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USHERING IN CHANGE IN MEDICAL EDUCATION - Evolution or Revolution ? Dr. K.R. SETHURAMAN, MD, PGDHE, Dean - Faculty of Medicine AIMST University, Bedong-08100, Malaysia |
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The MCI regulation of 1997 on undergraduate medical education has been a major event with wide ranging influence on the curriculum. However, many medical educators feel the need for further refinement and have conveyed it to us at NTTC. This article is based on their valuable inputs and suggestions. RESPONSIBILITIES OF EDUCATORS Educators have three primary responsibilities. They are - i. Preservation and transmission of existing human knowledge and skills. ii. Creation of new knowledge and skills. iii. Ushering in relevant changes that enhance quality of human life. Globally, medical education has done well in (a) and (b), but has been rather weak in (c). Flexner initiated major educational reforms in 1910's in USA. The next major attempt was the GPEP report of 1984. Impact-wise, the major initiative in Indian scene has taken place in the 90�s leading to the release of MCI-regulations of 1997 on undergraduate medical education. MAJOR REASONS FOR STASIS M. Gorbachev, former Supremo of USSR declared, �Change is Life; Stasis is Death.� Machiavalli has said, �It is better to manage change than inertia.� However, most educationists believe that �It is easier to move a cemetery than change curriculum.� Why is it so? 1. Inertia of Machiavallian proportions This is fostered by - i) Reluctance - �Why should anything change when excellent products (like us!) Have been produced by the existing system? ii) Benign neglect of several areas of knowledge and skills that do not fit into the existing disciplines, e.g., communication skills, humanistic medicine, medical anthropology, etc. 2. Tunnel Vision Medical educationists do not perceive the sweeping reforms and changes in the other fields like Engineering, Management, Agriculture, etc. University Grants Commission (UGC - 1973) document on educational reforms recommended four major changes: i) Enhance continuous Internal Assessment (and reduce the importance of a single final examination) ii) Devise National Examination to assure quality of the product throughout the nation iii) Adopt Grading System for assessment iv) Create a pre- and post-validated question bank to ensure quality of the assessment tools Indian Institutes Of Technology (IITs) have incorporated these for three decades while the medical educators are still hesitant at best or ignorant at worst. 3. Fuzzy Curricular Goal We proclaim to produce an MBBS graduate who is capable of delivering preventive, promotive, curative and rehabilitative primary (first-contact) health care. But majority of our graduates are ill equipped to be an effective or a successful `generalist�. Moreover, they have insecurity and feelings of inferiority (�I am just an MBBS graduate�). Most of the 16,000 graduating every year are desperate to specialize but only about 40% can do so. The remainder are left to fend for themselves. Compare this with the pride, job opportunities and fidelity to their discipline among engineering graduates. 4. Ineffective Problem-Knowledge Coupling Problem-knowledge coupling is very important in higher education as all professionals are basically problem-solvers (just log into www.pkc.org and see for yourself!). The MCI 1997 regulations has earmarked 6th and 7th semester (2-4 pm) for `clinical demonstrations�. This huge curricular time can be effectively used to impart problem solving skills to our students. How many medical colleges have done it in 1999-2000 when the first batch entered 6th and 7th semester? 5. Examination-Muddle This is characterised by - a) Obsession with secrecy - no pre-validation or post-validation is done in most examinations. b) Fear of corruption - while our counterparts in other professions are able to offer credit based curricula with 50% weightage to internal assessment, we shudder to think of it. Why? c) Fatalistic Acceptance of Unreliable Tools: The wide variations in examiner-bias, case-difficulty and the overall subjectivity of global assessment make most clinical examinations no better than `Russian Roulette�. We tend to accept it without a second thought and counsel our students. �Clinics are like one-day cricket. You may score a century or you may score a duck. It is OK.� Can we not press for a better system than what we had to go through when we were students? THE WAY FORWARD - Some Suggestions 1. Have a Clear Goal What is our goal for undergraduate medical education? Is it feasible, relevant, pragmatic and acceptable to student community as well as society at large? a) Should MBBS graduate be ready to function as a competent family doctor (with pride and not an apology)? b) Can the same graduate be ready to take up specialisation in clinical and non-clinical subjects? c) Like Engineering education which offers several streams with only one year of common foundation, should we offer several streams in MBBS education? 2. Create a System of Quality Assurance Adopt ISO-9002 norms for services and apply it to medical education in toto. If quality assurance of a transport service or a hotel is important to the society, then is it not even more important that medical education must conform to ISO-9002 norms? 3. Galvanise Medical Educators Remove distractions (like unregulated private practice) and diversions (like excessive research at the cost of teaching students). Ensure that in all disciplines, educators are available from 8-4 to teach. 4. Reform Evaluation System Make it relevant, valid, reliable, unbiased, transparent, accountable and fair. Enhance the quality and weightage of internal assessment. Consider national level standards for summative examinations. 5. Make Internship training more meaningful and effective Remove the stress of PG entrance examination so that the focus will revert to learning practical problem solving skills. CONCLUSIONS A zero-based approach is needed to totally revamp the medical education in India. We have a duty to ensure that competent family practice survives in the 21st century and that MBBS-degree regains its prestige. Back to the question raised in the title - Change through Evolution or Revolution? If we are responsive, pro-active and responsible, then the change will be a process of meaningful evolution - if not, societal demands may force an unplanned revolution upon us at not too distant a future. May collective wisdom prevail! REFERENCES 1. UNESCO (1972) - Learning to be - The world of education today and tomorrow. 2. UGC (1973) - Report of Educational Reforms Commission. 3. GPEP Report (1984) - American Association of Advancement of Medical Education. 4. Tapan P. Bagchi (1994) - ISO-9000 - Concepts, methods and implementation. Wheeler Publishing Co. Ltd., New Delhi, India. 5. MCI (1997) - Regulations of Undergraduate Medical Education. 6. Sethuraman KR (2000) - Trick or Treat - A Survival Guide to Health Care. EQUIP, P.B.No.8, Pondicherry-605006 - India 7. Sethuraman KR, Santosh Kumar (1997) - Implementing innovations in Clinical Skills Training. National Teacher Training Centre, JIPMER, Pondicherry. 605006 - India.
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