Is a revision in medical curricula sufficient to develop ethical and empathic future physicians?

Dear Sir,

Other side of the moon, “Do we need to change the medical curriculum: regarding the pain of others” by Sundeep Mishra, Indian Heart Journal, 167 (2015) 187–191 is very appropriate and timely.¹ Dr. Sundeep has rightly stressed the need for a revision in medical curricula to develop community and health-care oriented, applied educational programs to train skilled, professional, and empathic future physicians who are able to perceive pain, fear, and discomfort of the patient and act on it rather than indulging in detached reasoning thus becoming “Comfortably Numb”. But question is whether it is all possible by only changing the medical curricula or needs much more than that? I think under the hypnotizing influence of globalization, national thinking and policy are oriented towards privatization, corporatization, and liberalization, including increasing trends towards the commercialization of medical education where young doctors are no longer being produced with a view to serve the community rather a market-private-corporate initiatives to get a good return afterwards.

Is medical profession and corporate culture – the two concepts mutually exclusive?

Whether only teaching ethics and empathy to future physicians is sufficient?

1. Globalization and medical education system in India2, 3

Since glorification of privatization and corporatization, India has witnessed a phenomenal growth in numbers of private medical colleges. British India had just 19 medical schools and by 1958, it became 86, to 112 by 1980, and now increased to 381 medical colleges⁴ including 160 government and 188 private medical colleges. Unregulated rapid growth of private medical colleges, poorly implemented regulations relating to admissions, inadequate faculty strength, infrastructure, laboratories, or hospitals as per MCI norms, and still getting permissions under the influence of money or politicians patronage have adversely impacted quality of doctors. Perhaps the worst kind of gross unethical practice happens during inspections of new private medical colleges when busloads of patients are mobilized to fill up empty wards, carloads of doctors are paraded before the inspectors, and even instruments are hired or shifted between colleges.⁵

One revolutionary measure of National Eligibility-cum-Entrance Test (NEET) initiated by the government which would have gone a long way to rationalize medical college admissions and almost eliminated capitation fee was declared unconstitutional by a Supreme Court Bench of Chief Justice Altamas Kabir and Justices Anil R. Dave and Vikramajit Sen in a majority 2-1 verdict in 2013. Commercialization of medical education has affected poor brilliant students and has converted future doctors to become materialistic, self-centered, without values of sacrifice, service, and commitment to the country, a loss that may be difficult to overcome. Medical education today has become a market investment and most doctors go to corporate to get handsome returns.

2. Corporate penetration of medical profession

What has allowed this egregious corporate penetration to take place in an ancient, beneficent, and revered profession that had held itself together as a sacred calling for centuries? Human values, in general, are undergoing steady erosion. Consumerism and materialism, getting ahead in life, and being the envy of friends and colleagues are the rules by which most of us live today. The corporatization of medicine is the natural outcome of the way society is evolving under the influence of globalization and free market system. First, the culture of business and profit making is entering the medical establishment at all levels, starting right from medical education itself. The complete collapse of quality medical education in the form of substandard, poorly equipped medical colleges is perhaps causing the maximum harm. From its beginning in the remote past, the practice of medicine was permeated by a code of ethical conduct. In the Indian tradition, a young student was initiated into medical training only after careful assessment of his competence and suitability. But now students pay huge capitation fees and then go on to try and recover their expenditure by unscrupulous means. The committee for costs of medical care (CCMC) called the hospital as a place of business, its business being medical care. The hospital, however, is a little different. It needs to be a hotel, an industrial plant, a repair and rehabilitation center, a haven of refuge, and often, an educational institution.⁶

The age of “Doctor as God” seems to be at an end. “The new breed of Indian hospitals seems to be marrying trends with facilities, offering patients the best of both. Where then is the place of the ‘Devta Doctor’ in these new ‘Mandirs of Medicine’?⁷ Health care delivery system has become business of health with the entry of corporate hospitals, so several large business houses in addition to their regular business have diversified into the field of health, transformed health care into an industry exploiting a large and available market of illness, access to a ready qualified and trained labor, and the new miraculous state-of-the-art medical technology.⁸ With the rise of the corporate sector, the cycle in health care does not start with a trained medical person and a sick person in search of each other, but with an investor in the share market in search of profitable investment.⁹ The first consequence of the growth of the private sector is the rising cost of the health services, irrational therapeutics, over-prescription, unnecessary use of injections, and over-investigation which are pushing the cost of health care beyond the reach of the poor.¹⁰

What is most significant is however the transformation of doctor's mentality under the hypnotizing influences of globalization. In 1940s, the ideological premise of private doctors was of the responsibility of society to ensure health care to all citizens. Health sector reforms over the 1990s changed the conceptualization of health care from a ‘service’ delivery to a ‘commodity’, with the coming in of the market system.¹¹

Privatization has influenced the perception and practice of medical professional with an increased reliance on high technology, super-specialization, and devalued general practice. Correct clinical approach to patient care is slowly but surely fading from the training of medical graduates today. Even if a course on ethics or empathy is introduced into the curriculum, it may not be able to substitute for the culture of being ethical that was ingrained into students by their teachers and seniors through five and a half years of medical school mainly because of increasing commercialization where non-deserving students have paid large amount of money to get admission and so are least bothered about teachings of ethics or empathy.

3. Conclusion

Medical profession in India is in crisis and society no longer holds it in the high esteem it used to in the past. Today, the general perception is that commercial considerations override the professional and social commitment of medical professionals in a corporate set-up. More and more professionals under the hypnotizing influence of globalization, privatization, and corporatization are disregarding our traditional set of moral, ethical, and cultural standards and are no longer fashionable. We have lost our moral landmarks. With the breakdown of the traditional consensus, there is no more debate. The scarcity of role models for the medical neophyte only aggravates the malady. On one side, there is promotion and projection of health care as a business enterprise and on the other, medical profession is expected to follow medical ethics. This phrase, ‘Doctor, I salute you. You are just like Yam raja, the God of death. While Yam raja takes away life, doctor takes away the patient's life as well as his money’ sums it all.

It is time for us to overcome the inertia of the past and find the way to radical medical education and health care reforms including a change the medical curriculum. But the state, which is supposed to provide ethical and affordable medical education, is too busy concentrating on opening new private medical colleges, because that's where the money is. In our market-driven policies, money and profits have become the yardsticks, not equity or morality, ethics or empathy. Health is a complex issue. A simplistic approach to it is bound to fail. Corruption at various levels, games and gimmicks, lack of commitment, paucity of resources, faulty implementation, weak monitoring, and failure to increased health budget to at least 5% of GDP helped to make the collapse of public medical education and health care almost complete. Unless there is a paradigm shift in the understanding of medical education and its implications on health care system, there cannot be any substantial improvement in the current pathetic status of mentality of young medical professionals, even if medical curriculum includes ethics or empathy. India is an example of private success and public failure. We need to reform our institutions. If our policy makers do not do something, soon things are going to be incurable and beyond repair. ‘Human welfare’ has to take priority over ‘Productivism’. India must resist the market hegemony and change its priorities.

Conflicts of interest

The authors have none to declare. The above manuscript is solely the opinion of authors and the Editorial Board of Indian Heart Journal in no way subscribe to the above views.