important. A race to increase quantity, at the cost of quality, will have serious negative consequences. Good teachers are role models for students, and the best faculty must be encouraged. No compromise in the quality of medical teachers should be tolerated. The criteria for appointment as faculty must be constantly revised and updated, and original research must be given the highest importance. New medical colleges should be encouraged to collaborate with established centres of excellence, to mentor their junior faculty.
The NEET exam was a revolutionary step in bringing about transparency and meritocracy in the admission process to medical colleges. It has rescued our system from the vice of capitation fees. But its functioning has revealed further shortcomings in our system that we must address. A Tamil Nadu panel recently found that the introduction of the entrance test in 2017-18 negatively affected students from economically weaker sections with the results favouring the urban, English medium-educated and well-off students, prompting the state government to scrap NEET as a criterion for admission to MBBS programmes.
Moreover, the proliferation of private coaching academies has greatly increased the cost of preparation for this exam. We run the risk of medical admissions becoming out of reach of poor students, and to those in rural areas. This means we stand to lose many bright aspirants. However, I am afraid that scrapping the NEET exam altogether will be unwise and retrograde. It would only send us back to the pre-NEET era of tainted and suspect admission processes. We must not throw out, as it were, the baby with the dirty bathwater. We must conceive of measures to further strengthen the NEET system, or find better alternatives to ensure transparency and fairness in the admission process.
Governments, at the state and central level, can step up and implement special measures for the poorer sections and for students in rural areas so that they are in a position to compete with their counterparts who are better off. ‘Corporate Social Responsibility’ (CSR) initiatives can also be encouraged and channelised in this direction, to bridge the gap between the haves and the have-nots. Additionally, a more ‘hybrid’ model, giving some weightage to the performance in the state/central board exams, in a transparent manner, in addition to the NEET score, can be considered. Only by brainstorming to find the best alternatives can we meet the pressing demands of equity without compromising merit and efficiency.
Reforms in the post-graduate NEET are also necessary. One big drawback of the PG NEET is its timing. The exam is held at the end of the internship period, which has seriously affected the efficacy of the internship programme. Students, instead of learning the necessary practical skills during this period of internship, devote their time to prepare for the entrance exam. We must consider some alternatives. A common exit examination, whether at the end of the MBBS course or at the end of each ‘professional’ examination (akin to ‘semesters’ in the MBBS course), which could be utilised for PG admissions, is one option. Just as for the undergraduate NEET system, other ideas and possibilities must be explored and debated and the soundest options implemented.
More PG seats
Another urgent imperative is increasing the number of seats in post-graduate courses. A graduate level medical degree (MBBS), in today’s world, does not provide any assurance of professional success. Every student wishes to specialise in a field of his/her choice. Yet, the number of post-graduate seats falls well below the number of graduate seats. While efforts have been made in the last few years to address this anomaly, a significant gap remains. There is a critical need to reduce this gap so that every medical graduate can be confident of getting admission to a post-graduate course. This will also help in making the profession more attractive for young aspirants. Specialities like family medicine, which do not demand heavy investment in infrastructure and will help fulfill the pressing need for good general practitioners, should be encouraged to rapidly scale up post-graduate seats. It is worth noting that in the United States, which has among the most advanced healthcare facilities in the world, the number of PG seats is more than undergraduate seats.
At present, there are two streams for post-graduate education and super-specialities, viz. MD/MS (NMC) and Diplomate in Medicine/Surgery (NBE). The NBE was conceived as a post-graduate level programme for increasing the number of clinical practitioners, especially in private hospitals, as opposed to teaching faculty. Currently, however, both streams have become more or less equivalent. This results in unnecessary confusion and duplication, especially in the eyes of foreign universities. I feel it is necessary to streamline our system, and to have only one regulatory body to ensure uniformity of standards of training and evaluation.
Finally, something needs to be said about possible policy incentives which will help us kill two birds with one stone. Primary Health Centers (PHCs) were set up to cater to the primary health requirements of our rural and semi-urban populace. A lack of qualified doctors manning the PHCs has, however, hampered the system. The need to strengthen PHCs cannot be overemphasised. An option we must seriously consider is to post fresh graduate doctors at these PHCs, and give them an incentive in the form of preference for PG admissions. Alternatively, the Medical Council of India (MCI) had recommended to the central government in 2012 that a compulsory rural posting for one year be put in place, as a prerequisite for joining PG courses.
The government agreed to the proposal but deferred its implementation, in view of opposition from students and doctors. The opposition was not entirely unjustified, given the lack of infrastructure and basic facilities in the PHCs and the absence of reasonable remuneration and other facilities including accommodation. However, these concerns are not difficult to address, and the MCI had submitted its suggestions in this regard. Perhaps the current government can reconsider the matter, because this will not only galvanise the PHC system but will also provide valuable exposure to India’s budding medical professionals.
The time for complacency is well past, the time to act is now. We owe it to the future generations to act in the right earnest, and to fully equip the country’s systems to meet all potential challenges.
The author is Chairman, Cardiac Sciences, PSRI Hospital, New Delhi; former Director, PGIMER Chandigarh; and former Chairman, Board of Governors, Medical Council of India. Views are personal.
(Edited by Prashant)