Training good doctors must begin ground up
The usual complaint from politicians is that doctors are reluctant to go to villages to serve the rural population. Politicians try and devise quick-fix measures, some of which appear draconian. Yet, nothing seems to work in the long run. Today’s MBBS courses do not train a doctor in good bedside medicine, to practise in villages where diagnosis cannot be left to technology and tests. Their training is technology-focused and diagnostics-dependent; as such, it cannot be extrapolated to a village setting.
Scientific studies show that 80% of accurate diagnosis can be made by simply listening carefully to the patient and physically examining him/her. This message does not get through amidst the cacophony of the technological claptrap. Today’s doctors cannot diagnose a brain attack without MRIs and CAT scans. Even a simple tension headache needs a CAT scan to rule out early cancer! Healing outcomes were much better before any of these gadgets were invented. The obsession with tests and reports is more to save the doctor’s skin in this era of consumerist action.
Today’s MBBS courses are top heavy with theoretical information, cramming information for exams, and little hands-on bedside experience. Except during the end of the year examinations, students rarely spend enough time at patients’ bedsides. Doctors-in-training have little time in the midst of ever increasing specialities and the race to get their nose into graduate teaching and evaluation. We need a completely revamped course, much shorter than the present-day MBBS course, with more stress on bedside diagnosis. The filtered lot of terminally-ill patients in the teaching hospital ward setting, gives the student a distorted version of disease incidence and prevalence in society.
The course could be three-year long, with anatomy being taught in the first three months and alternate medical systems’ knowledge being taught in the final three months, along with medicine, surgery and midwifery. The evaluation system should be an on-going process without the need for end of the year exams, except in the final year where the student appears for an all-India test.
We can even relax the entry criteria. Admissions need not be based on the marks obtained in the entrance test, but on a well-devised aptitude test, with pass marks in the so-called 10+2 level as the cut-off. We should foster a culture of the intern ‘following in the footsteps’ of his mentor, in the true sense of the phrase. On successful completion of the internship, the young graduate must be made to serve in a village for five years, before qualifying to go for a one-year condensed MBBS course.
Nowadays, students also avoid the vital internship year during which they are supposed to have hands-on bedside experience. Post-graduation should depend not on the marks obtained in the final examination, but on the number of years of village service—the longer the better. The condensed MBBS course should be devised to fill the gaps in their initial degree course. This will ensure that we have a steady supply of good, humane, clinically trained doctors for our villages. The present public health centres (PHCs) could be closed to make room for village schools as the centre of village health.
The two new ideas, in tandem, will ensure that every Indian village is adequately covered for sickness and healthcare. On each of the topics discussed here, I have been writing exhaustively for years; these are available in books and articles all over the world. These ideas could be modified, depending on local needs. We must move fast in this direction; otherwise, our Western-oriented medical training will produce second-grade doctors for Western hospitals and not for our masses in far-flung villages.
This approach is also fair to the new doctors, since all of them would get an opportunity to go up the ladder, if they do well. In addition, this will deter young doctors from trying to get their post-graduate (PG) degrees without any hands-on experience, immediately after MBBS which only makes them good technologists and very poor doctors. We could then easily abolish the burden of huge amounts of black money changing hands under the table, for PG seats, ranging from Rs2 crore to Rs4 crore per seat, depending on the subject.
(Professor Dr BM Hegde, a Padma Bhushan awardee in 2010, is an MD, PhD, FRCP (London, Edinburgh, Glasgow & Dublin), FACC and FAMS.)