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Family medicine & medical education reform by P Zachariah
This week could see far-reaching beneficial consequences for health care in India. But we need to ensure that the emerging paradigm shift does not miss out on what medical education can and should do to overcome the inadequacies.

Recent events in our country have been full of sound and fury, which have disillusioned the public with their futility. But this week has the potential for promising developments in Indian medical education which, in turn, could have far-reaching beneficial consequences for health care in India. The Board of Governors of the Medical Council of India (MCI) has been continuously refining its proposals for major reforms in undergraduate medical education. These are to be discussed today with the State Directors of Medical Education and the Vice-Chancellors of universities, who together are the CEOs in this field of education.

The Board has been hard at work on these proposals for some months, with the aid of a designated Working Group for Undergraduate Medical Education. This Working Group, in turn, has been holding wide and sustained consultations with scores of expert groups, which have resulted in a general consensus that major changes are overdue and must occur expeditiously. Thus this week could be a rare, opportune and pregnant moment in the troubled history of regulation of medical education in India. The nation has a vital stake in ensuring that the emerging paradigm shift does not miss out on what medical education can and should do to overcome the inadequacies and inequities in our health care system. And to take our country to the happy consummation of quality assured and universal health care. There should not be a slip between the cup and the lip.

It is important to recognise the special potential and limitations of the present Board of Governors of the MCI, inherent in its origins. The long simmering discontent with the inefficiency and improprieties of the MCI finally erupted when, in April last year, its president was arrested on charges of corruption. The government moved quickly, in May 2011, to issue an ordinance entrusting the considerable powers of the elephantine Council to a small group of six nominated Governors. They were chosen with commendable care, both for their eminence in the profession and their reputation for integrity. In August, Parliament gave its assent to the provisions of the ordinance, but only for a one-year term ending in May 2011.

Thus, on the one hand, for the first time, a small body of reputed experts has the power and, indeed, the mandate to rectify the perceived wrongs of the MCI. They have recognised the need to move quickly on many other fronts as well such as shortage of medical manpower, quality of medical education, shortage of faculty in medical colleges, deficiencies in postgraduate training and so on. The issue of the short period of their trusteeship has now been resolved by extending their term to May 2012.

New medical graduate

Thus the MCI and the Health Ministry together are in a position to consummate this long process of gestation and produce a new Indian medical graduate. And hence the need and urgency to raise in the public domain one crucial aspect of reform of medical education which may not receive the priority it deserves. In spite of the danger of over simplification, the argument here can be stated briefly.

(1) It is generally agreed that the major challenge in health care is in ensuring sound and competent basic health care to the disadvantaged communities, both rural and urban. Indeed, it is an every day experience that even for those who can afford it, dependable and quality assured basic care is a very rare commodity.

(2) This type of care is non-specialised, has to address all common and urgent medical conditions, with limited laboratory and other facilities. It should ensure continuity of care for all members of the family, of all ages. It is mainly ambulatory. And it must include disease prevention and promotion of health, in the family and the community.

(3) Obviously this is not the kind of care that medical students are now exposed to in the so-called teaching hospitals. It is a different kind of clinical practice, usually referred to as Family Medicine (or family practice, though the former is a better term). This can be taught only through a significant exposure to secondary and primary levels of care, the lack of which is the foremost deficiency in Indian medical education today.

(4) Unless and until this component is introduced as a required part of the undergraduate course, India will never be able to solve the lack of competent, well trained, basic doctors in our primary and secondary level health clinics and hospitals. Without this, the proposed new medical graduate will not be the basic doctor who forms the backbone of a sound health care system all over the world and which India sorely needs.

The logic of this is such that a high powered “Retreat” of the Health Ministry on September 28 and 29, 2010 expressed its approval as follows: “Request the MCI to address the issue of curriculum change to make doctors more sensitive to primary health care. Subjects such as Family Medicine need to be given importance.”

But there are many difficulties in this proposal which might result in its being put aside for the present. Health issues have never been a powerful element in our political discourse. They have never been a decisive factor in the elections, unlike in Britain or the U.S. So there is no great incentive for political parties to reflect on or act decisively on the societal responsibilities of medical education.

Electorate easily pacified

In the public perception, sound medical care is equal to access to particular medical interventions and publicised advances in medical care. The electorate is more easily pacified by the offer of medical insurance of the type instituted recently in the southern States. The move suggested above requires the creation of a speciality which hardly exists now. This discipline has to work in close coordination for the State health care system whereas the MCI works at a national level.

Family Medicine is not a field of medical practice that readily attracts the private sector or professionals who make their career decisions based on socio-economic rewards. And, therefore, at this moment in the formulation of the reforms in medical education, there is a special need for all the custodians of Indian medical education, especially the Ministry of Health, to act on behalf of the public to ensure the following:

About 20 to 25 per cent of clinical training, during the “clinical” phase of MBBS, should occur outside the teaching hospitals, at the primary/secondary levels.

Since this is quite different from tertiary care, new departments of Family Medicine should be established in all medical colleges to implement the above.

Either by arrangement with the State health care system or on their own, medical colleges must have sufficient clinical services at the primary/secondary levels to implement the above two. The outlay required for these, in faculty and infrastructure, is minor compared to the prevailing requirements for medical colleges.

There is a tide in the affairs of men. This week has the possibility of a tide which, taken at the flood, could lead to better health for all of us. “Omitted, all the voyage of their life is bound in shallows and in miseries.”

(Dr. P. Zachariah was formerly a Professor of Physiology and continues to engage in issues in medical education.)