Postgraduate Medical Postgraduate Medical Education in India - Education in India -

20052005Prof K R SethuramanProf K R Sethuraman MD PGDHE

Director-Professor & HeadDepts of Medicine & Med Education

JIPMER, Pondicherry - INDIA

Academic Structure of Academic Structure of Higher EducationHigher Education

Bachelor / Undergraduate level Bachelor / Undergraduate level • 3 - 5 years leading to diploma or degree3 - 5 years leading to diploma or degree

Master's / Post-graduate level Master's / Post-graduate level • 2 - 3 years leading to PG-diploma or 2 - 3 years leading to PG-diploma or

degreedegree Doctoral / Post-doctoral level Doctoral / Post-doctoral level

• 2 - 4 years2 - 4 years

Indian Medical Council Indian Medical Council (IMC)(IMC)

Indian Medical Council Act • enacted in 1933 to establish standards

in medical education and to define medical qualifications

• Inadequate to meet the challenges posed by rapid development and progress of medical education

Medical Council of India Medical Council of India (MCI)(MCI)

In 1956, IMC Act was repealed and a new MCI Act was enacted

Further modified in 1964, 1993 & 2001 MCI-regulations on undergraduate medical

education in 1997 MCI-regulations on postgraduate

medical education in 2000

Objectives of the CouncilObjectives of the Council Maintenance of uniform standards of Maintenance of uniform standards of

medical educationmedical education (UG & PG) (UG & PG) Recognition/de-recognition of Recognition/de-recognition of

Medical Institutions of India Medical Institutions of India Recognition/de-recognition of Recognition/de-recognition of

Medical qualifications awarded Medical qualifications awarded abroadabroad

Registration of qualified doctors Registration of qualified doctors

College Recognition ProcessCollege Recognition Process State Government approval for State Government approval for

essentiality of a Medical College essentiality of a Medical College Central Government's permission to Central Government's permission to

such colleges - initially for one yearsuch colleges - initially for one year Annual Renewal after verification Annual Renewal after verification

until permanent recognition could be until permanent recognition could be grantedgranted

Courses without approval are Courses without approval are irregular & the degrees will not be irregular & the degrees will not be recognisedrecognised

Quantity - Number of Quantity - Number of CollegesColleges

> 250 medical colleges in India> 250 medical colleges in India 230 have been approved by MCI 230 have been approved by MCI

http://www.mciindia.org/apps/search/show_colleges.asphttp://www.mciindia.org/apps/search/show_colleges.asp

~ 40% is government run; ~ 40% is government run; ~ 60% is private~ 60% is private

Intake is ~ 25,000 UGs & ~ 8,000 Intake is ~ 25,000 UGs & ~ 8,000 PGs per yearPGs per year

Alternate Medicine StreamAlternate Medicine Stream

Ayurveda Colleges Ayurveda Colleges = 196 = 196 Homeopathy Colleges Homeopathy Colleges = 192 = 192 Siddha Colleges Siddha Colleges = 5 = 5 Unani Colleges Unani Colleges = 35= 35

Educational Deluge !Educational Deluge !

  1992

1996

1997

1998

1999

2000

Enrolment (-000s) in Medical sciences

179 220 230 241 252 271

Source - Ministry of Human Resources and Development

Current Demand -Current Demand - for for Postgraduate EducationPostgraduate Education

GPs have to compete with practitioners of alternate systems

Most MBBS graduates try very hard to get admitted to PG studies • Some try for 2 - 4 years of full time

entrance exam coaching • Parallel system of PG examination run by

the National board of examination

PG EntrancePG Entrance

All India Entrance Examination for 50% of PG seats in all govt-aided colleges

Annually ~ 2500 seats are available for graduates from any college

For some bright & savvy “MCQ monsters” this is an annual pot of gold!• They sell their seat to the wait listed!!!

Objectives of PG educationObjectives of PG education

Laudable list of objectives covering knowledge, competence & values

Not matched by a valid & relevant set of assessment tools to ensure that the outcome complies with all the objectives

Adhering to MCI objectivesAdhering to MCI objectives

At JIPMER we conduct a 30 hour module for all the 70 PGs on • research methods• ethics & professionalism• evidence based medicine • journal club presentation skills

Such efforts are much envied but rarely followed

Beyond MCI – Beyond MCI – National Board of ExaminationsNational Board of Examinations (NBE) (NBE)

provides a common national standard & mechanism of evaluation of postgraduates

conducts postgraduate & postdoctoral examinations in 42 disciplines

awards Diplomate of National Board (DNB) to those successful in exams

Why PGs jostle in DNB streamWhy PGs jostle in DNB stream Government of India has equated

DNB with corresponding PG degree (MD/MS) & post doctoral (DM/MCh) qualifications

Examinees appear from > 230 medical colleges & 370 accredited institutions • Broad Specialties (27)• Super Specialties (16)

Post Doctoral FellowshipPost Doctoral Fellowship in Sub Specialties in Sub Specialties

• Critical Care Medicine, Trauma Care, Cardiac Anesthesia,

• Reproductive Medicine, High Risk Pregnancy & Perinatology

• Vitreo-Retinal Diseases, Pediatric Ophthalmology

• Pediatric Cardiology, Interventional Cardiology

• Minimal Access Surgery, Vascular Surgery, Hand & Micro Surgery, Spine Surgery

Problems in Medical Problems in Medical Education are GlobalEducation are Global

42% of Ireland's medicos regret their career choice, compared with a quarter of both GPs & consultants

They would reject medicine if they were back at school and asked to choose again

Problems – Indian contextProblems – Indian context ““Blind imitation of Western model

has made our products misfits in our own society”

‘The painful truth is - a medical graduate is more at home abroad than in India’ – Dr Deshpande

• J Postgrad Med 1982;28:181-3

I know super-specialists with DM, MCh migrating to UK to work as locums

Problems – Academic contextProblems – Academic context Private health care is much more

remunerative than academics, there is paucity of good teachers• Myth - Those who can’t, teach others!!!

Allowing private practice in academics is a “Catch-22 situation”• “Teachers chase practice. Students

and teaching are inconveniences” Ind J Medical Ethics.2004:5:123

Problems – Academic scamProblems – Academic scam

current trend to offer expensive private tuition for students • At present for undergraduates only• additional income, especially for non-

clinical medical teachers may soon reach proportion of a

major scam• curricular duty ignored to pressurise

students to join coaching classes

Problems in Problems in Educational TechnologyEducational Technology

Infrastructure is often inadequate • unpredictable power supply• may ruin a well-planned activity

Six A’s of availability, affordability, accessibility, appropriateness, adequacy & acceptability of resources

Rapid obsolescence is a bugbear of computer-based technology

Problems in Problems in Educational Technology - 2Educational Technology - 2

maintenance of hardware is below par• overriding fear of breakdown

The fear leads to a “Catch-22” situation• in order to maintain equipment in

working order, keep it always under lock and key!

Problems in ExaminationsProblems in Examinations

Mistrust over the fairness of entrance & final examinations

Obsession with secrecy lack of pre- or post-validation

Fear of corruption • medical educators shudder to think of

50% weightage to internal assessment

Problems in ExaminationsProblems in Examinations

Fatalistic Acceptance of Unreliable Tools – “Can’t help it” syndrome• variations in case-difficulty,

examiner-bias, & subjectivity of global assessment in clinical/practical

• most clinical examinations no better than `Russian Roulette’

Problems in National Board Problems in National Board TrainingTraining

Of the 370 accredited institutions, only a few have academic ambience & are equipped to impart effective training

They seek accreditation for prestige & to get junior doctors to work for a pittance

plight of DNB trainees in several non-teaching hospitals makes sad reading

• www.aippg.net/forum/viewtopic.php?t=1102

Problems in ResearchProblems in Research

Only a few colleges take research seriously with active research councils

Plagiarism by PGs is a major problem now Open access initiative is double edged:

• it gives free access to information for researchers of the world;

• it also makes it very easy to plagiarise research findings

The Way ForwardThe Way Forward - - Some SuggestionsSome Suggestions

1. 1. Embrace quality assurance in education• Adopt ISO-9002 norms for services

2. Galvanise medical educators • by removing distractions

like unregulated private practice

• and diversions like excessive research at the cost of

teaching

The Way ForwardThe Way Forward – – Suggestions Suggestions contd.contd.

33. Adopt competency-based approach to training & evaluation • so that those who enter the

profession are competent• Implement formative and internal

assessment to ensure competencies not tested in the final exams

The Way ForwardThe Way Forward – – Suggestions contd. Suggestions contd.

4. 4. Usher in examination reforms • make in relevant, valid, reliable,

unbiased, transparent, accountable and fair

• Enhance the quality and weightage of internal assessment.

5. Develop national standards for summative examinations

To Sum Up …To Sum Up …

India has the largest technical human resource pool

Indian Doctors are truly global Every 7th Doctor in USA is Indian While quantity is laudable, quality is

not uniform: exemplary to abysmal We need mechanisms to assure

quality of health human resources