When angels fall…are we lowering the standards of medical education in India?

Medical teachers have been vested in the authority and the enormous responsibility of producing competent doctors. In a sense, they are the angels, who safe-guard the health and well-being of millions of our population. It is not by accident that the first step in safeguarding patient safety is the implementation of high-quality medical training and rigorous assessment methods.[1] The decision to permit a person to practice medicine should not and cannot be taken lightly as it has enormous consequences for the health and safety of patients who may seek the services of this person at a later date. However, what goes on in the name of training and in examinations during the medical course (including in many departments of pharmacology) is pretty appalling, to say the least.

The rot starts right at the very beginning. The reason that private medical colleges are vehemently opposing the National Eligibility cum Entrance Test mooted by the Medical Council of India (MCI)[2] is very obvious. The average plus two marks of students admitted to private medical colleges is somewhere in the range of 50%, whereas in government colleges it will range in the upper eighties. How is it possible for these academically poor achievers in private medical colleges to study medicine which is a very complex, demanding and difficult course by any standards? Once they have gained admission using their financial advantage, these students find the going so tough (or are disinterested) that they stop coming to class which starts a vicious cycle. However, the faculty bend over backwards (or are made to do so) and give them full attendance as per university regulations and give them full marks for internal assessment (IA). A recent shameful incident in which two professors were suspended for giving high marks for a student despite his poor performance, just because he happened to be the son of one of the members of the Board of Governors of the MCI is a rare example.[3] Passing students who have “good” connections is common occurrence and the faculty getaway doing this. Almost all students in private medical colleges have 98-100% in IA, whether or not they have done well in IA, which is why the MCI has scrapped IA marks from being added on to the final examination marks, in the new curriculum.[4] A sound tool which may help a student get good feedback on his or her learning has been abused and made redundant by the very people, who should be rooting for it.

The rot is further cultivated during the summative examinations. Teachers perceive poor performance of students as their personal failure to teach effectively. This is further complicated and compounded by the administration in private medical colleges which ask teachers to explain why students are performing so badly. Teachers try to prevent these awkward confrontations with deans, principals, management and so on by resorting to the easy way out, which is to lower the bar. Questions are conveniently leaked to students, invigilation is non-existent during exams and students are permitted to bring mobile phones into the examination halls so that a “life-line” from a friend is just a text message away. These are not isolated incidents in private medical colleges but those which are happening in government medical colleges too with a frightening regularity which is fast becoming a norm. The so called ′university examinations′ are no better. A random check on the number of “distinctions” in each subject will say it all. From just a handful of distinctions in each subject and many failures in the past, the pendulum has swung to a handful of failures and many distinctions. Do these students deserve these marks? A few may, but not the majority. The mindset that teachers should “push-up” a student is so ingrained, that it has become a rule that no student should be failed in the practical examination. In fact, when I had failed a student in the pharmacology practical examination some years ago, at a nearby medical college, the chairman remarked, “we never fail students in practical exams”. Marking starts with 50% as the lowest mark and 98% as the highest. Even if the student fails to utter a single word, he or she will get at least 50% from the external examiners and 80% or more from the internal examiners. The internal examiners, in their urge to “counter” the poor marks that may be given to academically challenged students by the external examiners, overcompensate, leading to the so-called poor students scoring unnaturally high marks, much above a mediocre student. This leads to a sense of frustration of the average students and even the high achievers. In the end, students stop trying to do their best in medical school, an observation which I am forced to make after watching good students not making any attempt to try their best and settling for mediocrity.

The worst deed of all is the dilution in the content of the subject when teaching. Students are only taught “important portions”. The “important” is meant to be the questions asked in the university examinations. The question papers from the last 15 years or so are taken and these questions are repeatedly taught to students in the garb of “training” them. None of the other so called unimportant stuff is taught. There is a gross disservice being done as students are not exposed to the full breadth and depth of a subject. Topics like vitamins, nutraceuticals, drugs acting on skin and the eyes, essential medicines list and rational use of medicines are either not “covered” or are delegated to be taken by a very junior teacher (also justified as “training the juniors by giving easy”). It is common for teachers to teach just two names of a drug class and ask for two adverse effects of a drug. The pharmacological rationale for choosing a particular drug in a certain therapeutic situation is neither taught nor expected to be asked in the exam. What is expected is recall of simple facts and names of medicines. When important concepts like pharmacoeconomics are taught and examined, these are converted into simple arithmetic sums and the concept is emasculated out of recognition. Students are made to mug up “model” prescriptions and write them at exams. Is this what we want them to learn? The argument is that at least they know the drugs of first choice for fifteen or twenty common ailments, which can be considered “learning”. The reality is that teachers are unable to create a challenging learning environment and develop innovative methods of assessment. For too long we have laid the blame on the doorstep of elementary and high school teaching, without realizing that as higher educationists, we need to lay a part of the blame right at our doorway too.

The attitude of many medical teachers who accept examinership and come (or go) as examiners never fails to amaze me. I have seen examiners spend the least time examining students and urging other examiners to finish fast. Each student is asked just two or three questions at top speed and the examiner moves to the next question even before the student has thought the answer through. The main agenda will be to go shopping or visit some religious place of worship or friends in whichever city they find themselves, or catch the earliest bus or train back home. Evaluation of answer books is fitted into the practical/clinical time schedule or not done at all leaving the officials in the university to “catch” someone else to do the task. An examiner in pharmacology, recently, went off to correct answer books during the practical examinations leaving the internal examiner to singlehandedly assess all the students. The fact that the university was paying him for evaluating the answer books as well as for the practical assessment did not faze him one bit. The internal examiners are expected to be “thankful” for the very fact that these people agree to come as external examiners. Having come, they test the limits of local hospitality to the very core, expecting every meal to be served free and to their taste, local transport, sightseeing and photocopying books and other resource material (free of course!). Examiners are paid well nowadays for their services despite which many universities complain that there is a dearth of examiners as many of them practice and do not want to leave their practices unattended for more than a day or two. The situation in clinical subjects is far worse, with examiners being a rare endangered species. This, I believe, makes a strong case for having only internal examiners for summative examinations - provided these angels can be trusted to be the guardians of their profession.

What should be done about this state of affairs? For starters, medical teachers must learn to say no. We are after all vested with this enormous responsibility of protecting the health of people when they are sick and vulnerable. Why cannot we refuse to compromise on standards? I recently met a young assistant professor who had refused to manipulate the outpatient department case records prior to the visit of the MCI inspectors. How refreshing to meet such people with strong ethical principles. The former vice-chancellor of Dr.MGR Medical University, Dr Mayil Vahanan Natarajan took the bold step of making it mandatory for students to pass each theory paper separately in order to pass in the subject.[5] This is indeed a welcome move and the first example I have seen where a university was attempting to raise the standard. As expected, students have started protesting all over Tamil Nadu, stating that this is unfair and will adversely affect a certain section of disadvantaged students.[6] This is the wretched state of affairs we find ourselves in because for too long we have been apathetic to the falling standards so that it has now become the benchmark. Anyone trying to improve standards is harassed, publicly condemned as being student unfriendly and stuck with a label of deliberately not having the interests of a certain community at heart. Politicians then step in to prevent the tensions from escalating and even the courts seem not to understand the core issue.[6] In silent acknowledgement of our falling medical standards, politicians and their close kin choose to go abroad for their own medical treatment. Would they have the courage to be treated by these medical graduates who do not have sufficient knowledge to make an informed decision? The sad example of many medical teachers being struck off the register of the MCI from a medical college in South India[7] reiterates the rot we are mired in. What we fail to perceive is that these incidents are played out to a larger audience in the West[8] which diminishes the confidence of the global medical fraternity in the medical education system of our country. The deans, principals and directors of many of these private medical colleges are our own brethren. They need to take a call on what they are doing to society at large and the medical students learning in their colleges in particular and learn to say “enough is enough”. Like the Panchatantra tale of the doves which got caught in a hunter's net learning to fly away as a group, carrying the net with them, we need to show the owners of these medical institutions that medicine is not for sale and that the angels will not fall. Are we ready for the challenge?