Medical education needs urgent treatment

Over the last four decades, the dismal state of affairs in medical education in this country has caused tremendous injustice to young students aspiring to become doctors. There has been an unfortunate demise of merit and a steady rise of money power in getting admissions into medical colleges. It would not be wrong to say that Goddess Saraswati has been unceremoniously replaced by Goddess Lakshmi when it comes to medical education.

In the old days, marks obtained in pre-university or equivalent examinations were good enough for admission into a medical college, based on that merit, and life was simple. However, this changed drastically over the years for many reasons, including wrong reasons.

There always was a huge discrepancy between the number of students aspiring to be doctors and the number of seats available and this led to the mushrooming of a large number of medical colleges, mostly in the private sector, and thus began the harrowing experience, year after year, for medical students. They had to take dozens of entrance exams, with the dates sometimes clashing with each other, held in different cities by different medical colleges, consortia, minority institutions, deemed universities and so on and so forth in each state. Even this, unfortunately, was not the end of the story.

Many a time, these entrance exams were used to manipulate the system into selling the seats to the highest bidder, in collusion with the authorities concerned, and most often resulted in merit taking a backseat. It was truly a travesty of justice and a fraud committed on innocent students who had put their hearts and souls into getting into medicine.

It would be unfair to tarnish the name of all medical colleges with the same brush and we have to acknowledge that many medical colleges have had fair selection criteria and have helped produce excellent doctors.

There are around 580 medical colleges in the country, predominantly in the southern and western states and mostly in the private sector, producing about 60,000 doctors a year, but less than one-third of these can get into clinical post-graduate training because of the lack of adequate post-graduate seats. This causes a huge gap in the demand-supply equation, which is the root cause of the corruption in medical education.

The high density of medical colleges, especially of the private ones, in the south is an interesting phenomenon. The first private medical college in the south came up at Manipal in coastal Karnataka which, at that time, was a sparsely populated dense forest area. Kasturba Medical College, started by TMA Pai way back in 1953, went on to become one of the top medical colleges in the country.

The entrepreneurship of the people of coastal Karnataka saw few more colleges in the area. By then, many businessmen realised that students who would not make the merit list were willing to pay handsomely, in the form of capitation fee, for a medical seat. Medical colleges mushroomed in these areas as a result. Southern and western India being dominant in healthcare and education, it was easier to get trained doctors to staff these colleges.

Indeed, a small state like Pondicherry has more medical colleges than all of north-east India, and more medical seats than a large state like Bihar. Many of these colleges are owned or affiliated with prominent politicians or religious institutions, adding more clout to the money power and influence they already had.

The danger of students getting in by paying huge capitation fees is that it may encourage them to indulge in corrupt and unethical practices, first to recover the money spent to get the seat, and then some more. After all, there has to be a return on one's investment!

There was a ray of hope when the National Eligibility and Entrance Test -- NEET -- was proposed a few years ago, but it was challenged in the Supreme Court and the decision was stalled. A review by the court led to the implementation of NEET, which would certainly create a level playing field for all students.

However, there are still many wrinkles that need to be ironed out. The problem of differential fee structures remains and a consensus must be reached on fixing the fee. If needed, a graded fee structure, based on merit and infrastructure of the college, could be worked out. In all fairness, the promoters, who have made huge investments in these colleges, should have avenues to recover their costs, although not at the cost of merit.

Interestingly, the National Board Exams (DNB) for post-graduate studies has the equivalent of NEET and one of the best, non-corrupt, systems of entry and exit exams in the country. The model is working well.

The root cause of the problem is the huge demand and supply gap, which can only be solved by opening many more medical colleges of repute, if need be in PPP mode, to increase the availability of both undergraduate and post-graduate seats. We should also look at encouraging DNB to increase the training programme and look at larger well-equipped, staffed corporate/private hospitals with trained teachers to start post-graduate programmes with a uniform entry and exit exam.

The proposed National Medical Commission bill was meant to address some of the failures of the current system of medical education, which includes the failure to maintain uniform standards of medical education; devaluation of merit in admissions; failure to create any summative evaluation of medical graduates and post-graduates; failure to put in place a robust quality assurance mechanism; heavy focus on nitty-gritty of infrastructure and human staff during inspections; extremely slow expansion of medical education; and failure to instill respect for a professional code of ethics in medical professionals.

The NMC is to end the 'inspection raj', maintain uniform standards by setting up common entry and exit exams, open up post-graduate seats to ease the huge shortage of seats and the bottleneck between under-graduate and post-graduate seats.

The bill, which is still being debated, is also to address some of the issues that have skewed medical education. However, as it is mired in controversy, it remains to be seen what form the final legislation takes. For instance, the exit examination is already out of the NMC scheme. But a resurrection of medical education's glory is possible only when the balance is tilted towards Goddesses Saraswathi.

(The writer is Chairman, Manipal Hospitals)