Proceedings of the Medical Educators
Item
- Title
- Proceedings of the Medical Educators
- extracted text
-
Proceedings of the Medical Educators
Review Meeting
A
June 1992
B
TOWARDS
COLLECTIVE
COMMITMENT
FEEDBACK
INNOVATIONS
communiTY health cell
Society for Community Health Awareness, Research and Action,
No. 326. Fifth Main, First Block,
Koramangala, Bangalore 560 034.
TOWARDS
A’ COLLECTIVE
COMMITMENT
- Proceedings of the Medical Educators Review Meeting, June 1992
(This meeting was organised as the final event of a research
project entitled "Strategies for Social Relevance and
Community Orientation in Medical Education - Building on
the Indian Experience)
Edited by : Ravi Narayan
Community Health Cell
Society ffor
Community
Health
Awareness,
Research
326, Fifth Main,
First Block, Koramangala,
Bangalore - 560 034.
A
C.H.C. / C.M.A.I. / C.H.A.I. Project
December, 1993
and
Action
TOWARDS
A' COLLECTIVE
COMMITMENT
- Proceedings of the Medical Educators Review Meeting, June 1992
(This meeting was organised as the final event of a research
project entitled "Strategies for Social Relevance and
Community Orientation in Medical Education - Building on
the Indian Experience)
Edited by : Ravi Narayan
Community Health Cell
Society ffor
Community
Health
Awareness,
Research
326, Fifth Main,
First Block, Koramangala,
Bangalore - 560 034.
A
C.H.C. / C.M.A.I. / C.H.A.I. Project
December, 1993
and
Action
C 0 N T EI.N T S
Paqt
Nos.
1.
Background
1
2.
Objectives of Review Meeting
2
3.
Programme
3 - 4
4.
List of Participants
5 - 7
5.
Tasks and Challenges
8 - 13
- individual level
- institutional level
- collective level
6.
Introductory Session
*.
14 - 17
7A. Strateaies for Social Relevance and Community
Orientation-Indian Experience
CHC Medical Education Proiect-I (Session I)
18 — 29
7B. Discussion (Session I)
30
8.
Innovations in Medical Education (Session Il/lII)
8A. Christian Medical College, Vellore
B. Smt. NHL Municipal Medical College, Ahmedabad
32
33
34 - 40
41
C. St. John's Medical College, Bangalore
42 - 43
D. Innovations and Experiments in the Medical
Colleges of Rajasthan
44 - 46
E. Christian Medical College, Ludhiana
47
F. The Consortium of Medical Colleges, New Delhi
48 - 50
G. VHAI's role in Rational Drug use education
in Medical Colleges
51 _ 54
H. The Miraj Manifesto
55 _ 59
I. The NIMHANS initiatives in Mental Health
60
j. The GK Project Medical School, Bangladesh
61
K. The Christian Medical College Network
62 - 63
9.
Report of Day One
10A.
,
Graduate Feedback on Medical Education
CMC Medical Education Project-II (Session V)
68 - 75
11A.
Medical Education for the Real India
-Reflections of a Development Trainer (Session VI)
76 - 82
64 - 66
(Session IV)
10/11B. Discussion (Session V and VI)
,
83-85
12.
In Conclusion
86 - 88
13.
Participant Feedback on the Workshop
89 - 92
14.
Post Script
93 - 99
APPENDICES
A.
Building Collectivity: A Preworkshop opinion
poll
101 -107
B.
Medical Education : In Need of Cure
108 - 110
C.
Training of Doctors for India
111 - 120
D,
Block Posting - An effective method for
Community-based , Community-oriented
Training Programme
: ‘J
121 - 128
Recent changes in Undergraduate Medical
Education at Smt. NHL Municipal Medical
College, Ahmedabad
129 - 132
F.
Three Approaches to Education
133 - 134
G.
Self Assessment Guide - Indian Experience in
Medical Education and Social Community
Relevance
135 - 138
H.
A note and evolving content list of a Faculty
Resource Manual (Book) - CHC Team
139 - 148
I.
An Additional Reading List
149 - 15C
E.
1
1. BACKGROUND
A Project entitled - Strategies for Community Orientation and
Social Relevance in Medical Education - Building on the Indian
Experience was undertaken by Community Health Cell team, (of
the Society for Community Health Awareness, Research and Action)
from April, 1990 till March,1992. As a sort of 'finale' to
this project it was decided to bring together key medical
college faculty, and 'medical education' resource persons as
well as some representatives of voluntary health sector,
coordinating agencies, networks, health policy researchers,
community health trainers and others to consider the findings/
outputs of this study and to explore various forms of follow
up at individual, institutional and collective level.
<
The Project had been sponsored by CMAI and CHAI and apart from
the 4 CMCs (CMC-Vellore, CMC-Ludhiana, SJMC-Bangalore and
MMC-Miraj), it had also established contact with faculty of
many other institutions and organisations through an interactive
research process that had been evolved over the two years.
This research process had included correspondence, surveys,
field visits, informal and formal meetings and circulation of
many reports and reflections. The main objective of this
interactive process had been to increase the collective
commitment to the evolution of appropriate medical education
more in tune with our social realities and community health needs.
This final meeting entitled Medical Educators Review Meeting
(MERM-I) was therefore,
both the formal end of the Project
(the beginning of the end!) as well as the beginning of a phase
of lobbying and collective action (the end of the beginning!)
These proceedings of this two-day meeting in June, 1992 bring
together the key discussions and reflections and ’symbolise the
challenges that will face a 'critical mass' of medical educators
if they decide to commit themselves individually, institutionally
and collectively to an appropriate alternative medical education
that is socially relevant and oriented to community needs of
India.
2. OBJECTIVES OF REVIEW MEETING
I. To consider the findings / output of the CHC/CMAI/CHAI
Medical Education Project and discuss possible follyf-up
within institutions.
II. To share institutional initiatives in the 1980's and
institutional plans for the 1990s in the direction of
appropriate medical education.
III. To explore the
formation of an informal study group
of concerned individuals to carry on collective
reflection on key issues.
IV. To begin to build a collective commitment to change
by networking and communicating informally.
★ ★
3,-
3.
PROGRAMME
20.06.1992
8.00 A.M.
Saturday
8.30 A.M. - 09.30 A.M. Registration
Breakfast
9.30 A.M. - 10.30 A.M. Introductory Session
Welcome & Introduction;
Getting to know each other/self
introductions;
Framework of Meeting.
10.30 A.M. - 10.45 A.M. - TEA 10.45 A.M. -
1.00 P.M. Session I Chairperson: Dr.N.H.Antia
i) Objectives and Methodology
-Dr. Thelma Narayan
ii) Key Findings - Innovations,
promoting factors and
obstacles to change
- Dr. Ravi Narayan
iii) Some perspectives and
outputs (animations)
- Dr. Shirdi Prasad Tekur.
Discussions.
1.00 P.M. - 2.00 P.M. - LUNCH 2.00 P.M. - 3.00 P.M. Discussions
3.00 P.M. - 4.30 P.M. Session II, Chairperson:Dr.Alfred
Mascarenhas
Innovations in Medical Education:
Reports by participating
institutions.
1. CMC-Vellore: Dr. Chellam
Kirubhakaran
2. NHLMC-Ahmedabad Dr.Shubha Desai.
.3. CMC-Ludhiana-Dr.Mohan Verghese;
4. JLNMC-Ajmer-Dr.Shiv Chandra;
5. SJMC-Bangalore-Dr.Dara Amar.
6. BMC-Bangalore - Dr.M.K.
Vasundhra;
4.45 P.M. - 6.00 P.M. Session III, Chairperson:Dr.Alfred
Mascarenhas
4
4
5
5
—
4. LIST OF PARTICIPANTS
NOTE; While the main focus of the Review Meeting was on present
faculty of medical colleges, we had a few invitees who also
represented the coordinating agencies of the voluntary health
sector, health policy research centres, development training,
networking agencies, etc., apart from a few retired faculty
■>
who had shown deep commitment to medical education during
their career and had helped the Project in an advisory
capacity. This mix of participants added a richness to the
dialogue.
MEDICAL COLLEGE FACULTY•
A. Christian Medical College,
Vellore - 632 002.
*1. Dr. Abraham Joseph,
Professor and Head,
Department of Community
Medicine.
2. Dr.Chellam Kirubhakaran ,
Professor,
Department of Child Health.
3. Dr. Sara Bhattacharji.
Professor,
Department of Community
Health.
4. Dr. Molly Thomas,
Professor and Head,
Department of Pharmacology.
5. Dr. B. Madhav Ram,
PG Registrar,
Department of Community
Health.
B. Christian Medical College,
Ludhiana - 141 008.
6. Dr. Mohan Verghese,
Professor of Surgery.
*7. Dr. Alex Zachariah,
Principal.
D. Smt. NHL Medical College,
Ahmedabad - 380 006.
9. Dr. Shubha S. Desai,
Professor of Medicine.
*10. Dr. Varsha J. Patel,
Assistant Professor,
Department of Pharmacology.
E. St.John's Medical College,
Bangalore - 560 034.
11. Dr. Prem Pais,
Professor,
Department of Medicine.
12. Dr. Dara S. Amar,
Professor and Head,
Department of Community
Health.
13. Dr. Ragini Macaden,
Professor and Head,
Department of Microbiology.
14. Dr. G.D. Ravindran,
Assistant Professor,
Department of Medicine.
F. Miraj Medical Centre, Mira-j
15. Dr. R.G. Shinde,
Professor and Head,
Department of Medicine .
16., Dr. Deepak M. Kamle,
Associate Professor,
Department of Surgery.
17. Dr. R.G. Ranade,
Associate Professor,
Department of OBG.
6
6.
18. Dr. Shashi Ranade,'
Department of Paediatrics .
G.Bangalore Medical College,
Bangalore - 560 002.
19. Dr.M.K. Vasundhra,
Professor and Head,
Department of PSM.
H.JIPMER, Pondicherry-605 006
*20. Dr. Asha Oumachigui,
Professor,
Department of OBG.
*21. Dr. D.K. Srinivasa,
Professor,
Department of PSM.
I.King George Medical College,
Lucknow - 226 003.
*22. Dr. Siddarth Das,
Associate Professor,
Department of Medicine.
J.MGIMS, Sevagram - 442 102.
*23. Dr. Ulhas Jajoo,
Associate Professor,
Department of Medicine.
27. Dr. P. Zachariah,
Editor,
Christian Medical Journal of
India,
2/A, Chitteri Road,
Thorapadi P.O.
Vellore - 632 002.
28. Dr. George Joseph,
Executive Director,
Church of South India,
222, Cathedral Road,
Madras - 600 086.
29. Dr. Alfred Mascarenhas,
Principal,
St. John's Medical College,
John Nagar,
Bangalore - 560 034.
30. Prof. S.V. Rama Rao,
72/4, "Prayag",
5th Main, 7th Cross,
Chamarajpet,
Bangalore - 560 018.
HEALTH CARE/HEALTH POLICY
COORDINATING AGENCIES/OTHER
INSTITUTIONS .
A. Voluntary Health Association
of India
K.CMET-AIIMS, New Delhi - 110 029.
*24. Dr. Usha Nayar,
Organising Secretary,
Centre for Medical Education
and Technology,
A.I.I.M.S., Ansari Nagar,
New Delhi - 110 029.
MEDICAL.EDUCATION RESOURCE PERSONS
25. Dr. C.M. Francis,
Director,
St. Martha's Hospital,
Nrupathunga Road,
Bangalore - 560 009.
31. Dr. Mira Shiva,
Head - Public Policy Division
Voluntary Health Association
of India,
Tong Swasthya Bhavan,
40 Institutional Area,
New
Delhi - 110 016.
i
-------------------32. Dr. Pramesh Bhatnagar,
Senior Programme Officer,
Voluntary Health Association
of India,
Tong Swasthya Bhavan,
40 Institutional Area,
New Delhi - 110 016.- -
26. Dr. V. Benjamin,
17, Cline Road,
B.L. Rice Nagar,
Bangalore - 560 005.
7
7
B. Catholic Hospital Association
of India
33. Dr. Mani Kalliath,
.Medical Officer-Urban,
Catholic Hospital Association
of India,
P.B. No.2126,
Gunrock Enclave,
Secunderabad - 500 003.
C. Christian Medical Association of
India
34. Dr. Daleep S. Mukarji,
General Secretary,
Christian Medical Association
of India,
Plot No.3, A-3 Local Shopping
Centre,
Janakpuri,
New Delhi - 110 058.
D. NIMHANS - Bangalore
35. Dr. Mohan Isaac,
Additional Professor,
Department of Psychiatry
NIMHANS, Hosur Road,
Bangalore - 560 029.
E. K.S.S.P. Thiruvananthapuram
*36. Dr. V. Raman Kutty,
Kerala Sastra Sahitya Parishad
Parishad Bhavan,
Thiruvananthapuram,
Kerala - 695 035.
HEALTH/EDUCATION
POLICY RESOURCE
PERSONS
37. Dr. N.H. Antia,
Director,
The Foundation for Research
in Community Health,
84-A, R.G.Thadani Marg,
Worli,
Bombay - 400 018.
39. Dr. Zafarullah Choudhury
Project Coordinator,
Gonoshasthya Kendra,
Nayarhat, Dhaka - 1350,
Bangladesh.
*40. Dr. Palitha Abeykoon,
Incharge-Medical Education
Unit,
WHO-SEARO,
* Indraprastha Estate,
Ring Road,
New Delhi - 110 002.
COMMUNITY HEALTH CELL-BANGALORE
41. Dr. Thelma Narayan,
Member Incharge-Research
and Evaluation,
Community Health Cell,
326, 5th Main,
1st Block, Koramangala,
Bangalore - 560 034.
42. Dr. Shirdi Prasad Tekur,
Member Incharge-Training
and Advisory Services
Community Health Cell,
326, 5th Main,
1st Block, Koramangala,
Bangalore - 560 034.
43
Dr. Ravi Narayan,
Coordinator,
Community Health Cell,
326, 5th Main,
1st Block, Koramangala
Bangalore - 560 034.
NOTE; 10 potential
participants shown with
asterisk could not attend
the meeting eventhough
many of them participated
in the interactive
process preceding it.
38. Mr. Desmond D'Abreo,
St.Joseph's Highlands
Lower Bendur,
Mangalore - 575 002.
8
8.
TOWARDS A COLLECTIVE COMMITMENT:
_5. TASKS AND CHALLENGES
The main purpose of the Medical Educators Review Meeting was to
promote a collective commitment to a process of change in Medical
Education. The group discussions and the plenary sessions were
all geared to identifying possibilities for action at three
different levels:
i. Individual level tasks
ii. Institutional level tasks
iii. Collective tasks i.e., through networking.
From the group discussions on the second day and the final plenary
session, the following key ideas, perspectives and suggestions for
action emerged.
A.
At Individual Level
(While change in education requires commitment at institutional
(management) level and at collective (professional) level, all
the participants felt that much could be done at individual level
to help initiate the process of building a 'critical mass' of
medical education enthusiasts, committed to change, beginning
with oneself. A study, reflection, renewal,experimental and
learning process begin at an individual faculty member level
could itself become the fore-runner of change at the larger level.
For this purpose a diverse range of guidelines emerged. This
list is significant because many of the participants had already
been'change agents' in their own institutions).
1. Start with small creative changes rather than trying to
modify the whole system.
ii. Identify specific tasks within department and among various
departments that can be undertaken by staff and students.
iii. Recognise the dichotomy in our own stated ideas/objectives
and the actual field/classroom realities in training and
set up a system of values and role models for ourselves
as a stimulus.
iv. Reflect and introspect into your own small innovationsbuilding it further step by step rather than waiting for
external correction or evaluation stimulus.
v. Identify and keep track of current realities and the
increasing recognition of the need for change.
........ ....................................................................... .... .... ................................................................. >
.9
9.
vi. Learn from all institutions who have tried changes and
not focus just on the innovators. Even institutions
that do not introduce change have their own expectations
and understanding of the realities that could be
significant. We should interact, learn and share with
them as well.
vii. Study the relevance of the content of current education
to the actual morbidity pattern at community levels and
also in the context of other health needs and available
resources.
viii. Overcome our own fear’s and diffidence to initiate change
and think anew and gain self confidence realising that
it is ultimately individuals who initiate all larger
movements.
ix. Identify and promote ideas from individuals/colleagues
who are from mainstream colleges which are not
necessarily pacesetters.
x. Become members of professional organisations and networks
and attend meetings/workshops to broaden our knowledge
and skills.
xi. Strategies of medical education should include exposure
and involvement to non medical initiatives and efforts
as well. Take interest and get involved in them.
xii. Identify motivating factors that cause a 'change' or
switch in individuals decision making to broaden out.
xiii. Promote interaction with other groups and institutions
who are committed to change.
xiv. Recognise that every opportunity has to be used
creatively to push for change and there are ways of
getting around obstacles.
xv. Develop a 'questioning attitude' among students and
colleagues so as to raise new issues and insights and
promote originality. This prevents frustration from
setting in the process.
xvi. Get started with what you know rather than waiting for
ever to get the best suggestions.
xvii. Sensitise ourselves to national priorities through
analysis and then explore how each of us can be involved
with the promotion of national priorities within our
teaching and work - i.e., locate our efforts in a
social/national context.
.10
10.
\
xviii. Explore and undertake research projects focussed on
national needs.
xix. Accompany students to the community to enhance own teaching
skills at community level.
xx. Focus teaching on essential/core curriculum and mention
challenges at all levels of health care - primary,
secondary and tertiary.
xxi. Understand Health economics and be sensitive to costs of
health care so that one can balance professional excellence
with social relevance.
xxii. Delegate responsibilities and promote skill transfer within
the departmental team. At the community level respect
affirm and support health workers at different levels in
your day to day dealings.
xxiii. In the context of social relevance, some changes in our
lifestyles, and monetary and material expectations are
called for and have to be seen as challenges.
xxiv. We should try and set examination pacers that are more
representative of peoples' needs.
xxv. Encourage feedback from staff and students and create
structures to deal with this feedback.
xxvi. Share the 'new understanding' and ideas about innovations
with other colleagues who were unable to participate in
the workshop.
xxvii. Personally discuss and motivate students to the challenges
of changing educational system towards greater social
relevance.
xxviii. Promote staff-student relationship on the guru-shishya
model an-’ promote dialogue at all levels.
xxix. We shoulc strive to become 'role models' to enhance this
change effort and improve our communication skills as well.
xxx. Must involve more deans and principals and government
medical college staff and health decision makers and
planners in all our meetings.
-Z
. .11
11.
Al. Some individual participants made some personal
commencements to undertake tasks to support the emerging
collective commitment .
i. To promote importance of 'ethics' and 'value system'
-at all levels (Dr. C.M. Francis).
ii. To incorporate the concept of social relevance into
all our training programmes (Dr. Mohan Isaac).
iii. To equip students better in obstetric skills keeping
the new understanding and orientation in mind
(Dr. Ranade).
iv. To develop a measurement instrument for monitoring
attitude change (Dr. Dara S. Amar)
v. Promote communications between individuals and
change agents (Dr. N.H. Antia).
B. At Institutional Level
i. Start Medical Education Cell (ME Cell) in each
institution having representatives of various
departments and organise regular informal meetings.
ii. Initiate teachers training programmes in conjunation
with National Teachers Training Centres at Pondicherry,
Chandigarh, Varanasi, etc. Identify enthusiastic staff
who can be sent for training to such centres. When a
core group of trained staff are available, then
initiate institutional based training for all staff
of the institution at all levels.
iii. Study the innovations and recommendations that have
arisen out of the CHC project and try to apply/
introduce it into the institution after discussions
in the ME Cell.
iv. Organise similar workshops and medical educators
dialogue for regional groupings of medical college
including government institutions to enhance the
dialogue and sharing of experiences.
v. Teachers should be encouraged to apply 'learnings of
workshop' in day to day teaching efforts i.e., setting
up institutional/departmentalinstructional objectives,
new evaluation procedures etc. Every department
should be gradually involved in these efforts.
. . 12
12.
vi. Find ways of enhancing student participation and fbedback
in all institutional efforts.
vii. Constantly sensitise staff and students to the institutional
goals. Discuss the objectives of the institution with
students atleast once a year.
viii.
The institutions must build up a good collection of audio
visual aids and other aids to teaching based on the newer
concepts of education.
ix. Students should be exposed more and more to the community/
field realities of health care in the training programmes.
x. The graduate feedback study undertaken by CHC should be
compared with similar studies which could be undertaken by
institution on relevant samples of their own graduates and
feedback for further action generated.
xi. Evolve ways of dealing with political interference in
institutions and get around obstacles.
xii. Analyse the situation and streamline the process of change
using every opportunity to encourage staff towards
innovation.
xiii.
Develop a health information system that can support
change and a monitoring system that can keep track of the
process.
xiv. Create greater awareness of the 'medical education
situation' and the urgent need for change.
xv. Look into the problem of gender discrimination within
medical education and institutional effort.
xvi. Evaluate institutional effort in a more detailed and
rigorous matter.
xvii.
Explore further the possibility of a premedical
orientation course of 6 months - 1 year which could be a
preselection course to look for aptitude of students.
Explore the 'practical' and 'legal' difficulties that
may be encountered and try to overcome them through
creative planning efforts. This course would help to
enhance the selection process and minimise the wastage of
efforts.
xviii. Identify institutions and projects involved in community
services with whom the pre-selection course could be
organised. The same projects could also be involved in
community phases of curricular training programme and
staff and students could be given opportunities for
exposure.Such programmes could also be given greater
weightage.
..13
13.
xix. To encourage all graduates to work for 2-4 years as a
compulsory posting in peripheral health care institutions.
To learn from the experience of other institutions who already
have such rural bond/placement schemes.
C. At the Collective Level
i. Promote and actively participate in alternate Networks of
Medical Educators.
ii. Formalise these groups and networks to enhance the voluntary
but collective monitoring of change in medical education.
iii.
Promote further interaction and dialogue among members of
the network - enhancing the sharing of experimentation and
innovation.
iv. Create awareness and involvement of network members in
larger health related issues other than merely medical
education as at present.
v. Identify guest faculty from the network institutions for
training programmes in other member institutions.
vi. Organise meeting with senior opinion makers and key
decision makers in the region/national level and promote
our objectives and perspectives among them.
vii.
Promote 'public debate' and explore mass media publicity
of our efforts, initiatives and emerging objectives.
viii. Create a system of honouring health workers who have
promoted these objectives at appropriate times rather than
posthomously or after retirement.
ix. Work with Medical Council of India and other policy
making bodies and associations to promote these perspectives
and shared commitment.
x. A network of medical education cells should be initiated
so that institutions can learn from each others experience.
*
★
★
. . 14
14.
6 . INTRODUCTORY SESSION
The Introductory session of the meeting consisted of fcur
subunits:
A. WELCOME
The participants were welcomed by Dr. Ravi Narayan, Coordinator.
of the Society for Community Health Awareness, Research and
Action (Community Health Cell, Bangalore) on behalf of CHC
(the host); CMAI-New Delhi and CHAI-Secunderabad (the sponsors);
and the CMC-Network, which were the supportive peer group for
the project.
The participants represented an interesting network of medical
education enthusiasts who had been identified and brought
together by the process of the CHC Project. These included:
i. Some Deans/Principals (current/retired) of Medical
Colleges;
ii. Some faculty of medical colleges;
iii. Representatives from coordinating agencies in health
including VHAI (New Delhi), CMAI (New Delhi), CHAI
(Secunderabad) , CSI, Ministry of Healing (Madras).
(Some members were also part of training network/fora
like CMC Network; the newly evolving consortium of
medical colleges; and IAAME.
Special Invitees
Three special invitees and resource persons were also welcomed
and introduced to the participants. These were:
i. Dr. N.H. Antia - plastic surgeon and leprologist who was
a participant of the ICSSR/ISMR study group on Health for
All - an Alternative strategy and a key policy promoter
of alternatives in health care and training.
ii. Dr. Zafarullah Choudhry - the charismatic leader of the
Gono Shasthya Project in Bangladesh - which had innovated
a health workers training strategy; facilitated the
well known Rational Drug Policy of Bangladesh and was
presently involved in considering the evolution of a
relevant community based medical college for that
country.
iii. Mr. Desmond Abreo - Development theologian and well
know social activist - involved in the evolution of
—---------------------------------------------------------------- --------
> . .15
15.
alternative strategies for training for the development
sector in the country.
The presence and participation of these three people was a
source of much inspiration to the group.
The participants were welcomed to the Garden City, to this
two day dialogue-to get to know each other and share each
others hopes and plans.
B. REFLECTION ON THE GANDHIAN TALISMAN
To set the mood for the meeting and to bring in the peoples
perspective a two minute silent reflection was suggested on
a quotation by Mahatma Gandhi:
"Whenever you are in doubt recall the face of
the poorest and most helpless man who you may
have seen and ask yourself if the step you
contemplate is going to be of any use to him...
will it restore to him a control over his own
destiny?".
C. Then using slides, an introduction was given to the meeting,
the background of CHC's interests and efforts in medical
education; the linkage with CHAI and CMAI and the newly
evolving CMC Network; the evolution of objectives of the
Project; and the linking of the project objectives as a
preparatory step towards the facilitation of a medical
education cell and a faculty development programme for a
potential alternative track experiment evolving at Miraj,
Maharashtra.
D. To give the opportunity for all participants to get to know
each other, a self introduction session then followed.
This short session helped to bring out the diversity and
multi faceted experience of the group that had been gathered
for the review meeting by CHC. Apart from the organisations
mentioned earlier. The disciplines included:
Medicine, Surgery, Obstetrics & Gynaecology, Paediatrics,
Preventive & Social Medicine/Community Medicine, Psychiatry,
Plastic Surgery, Cardiothoracic Surgery, Microbiology,
Anatomy, Pharmacology, Physiology, Health Planning, Social
Work.
. .16
16.
The participants brought many concerns and expectations to the
meeting. These included:
- 'Concern about what was going wrong with the orientation of
medical students from prestigious medical colleges especially
Christian.'
- Interest to dialogue with health trainers from the background
of intense involvement in development training.
- Sectors know so little about mental health in primary health
care. What can we do about it? How do we get over this
1acunae?1
- 'involvement of medical college faculty and social conscious
doctors in wider issues. Also support the prevention of
'Zombification' of medical education, by moving with the
'enthusiasts' and by passing the 'resisters'.'
- 'Get ideas from those who have tried earlier to help get ideas
for a formative project of an alternative track.'
- Came to learn how to get students more interested in community
medicine issues, which are often low priority among students.'
- Crabbed opportunity of attending meeting to learn from
experience of others and share the experience cf own institution. '
-'Concern about the medical education system and what is
happening to it with an interest to share this understanding
with policy makers to lobby for change.'
-'Keen to learn how to implement changes and how to change
examination system which is the key to change. '
-'Concerned about lack of dialogue between health services and
medical education with medical college faculty being ignorant
of needs of doctors in the health services.'
-'Plan to start a community based medical college hence keen
to share ideas and listen to the experience of others. '
-'Concerned about the erosiam of ethics and values among
students and the growing phenomena of education and health
services not being need based.'
- 'involved in the training of a range of medical and non
medical groups and apart from sharing this experience, wish
to explore what and how can be taught in (i) behavioural
sciences and (ii) Ethics.
-'Represent CMAI the oldest network with 2 medical college and
80 schools of Nursing - what are the new directions and
challenges?
17
-'Concerned about where our medical graduates go after all our
efforts at reorientation.'
-'Having been responsible for the original stimulus to the
study, wish to be a spectator to see what others say and feel
about the needs and the process.'
-' Torn between the requirements of academic excellence and exam
regulations vs. what our country needs and concerned about
how do we step down from the Ivory tower to reach the community.'
-'have long been involved in medical education and having made
lots of mistakes keen to hear about the exciting alternatives
that are being suggested.'
-'Want to be exposed to new strategies and also be open to
unlearn some of the irrelevant ideas that orthodox medical
education has promoted.'
-'Studied the concept of community orientation in medical education
as topic for post graduate thesis and interested to meet and .
learn from' other enthusiasts.'
At the end of this sharing session what became very obvious to
the group was that'round the table' - there was a collection of
highly motivated medical education enthusiasts- bringing together
much concern - much experience - much reflected wisdom and a lot
of openness to reflect on mistakes and uncomfortable realities
- All in all a very good ethos for serious dialogue.
After the self introduction session the two day programme end
some of the organisational dynamics was shared with the
participants by the organisers.
After tea - the first session was devoted to a presentation of
the background, objective, methodology, findings and outputs of
the CPC Medical Education Project by the ChC learn -(Dr. Ravi
Narayan, Dr. Thelma Narayan, and Dr. Shiroi Prasad Tekur) using
summarised dates, visuals and cartoons on OHP sheets.
A summary of this presentation follows.
18
IP.
7-A. SESSION-I
THE CHC PROJECT: Strategies for social relevance and community
orientation - Building on the Indian experience.
An_Overview *
An interactive Research Project with the above title was conducted
by us from April, 1990 till June, 1992, sponsored by the
Christian Medical Association of India (CMAl)-New Delhi, and
Catholic Hospital Association of India (CHAI)-Secunderabad, and
supported by a newly emerging Network of Christian Medical
Colleges in India (CMC Network).
The Society is a secular, professional resource group which has
’evolving educational strategies for promoting community health
action in the voluntary and governmental sector as among its many
obj ectives.
The researchers had a long history of interest in appropriate
medical and health humanpower education, which included a decade
in community orientation of medical education at St.John's
Medical College - Bangalore (1973-83) and many initiatives towards
evolving an appropriate training strategies through the Community
Health Cell, a grassroots technical resource centre, which they
coinitiated and facilitated since 1984. All these initiatives
and reports (1973 to 1991) were brought together in a
mimeographed report entitled 'Step by Step' as the first output
of the Project.
Premises of Study
The first premise of our interactive study was that there are
atleast four sectors of innovation from which stimulus for
reforms in medical education can and have emerged.
i) The Expert Sector - Starting from the Bhore Committee
Report of 1946 till the recently circulated draft outline
of the National Education Policy for Health Sciences
(Bajaj Report), there have been a series of expert
committees in India offering ideas and recommendations of
great relevance to the Indian situation.
ii) The Medical College Sector - Some medical colleges have
made serious efforts to operationalise some of the expert
'ideas' and recommendations and some have gone further to
evolve community oriented training strategies. Much of
this reform is within the framework of 'structure' and
'function' stipulated by MCI.
The 'medical college' sector includes ideas and
recommendations put forward by professional associations
at their annual meetings and also covers much of the
s-----* presented by the CHC Team.
-------------------- ——. 19
19.
materials that has been regularly presented and discussed at
the annual meetings of the IAAME.
The 'Expert Sector' and the'Medical college Sector' would
together constitute what we would like to term as 'traditional/
orthodox expertise'.
iii)
'Voluntary' Training Sector
Since the 1970's a large number of innovative community health
oriented training programmes for health humanpower has
developed especially within the so called voluntary/nongovernmental sector. Many are geared to training or
reorienting doctors and nurses (produced by the orthodox system)
towards community health oriented work. Many others train
'lay people' (non-doctor, non-nurse) in community health work.
a large number of
‘alternative training experiments'
supplementing these efforts have also emerged in the
development and informal education sector. While these may
appear to have developed in a 'separate universe' there is
growing recognition that their pedagogical innovation,
approaches and focus have great significance for professional
humanpower education in the country.
iv) The 'PHC graduate' sector
There are a large number of young graduates of the existing
orthodox medical education system who have worked in small
peripheral rural hospitals, primary health centres and
community health projects and have had to creatively adapt
their own inadequate education to the ‘professional challenges'
and 'emotional demands' of community oriented health care.
Most of these 'creative tensions' and 'appropriate responses'
and ideas are waiting to be systematically tapped and explored.
The ‘Voluntary training sector'and the 'PHC graduate sector'
would together constitute, what we would like to term as
the 'alternative' expertise.
B. The second premise of our 'interactive study' was that while the
above sectors of 'innovation' have, separately and taken together,
a lot of interesting ideas to offer to all of us who seek to
reform medical education, there is inadequate documentation and
reporting and inadequate networking and hence this expertise lies
relatively unknown within sectors and between sectors. Medical
College based innovators know tlittle of what each other are
doing; the voluntary sector trainers have little dialogue even
amongthemselves; the graduates in the periphery are seldom
contacted for feedback; and therefore there is a 'gross' lack of
awareness of the wealth of experience available in the country
itself. This is further accentuated by the fact that medical
education experts and policy makers, being unaware of the
:.2O
20.
diversity and multifaceted experience in the country, tend
to get carried away by ideas and 'expert advise' that have
originated in other countries - in situations of different
socio-economic cultural conditions and rather different
educational systems. Many policy recommendations and reforms
are therefore not adequately grounded in local realities and
local experience.
C. The third premise of our study is that there is not only little
knowledge in the country of local experience in all the sectors
identified earlier but there is also the additional problem
that innovaters within and without the system have not
subjected their own 'innovations' or 'reflections' to any type
of objective evaluation and or peer group assessment. In some
instances, where this may have been attempted, the results are
not available to others to learn and reflect upon.
The objectives of the Project were:
1. To document descriptively / analytically - key recommendations/
experiments / innovation/ experience in medical education.
2. To review key alternative training experiments to identify
issues, perspectives, ideas, pedagogy relevant to medical
education.
3. To build an Anthology of Ideas from a sample of recent medical
graduates with primary / peripheral health care experience.
The methodology of the study was multipronged and multi
dimensional including classical approaches such as literature
review; survey of medical colleges; a survey of graduate feedback,
based on experience in peripheral health care institutions; an
overview of training programmes in the alternative 'voluntary'
training sector. It also used interactive approaches such as
peer group correspondence and meetings, and field visits to
colleges and group discussion with faculty and interns, and others.
The medical college survey and literature review lead to the
identification of 32 colleges out of a sample of 125 colleges,
who has tried out some ideas or innovations in this area. Totally
50 initiatives were identified which could broadly be classified
into six broad thrusts:
a)
b)
c)
d)
e)
f)
Improving pedagogy and educational technology.
Widening horizons.
Improving skill development.
Moving beyond the teaching hospital.
Transcending existing compartmentalization, and
Promoting self learning.
. .21
21.
These initiatives were also divided into five sub-groups:
a)
b)
c)
d)
e)
General objectives and curriculum contents;
Preclinical phase;
Paraclinical phase including community medicine teaching;
Clinical phase; and
internship.
The initiatives in each category included:
a) General obj_ect_ives_and_curriculum structure
1. Defining Institutional Objectives
2. Defining Intermediate (Departmental) and Instructional
obj ecfives
3. Development of Medical Education Cell with adjunct faculty
4. Faculty Training Programmes in medical education skills
5. Selection Procedures other than academic merit (Psychological/
Social skills/leadership/value orientation)
6. Curriculum development including
i.
ii.
iii.
iv.
integration
identification of core abilities
prioritization (curriculum planning committees)
identifying skills
7. Examination Reforms
i. objective examinations
ii. restructuring assessment towards HFA/PHC priorities
8. Faculty/student involvement in Medical Education feedback/
research.
9.
10.
11.
12.
Tutorial system
Student electives
Students involvement in Research
Regular faculty meeting/facuity-student meetings
i. curriculum issues
ii. Social-Societal issues
13. Student nurture programmes - curricular/extracurricular
14. Rural Bond (Placement) Scheme
15. Continuing Medical Education for alumnus/others
b) Preclinical phase
16. Foundation Course for entrants
17. Community-based orientation programmes
18. Introduction of New Subjects
i.
ii.
iii.
iv.
v.
Behavioural Sciences
Ethics
First Aid
Nursing
Integrated Growth & Development
. .22
22.
19.
20.
21.
22.
Clinical Orientation in pre-clinical phase
Humanisation of pre-clinical practicals
Samaritan Medicine - interpersonal skills
Urban-slum based-multi-disciplinary student programmes
C. Paraclinical phase including community medicine teaching
23. Reorienting Pharmacology Training
i. Rational Therapeutics
ii. Essential Drugs Concept
iii. Clinical Orientation
24. Synchronisation of para-clinical subject lectures with
clinical teaching
25. Involvement in Integrated teaching
27.
28.
29.
i. Para-clinical and clinical subjects
ii. Clinico-Pathological-Social Case Conference
Community Based Family Care Procramme/Family Health
Advisory Service
Community Block Posting (First Clinical Year)
Junior Clinical Clerkship
Special Training Programmes
30.
31.
32.
33.
i. Epidemiology
ii. Biostatistics
iii. Health Education
iv. Clinical Epidemiology
v. Management
vi. Health Economics
Rural/Urban Slum health visits/camps
Community Block Posting (2nd Clinical Year)
Senior Clinical Clerkship (2nd Clinical Year)
Epidemiological / Public Health Projects.
26.
D. Clinical phase
34.
35.
36.
36.
37.
Integrated Teaching (interdepartmental)
General Cutpatient Department (GCPD)
Curative/Preventive General Practice Unit (CPGP)
Clinical Clerkship in Primary Clinical Departments
Training in
i.
ii.
iii.
iv.
Emergency Medicine
Social Paediatrics
Social Obstetrics
Clinical Pharmacology
38. Community visits by Clinical Departments - Camps and
regular clinics in Rural/Urban field practice areas
39. ROME Scheme
40. Interdepartmental Coordinated Clinics in Hospital Programmes
41. Peripheral Hospital Postings
i. TB
ii. Leprosy
• .23
23.
iii.
iv.
v.
vi.
Eye Hospital
Rehabilitation Centres
Isolation Hospital / infectious diseases
District / Peripheral Hospitals
E. Internship
42.
43.
44.
45.
46.
Interns orientation programme
Community Health postings in Rural/Urban field Practice areas
Community based camps/clinics by clinical departments
Posting to Government PHCs and sub-centres
Involvement of interns in special situations
i.
ii.
iii.
iv.
v.
vi.
Epidemic control
Disaster relief
Plantations
NGOs Health ^rejects
Immunization programmes
FP motivation
47. Involvement of Interns in Primary Health Care Training of
Health Workers, Dais, Auxiliaries
48. Internship training in specific additional skills
i.
ii.
iii.
iv.
v.
vi.
Rational Drug Use
Management
Ethics
Health Education
Epidemiological Projects
Clinical Research
49. Internship training in special clinics in Hospital SituationCurative General Practice Unit/GOPD etc.
50. Internship Assessment / Evaluation.
6 pacesetter colleges were identified and some general features as
well as key innovative strategies were outlined. The common
features of pacesetter institutions were:
a)
b)
c)
d)
e)
f)
Established with specific / focussed mandates.
Smaller number of admissions (50-70).
Autonomous or private management.
Own entrance examinations and selection procedures.
Adequate teaching hospital beds.
Well organised rural and urban field practice areas.
10 key factors that promote change in a medical college curriculum
were identified which included:
a) institutional mandate;
b) institutional objectives;
1
■
■
-<.24
24 .
c)
d)
e)
f)
f)
g)
h)
instructional objectives;
medical education cell; a faculty development process;
field practice areas;institutional policy supporting community
health;
cultural transformation and value orientation;
networking and dialogue; and
reflective evaluation.
12 obstacles or barriers to change were also identified by the
interactive approach in the study and described as twelve
'pathologies'. These were:
1. Mental Disorientation
A confusion in medical college leadership objectives about the
change process is the first important carrier. This manifests
as a confusion - primarily between the pursuit of technical
excellence for the sake of professional satisfaction versus the
pursuit of technical excellence for the sake of social relevance
2. Nystagmus
The second important barrier, which is complementary to the
first is the absence of clearly defined institutional and
instructional objectives leading to a continuous shift in focus
between primary health care orientation and tertiary health
care orientation in all the efforts.
3. Optic Atrophy
Continuing 'cultural colonialism’ manifesting in the belief
system that 'what is west is best1, results in the pursuit of
some ill defined International NBBS standard. In practice it
means that community needs, socially relevant issues, local
health culture and tradition and local grassroots innovation
are outside the field of vision of medical college faculty.
This reduced field of vision, limits the stimulus for change.
4. Anemia
Promotion of individual professionalism, or at best
departmentalism, in career advancement rather than collective
institutional team work, results in weak individual responses
to reform. Sometimes the change process is unidepartmental
making little dent on the system and causing the efforts to
become rather anaemic.
5. Cancer
Inadequate management planning including improper financial
resource management, lead to an initially insidious, and
later rapidly growing, entry of the cancer of market economy
in medical practice, cost of services, prescribing and
. .25
technology policies in the institution. This defeats the
purpose of reform by bringing in double standards.
6. Manic-Depressive Psychosis
When planning for change far outweigh implementation of
change, there is increasing rhetoric and simultaneous growth
in faculty cynicism or dissatisfaction. The institution then
passes through, manic phases of planning followed by
depression, caused by limited funds, flagging institutional
leadership and inadequate follow-up.
7. Atopia - Allergy
Absence of viable and effective linkages, between colleges
and the 'teaching community1 and the health care delivery
system beyond the teaching hospital, results in adhoc,
irregular, ill planned community exposure programmes that
cause 1 allergy rather than enthusiasm in the students. This
atopic response severely affects the reorientation process,
with community based experiences becoming couter-productive.
8. Atherosclerosis
Bureaucratization and routinization of effort leads to changes
becoming statutory and imposed - promoting an atherosclerosis
of creativity. This is also symbolised by the absence of
active feedback from students, faculty and community, to
modify programmes and keep them responsive to change. This
leads to a resistance, to new ideas and decreased circulation
of enthusiasm towards community orientation.
9. Schizophrenia
The growing dichotomy between community medicine and clinical
medicine is a serious obstacle, caused atleast partially, by
the creation of separate preventive and social medicine
departments and forcing a rural orientation mandate on their
faculty. This has meant, that while one department pushes
towards the health care challenges of 'Interior India', the
rest of the departments feel psychologically free, to push
towards the 'East Coast of USA'. This growing dichotomy,
produces schizophrenic responses in students and faculty,
al ike.
If PSM Departments also show these schizophrenic responses,
then it can be disastrous for change.
10. Graft Rejection
Caution is required in the planning and evolution of
community oriented experiments and innovations. Care must
be taken to ensure that, the problems caused by transplanting
western high technology hospital models are not repeated
26.
when we accept 'community oriented education models' that
have been developed in different cultures, health care systems
and educational systems.
While we need to learn from different experiments all over
the world, we should critically evaluate ideas, in the
context of our own, rather different, socio-economicpolitical-cultural realities, as well as different educational
environment and aspirations. This will prevent costly and
painful graft rejections, at a later date.
11. Autism
The danger of too much rhetoric and too little active
promotion of change by management; or of discontinuous
experiments, waxing and waning in intensity leads to autistic
response in the faculty and more and more of them insulate
themselves and withdraw from involvement in change. This is
not an uncommon feature of many institutions including those
with histories of pioneering efforts in the past.
12. Senile Dementia
Finally, the most important barrier to change is a
combination of commitment to status quo; a defensive response
to critical reflection and evaluation; a rationalisation of
inadequacies; and a lack of openness to criticism and new
ideas.
These lead to the setting in of a senile dementia in the
institution. Management and leadership controlled by the
'orthodoxies' of Secondary and Tertiary Health Care
professionals sustain this response greatly.
The challenges for the 1990s identified by the Project were:
1. Urgent Need for chance
There is a growing disatisfaction with all aspects of
medical education - the content, the focus, the methodology,
the process and therefore there is urgent need for action.
2. Multi pronged effort
This action has to be part of a multipronged effort at
different levels of the system
* At policy making;
* At human resources planning;
* At administration, governance and organisation of
medical education;
* At social control of medical education;
* At health care service delivery linkages and a host of
other levels as well.
. . 27
27.
3. Curriculum change
A change in the curriculum - in objectives, content, focus,
methodology and training base has to be an integral part of
this effort and within the context of the broader framework
of change.
4. Emerging new Framework
The emerging alternative framework could induce the 50
strategies that have been identified by the survey, building
creatively on the diversity of experiences of atleast 25 or
more colleges, that have attempted 'change1 and constitute
the Indian orthodox experience.
5. Experimental Curriculum
There is urgent need, to evolve the concept of an experimental
parallel track or curriculum and allow a few selected colleges,
to integrate these 50 strategies and go beyond, the constraints
of the existing compartmentalisation of phases and examinations
in medical education. Colleges selected for this purpose,
must have demonstrated their competence to evolve, sustain
and evaluate the process of change.
6. Graduate Feedback
Our survey of graduates, with experience of work in peripheral
health care institutions, has demonstrated, that this sort of
feedback is an essential component of the planning of medical
It helps us, to move from
education and curriculum change.
’empiricism1, to change, derived from experiential feedback
and inquiry.
7. Positive Factors for change
10 factors described in this study have been identified as
those that promote and sustain change. .Medical College
leadership must promote these positive factors, actively in
the 1990s.
8. Negative Factors affecting change
have been identified
12 factors described in this study
as those that act as blocks or barriers to change. Medical
College leadership must counter these negative factors
actively during the 1990s.
9
Inspiration from Alternatives
Many emerging alternative formulations, prescriptions and
training experiences have been identified. These should be
taken seriously and must inspire the efforts at moving
medical education from the tertiary care situation to the
. .28
28.
29.
from 1992. Unfortunately due to change in government regulations,
this experiment could not start up. It is however hoped that
the publications will continue to be a stimulus for all those
who seek to experiment with alternatives even within the somewhat
compartmentalised existing structure of medical education in
India.
For further details and information, refer tc
the published report entitled "Strategies fcr
Social Relevance and Community Orientation Buildinc on the Indian Experience", (1993),
new available on request from CHC, Bangalore
(trice
40-00).
. . 30
30.
7-B.
DISCUSSION
- SESSION - I
The presentation of the CHC project overview was followed by an
animated discussion among the participants, who offered interesting
comments and raised many significant issues in the light of the
findings of the Project.
The salient issues and questions raised were:
i. The study has shown that there are things being done in India
within the constraints and many of us do not know about it.
It is heartening to note that it is happening not only in
private relatively autonomous colleges but also in some of
the government colleges. There are resources, experience,
and expertise available. How do we use them to promote the
positive factors and avoid the pathologies. In many of the
innovations,individuals have played the crucial role as
'a committed believer'. This must be emphasised. How can
such individual be identified? and supported?
ii. There was need to look for ideas and answers within each
institution, each region rather than always looking out for
answers from an external agent.
iii. Students and interns were obsessed with postgraduate
examination system and this affected their openness to
change / reform initiatives.
iv. While rural placement scheme after internship was a good
idea many students were scared to loose two years in
seniority if they opt for the two year rural experience.
v. Students nowadays are motivated towards superspecia]ities
and specialities rather than general practice. How can
this be countered?
vi. Students are often pressurised for time especially in
preclinical course which have rather detailed syllabus.
They and the staff are concerned how to finish Anatomy
and Physiology portions in existing curricula. Hence any
additions would mean extending the course (!)
vii.
The image of preventive and social medicine department has
to change to a more facilitatory role so that each
department can begin to identify what they can do in the
context of these alternative visions and objectives.
viii. For efforts to be successful, the innovators must be
linked with administration. This is an important pre
requisite .
•..31
ix. Reduce gap between what is often professed and what is the
reality at the training/field level.
x. There is need for a spirit of innovation and change suited
to particular local situation. It is not enough to just
repeat the 50 ideas that have been identified by the project
though they may have innovative elements. All innovations
must be critically examined and experimented with.
xi. For implementation to be successful croups of staff and
networks of enthusiastic colleges need to be involved in
the process of change.
xii. The selection procedures tried out by St. John's Medical
College was very interesting. Has any follow up on the
impact of these ideas been tried out?
xiii.
Faculty development should be priority. There is alsc
need for prioritization in efforts as well as need to
get a peoples perspective as well.
xiv. There is need to break walls and get further autonomy.
There is need to get out of the shackles of an affiliating
system which prevents experimentation.
An all India movement
for autonomy in medical education is required.
xv. Is a Health University a good idea or will it promote a
monoculture? We need to address this question seriously
in the Indian situation.
xvi. We need to share experiences more and more.
to share our failures.
xvii.
We also need
There is need to publicise the findings of this study
and also to follow up with more studies as well.
xviii. Medical education is ultimately a sub-set of the health.
service which is a sub set of the larger society with
its social-economic-political dimension. Change in one
must go hand in hand with change in the broader system
and vice versa.
xix. There is need to look at other systems of medicine eg.,
role of Ayurveda to help develop a more integrated,
technically, economically and culturally sound system.
xx. There is need to move from illness orientation which is
still so prevalent to a health orientation. What role
can medical education play in this transformation?
32
xxi. While talking about attitudinal changes and career options
are we underplaying the increasing materialist ethos of
our Society? Doctors still see lucrative practice as an
important coal of medical education? Most of the
sabatticals from medical colleoes are nowadays to Middle
East to make money? Can Medical students be expected to
have different values?
xxii. Finally, it was again reiterated by many that the most
heartening fact from the study is that so many efforts are
being made to change even within the existing system.
Many of us do not realise how much freedom we have and how
much leeway for innovation, exists even within the so
called MCI regulation constrained curriculum? In this
context the proposed MCI Meeting on Need based medical
education planned for 1992 August was welcomed and it was
hoped that some further changes would be considered to
increase the possibility of reform and pursuing innovative
ideas.
ANP COMMUNITY HEALTH TfiAiHfBJ
MEDICAL
imclupep
in
srupy
— a rcgioHat disf nbn&pn.
- McWi'caJ Colics (64*1-32)
O -
Trwhtfl .(totaZ-22)
SESSION Il/lII
8. INNOVATIONS IN MEDICAL EDUCATION
Since many of the participants represented institutions that had
been involved in changing medical education and developing
alternative ideas and innovations (which had been the focus of
the CHC Medical Education Project), this session was organised to
oive
all the participants an opportunity to listen at first
hand from some of the innovators and pace-setters themselves so
that some details as well as the feeling for the process of
change could be shared as well. Two sessions were held.
The first one focussed on Medical College initiatives at
institutional level and some experiences were shared from
CMC (Vellore), Smt. NHL Municipal Medical College (Ahmedabad),
St.John's Medical College (Bangalore), JLN Medical College (Ajmer),
CMC (Ludhiana) and Government Medical College (Bangalore).
In the second session the focus was on other groups involved in
initiating alternatives or providing complementary/supplementary
efforts to the process of change. In this session,presentations
were made by Voluntary Health Association of India on Rational
Drug use Education in Medical Colleges;
the consortium of
medical college initiatives facilitated by CED Illinois;
the
Miraj manifesto and alternative project; the alternative
medical school project of Gonoshasthya Kendra, Bangladesh;
the
Christian Medical College Network facilitated by CMAI; and the
efforts in Community Mental Health teaching by NIMHANS,
Bangalore.
The two sessions chaired by Dr. Alfred Mascarenhas (Principal,
St.John's Medical College, Bangalore) was very interesting and
all the participants got a feel for the exciting
challenges and problems of initiating change in medical
education. There was optimism tempered with realism in all the
efforts and it was a very effective session.
(Some of the participants gave us summaries of their
presentations, some left us copies of their OHP sheets and
some left us to make summaries of their presentations from
the notes of the rapporteurs. The articles that follow
represent this diversity) .
.. 34
BA. CHRISTIAN MEDICAL COLLEGE, VELLORE*
Introduction
We recognize that the present-day medical education is not
responsive to the needs of our population. To bridge the gap
between the training imparted to the medical graduate, and the
expertise expected of them, we must make many changes in the
overall direction and content in the medical curriculum. As
part of the consortium deliberations we have had discussions with
our own colleagues to see how change can be effected.
Our presentation will include:
1. Review of the data collected to assess the present scenario.
This includes:
a. a survey of outpatient morbidity statistics in a tertiary,
secondary and primary set-up;
b. a survey of the perceptions of interns and recent
graduates working in small hospitals as primary care
physicians, about the medical training they received;
c. a survey of the perceptions of the medical faculty were
also asked to give their perceptions of the training
imparted by them;
d. Medical Superintendents of Mission Hospitals where our
graduates have worked.
2. The second aspect of the presentation will describe some
innovations we have introduced and further innovations we
have envisaged, on the basis of the data obtained by the
above inquiry.
Assessment of Medical Curriculum
Clinical bedside teaching has changed very little over the
decades;
its content and emphasis have not been balanced;
there is undue stress on:
1. "Diseases" rather than symptom oriented approach.
2. Elicitation of physical findings rather than expertise in
elicitation of history.
3. Use almost solely of in-patients with little emphasis on
out-patients diseases either in the secondary or peripheral
areas.
4. Emphasis on how to face the final University examination.
35.
This poorly balanced approach results in graduates who have good
knowledge of advanced stages of diseases and its management at
the tertiary level. However, they are ill equipped as a
Primary Care Physician because of their inability to recognize
and treat disease early. In addition, the major draw-back is
that there is very little exposure to the common diseases
encountered on an ambulatory basis.
In order to gain some idea about the common diseases seen in
ambulatory care, we collected out-patient morbidity statistics
at the three levels:
a. From the peripheral village clinics (Primary).
b, From the secondary care centre.
c. From the tertiary care centre.
TABLE I
OUT-PATIENT MORBIDITY DATA RANKING OF DISEASES IN ORDER OF
PREVALENCE
TERTIARY (C.M.C.H.)
SECONDARY
(CHAD-Base Hosoital)
*
PRIMARY
(Mobile Clinics)
1. Ill-defined
2. Ante-natal
3. Skin
4. Upper Respiratory
infection (URI)
5. Musculo-Skeletal
6. Fungal
7. Otitis-Media
8. Tuberculosis
9. Trauma
10.Leprosy
Ill-defined
Skin
URI
Trauma
URI
Ill-defined
Skin
Musculo-Skeletal
Tuberculosis
Musculo-Skeletal
Antenatal
Acid-Peptic disease
Anaemia
Helminthiasis
Anaemia
Epilepsy
Helminthiasis
Trauma
Hypertension
Fungal
* The CHAD - base hospital is the 60 bedded - Secondary health
centre of the Community Health Department.
It is clear from table I that several common problems appear
uniformly at all levels. Some diseases such as leprosy and
tuberculosis are not shown at the primary and secondary levels
as these cases are dealt within special clinics and therefore
not represented in this survey. The same is true for antenatal
and immunization clinics.
Against this scenario, we then surveyed faculty and students to
see which topics were commonly discussed, and which were
usually excluded. Table 2 gives this information regarding
clinical teaching in the department of Medicine.
. . 36
36
TABLE 2
SURVEY OF FACULTY AND STUDENTS ON CLINICAL TOPICS TAUGHT(MEDICINE)
FACULTY AND STUDENTS
STUDENTS
1.
2.
3.
4.
5.
6.
7.
Ischemic Heart Disease
Diabetes
Hypertension
Urinary Tract Infection
Upper respiratory tract infection
Convulsions
Low back pain
Asthma
Malaria
Typhoid
Tetanus
Anaemia
Renal failure
Pericardial
disease
8.
Vertigo
Comparison of Tables I and II shows clearly that clinical teaching
in Medicine rarely includes topics which would be encountered very
commonly in the daily life of a Primary Care Physician. No doubt,
these are common diseases which are taught in didactic lectures,
but practical exposure to them and therefore expertise, is inade
quate.
An Evaluation
The second part of the study was to get an assessment of the
undergraduate education programme conducted in our institution by
students, recent alumni, and faculty members and Medical
Superintendents of the hospitals where our graduates are working.
Fcr this purpose a pre-tested questionnaire was given to the
interns of 1999 who were about to complete their internship and
also to those who graduated before 1987. The third group was the
faculty members involved in teaching undergraduates in subjects
which had an university examinations.
The questionnaire was sent to 60 interns, 109 recent graduates
and 55 faculty members and 60 Medical Superintendents. The
response rate was 87%, 42%, 69% and 35% respectively.
5
The findings were not presented in
detail but are available on request.
The third pert of the paper focusses on all the innovations
in medical education in CMC-Vellore that have been introduced
over the years and some which evolved in response to the
study.
37
A Contd.
INNOVATIONS IN MEDICAL EDUCATION AT CMC-VELLORE
1.
FOUNDATION COURSE FOR ALL NEW COLLEGE ENTRANTS
It has been felt that students coming out of schools at plus Two
level find it difficult to handle new subjects and different methods of
learning. To make the transition between school and medical
college education smoother and more meaningful, we had intro
duced a mini foundation course for all new entrants to the
medical school.
The course was spread over five days with the students working
in groups of ten guided by a tutor. The tutors were selected
from the teaching departments of Anatomy, Physiology, Bio
chemistry and Community Health where the students would be
spending the next 2 years. The tutors had a briefing session
on Problem Based Learning and on the course. Reading materials
and other necessary references were provided. The students
were also taken to the Library and were given instruction in
looking up references.
The course was programmed in such a way that by the end of the
first day the students get an opportunity to get to know each
other well. The Communication Workshop really helped in this.
This was followed by un-structured and structured group discu
ssions, which helped them to understand the mechanism of group
dynamics. The group discussion topics were chosen carefully
to introduce certain value systems in the young minds. They
were also introduced to the concept of problem based learning.
The following days were spent in groups applying this method
of learning to a clinical problem. The course content and the
programme were evaluated on the last day.
Obj ectives :
1. Help transition from school to college smoother and
meaningful
2. To introduce mechanism of group dynamics and team concept
3. Demonstrate linkages between basic sciences and health
care through problem based approach
4. Demonstrate self directed learning
5. Develop communication skills
6. To introduce value based education
2. FOUNDATION COURSE FOR THE FIRST CLINICAL YEARS :
(USING PROBLEM BASED APPROACH)
The medical students who complete their pre-clinical subjects
are usually taught pre-clinical subjects under very close
supervision by their teachers. That is not the case in
clinical years. More over they start to interact with patients
. . 38
and their relatives. They also may not have enough experience
in interviewing skills. Then they learn new subjects like
medicine, surgery, pathology, microbiology and pharmacology.
Therefore, we introduced a clinical foundation course with the
following objectives to be learned through a problem based
approach.
The objectives of the course are:
A. To provide
1. skills in self directed learning using problem based
learning
2. skills in problem solving
3. communication skills
4. awareness of ethical issues.
B. To demonstrate
1. Horizontal integration of para and clinical subjects.
3, PERIPHERAL. HOSPITAL POSTINGS
Our morbidity survey shows that there is no difference in the
pattern of disease in inpatients between the peripheral
hcspital and teaching hospitals. However most of the teaching
is not based on these diseases. Even when common problems are
seen their management in the two centres varies greatly. The
health priority problems seen in the tertiary hospitals
hospitals are in an advanced stage requiring sophisticated
investigations and high technology in treatment, whereas the
same diseases are seen at the peripheral hospital in their
early stage needing simple treatment.
To put the things in their proper perspective we offered one
week peripheral hospital posting as an option for the past
two years. Based on the feed back from the students, we plan
to give all students two weeks of posting in a peripheral
hospital of 50-100 bed strength with atleast one postgraduate
qualified doctor. Certain criteria have been laid down for
the selection of these hospitals. This posting would give the
students ample opportunity to learn of the prevalence and
pattern of diseases in a peripheral area; clinical decision
making and management with the available minimal resources.
They would be able to observe and take active part in the
management of patients, particularly emergency surgical,
medical and obstetrical cases. It would help them to realize
the value of team approach, the cost of medical treatment and
socio-economic aspects of the diseases.
. 39
39.
The following suggestions were given by the students to improve
the programmes.
1.
2.
3.
4.
5.
Only small hospitals should be selected
Postings should not be close to the University Examinations
Hospitals in cities and large towns should not be selected
The programme in the hospital should be well organised
The hospital staff should be informed of the programme in
advance and they should be aware of the objectives of the
programme.
The students listed the following skills which they gained
during the posting.
1. Assisting in surgeries and minor procedures
2. Assisting in deliveries and caesarian
3. Improving the interaction between the doctors and community
and management of emergencies such as snake bite, fractures
etc.
J. STUDENT CLERKSHIP
Our study had brought out that our students do not possess
adequate skills in management of patients. An earlier study
showed that obstetrics residential posting was very useful in
acquiring management skills. Therefore we plan to give
residential posting for 1 month each in Medicine, Surgery and
Paediatrics. They would work along with the interns, managing
patients in the hospital. We envisage that by the end of this
posting they would be able to manage common clinical problems
and would be able to do simple essential lab tests and integrate
other investigations into clinical management.
They would be able to do
simple procedures like venesection, catheterization of bladder,
setting up of I.V. infusions, giving blood transfusions and
lumbar puncture. Problem oriented learning method will be
used and would be supplemented by small group discussions.
5. EMERGENCY MEDICINE / CASUALTY POSTING
Our study had also brought out that our students are not
exposed to emergency care medicine. Firstly they do not get
an opportunity to see these problems as soon as they reach the
hospital. These clinical problems are not discussed by
teachers during routine clinics. Yet another reason for the
lack of emphasis on emergency medicine may be that they are
not assessed on it during the examinations. To overcome this
lacuna we plan to give our students a posting in the
casualty department. This will be given in small groups of
2-3 students from 6.00 p.m. to 6.00 a.m. They would observe
and take part in the diagnosis and immediate management of
. .40
40.
NOTE: A larger more detailed paper - providing details of student
evaluation of all these innovations is available on request
from Principal, CMC-Vellore or CHC-Bangalore.
41.
8-B. SMT. N.H.L. MUNICIPAL MEDICAL COLLEGE, AHMEDABAD
A Report of innovations/experiments in undergraduate Medical
Education at Smt. N.H.L. Municipal Medical College, Ahmedabad,
was presented by Dr. Shubha S. Desai. She focussed on the four
main thrusts of the changes (see also Appendix 'E').
a) Introduction of Educational Technology
These included the NTTC workshop followed by a satellite
workshop organised in the institution by NTTC faculty. Later
a mini-workshop for faculty was conducted by local resource
persons in the institution.
b) Formulation of objectives at institutional level
After the workshop - the institution formulated its objectives
by:
i. reviewing institutional objectives of different medical
colleges;
ii. discussion with institutional teaching staff;
iii. discussion with general practitioners;
iv. discussion with students and patients.
An evaluation committee was also set up which worked on the
development of a bank of multiple choice questions.
c) Internship Reorientation Programme
A 3 day workshop was introduced for all interns as a
reorientation programme. It included group dynamics,
rational therapeutics and a project on drug prescription
apart from some videos.
d) Comprehensive clinical postings
This consists of two types of posting
i. During the preclinical course - first MBBS students are
posted to Medicine, Surgery and Obstetric/Gynaecology
during evening hours.
ii. During Sth semester (clinical year) students get a weeks
posting each to the path lab, the casualty department
and a peripheral dispensary.
A summary from the
O.H.P. sheets shown at the meeting
-- --------------------------------------------- ------------------—^..4 2
I
42.
8-C. ST. JOHN'S MEDICAL COLLEGE,
BANGALORE
An overview of Medical Education initiatives at St. John's
Medical College, Bangalore, was presented by Dr. Dara S. Amar,
Professor of Community Health. These included the following:
1. Institutional objectives had been enunciated by the college
and departmental/institutlcnal objectives had been evolved
by different departments.
2. At the Institutional level there were many formal and
informal groups of faculty who worked together on issues
related to medical education:
i. Medical Education Cell;
ii. Core group of faculty of the college who represent
it in the Medical College consortium;
iii. Ethical cell;
iv. Epidemiological cell;
v. Regular clinical conferences.
3. Pedagogy Training for all staff was provided by core group
of NTTC trained faculty.
4. Promotion of Health Team training - Doctors, Nurses, lab
technician, health workers, etc., were all trained in the
same institution.
5. All training was multidisciplinary and enhanced interaction
across departments.
6. There were many programmes and inputs beyond university
curriculum requirements. These included:
i.
ii.
iii.
iv.
v.
vi.
vii.
viii.
ix.
7.
Teaching of Psychology and Behavioural sciences;
Teaching of Medical ethics including clinical ethics;
Communication skills;
Rural Orientation Programme (ROP) at preclinical
level and Community Health Awareness Programme(CHAP)
at clinical level;
Many timetables in training were problem oriented;
Retreats for medical students;
Issue based seminars;
Clinical postings at night to get experience of
emergencies;
Summer vacation assignments
Curriculum content was being deterrnined/modifled by local
morbidity survey.
k-----------------------------------------------------------------------------------------------------------------------------
. .43
43.
8.-Promoting Health and Development interaction at the
Mugalur Health and Development Training Centre including
the Mahila Vikas Project (womens development programme).
9. Tutorship scheme for students.
10. Orientation to alternative/indigenous systems of medicine.
11. Rural placement/bond scheme after internship.
12. Regular colloquia for alumni doctors and community health
workers.
13. An Internship orientation programme.
14. Internship postings to plantation health services.
15. Internship posting to other voluntary agency/NGC projects.
16. Evaluation of effort including attitude assessment.
(From O.H.P. sheet presented at workshop.
For further details, write directly to
Medical Education Cell, St. John’s
Medical College, Bangalore-560 034. For
some of them also refer to Faculty
Resource Book evolving out of CHC Project).
-Ed.
. .44
8-D. INNOVATIONS AND EXPERIMENTS IN THE MEDICAL COLLEGES OF RAJASTHAN*
(1975 - 1992)
I. Project / Group Exercises
In late seventies project exercises were started at Medic si
College, Jodhpur and Jaipur. Students from VII semester
onwards were clustered in group of four each. Each group
was given a study topic to be conducted in the field practice
area attached to the Preventive and Social Medicine
Department. This exercise was to be completed in the six
months period and was to be presented by one of the member
of group of four. The project report was prepared on set
lines i.e., introduction, objectives, review of literature,
methods, observation, discussion, summary and references
if any. These reports were usually typewritten and
submitted in the Department. Most of these studies included
a sample of 25-50 families.
Some examples of topics of study:
1. Determination of prevalence of malnutrition in the
community.
2. Dietary survey in 50 urban families.
3. Prevalence of Anemia in pregnancy
(SMS MC, Jaipur / SNMC, Jodhpur).
II. integrated Teaching of Maternal and Child Health/Family
Welfare (MCH/FW) to undergraduates
It was again in the late seventies that Government of India
in collaboration with WHO took up a project on integrated
teaching of MCH/FW to medical undergraduates. To begin
with heads of Obstetric/Gynaecology, Paediatrics and
Preventive and Social Medicine were trained at WHO
recognised training centre for this Project - Ahemadabad/
Trivandrum. Group of these three senior teachers were to
initiate the integrated teaching of MCH/FW, fitting into
the existing curricula. Because of being busy in various
assignments by virtue of their senior positions, these
trained Professors could not do much except trying to
motivate their subordinates through informal discussions.
Almost 12-18 months later when a questionnaire arrived
from Ministry of Health and Family Welfare, there was a
stir. To complete the formalities an ad-hoc integrated
teaching programme was formulated in which junior
faculty members were to sit together and teach students
on various MCH/FW issues. Since most of these junior
teachers were neither properly briefed by the trained
*Dr. Shiv Chandra, Associate Professor, PSM Department,
Medical College, Ajmer.
. . 45
45.
professors on the concept of integrations nor were they
mentally prepared to share their teaching competance/skil1,
this project eventually fizzled out (JLN MCA).
III. Family Care Exercises for undergraduates and its liberalization
In al] the Medical Colleges of Rajasthan, it became a
convention to allot a family to medical undergraduates.
Students are using many
predesigned protocols in the shape
of 'Family Health Advisory Notebook' to conduct such a study.
Families for this study were allotted to the students in the
field practice area of PSM Departments. Supportive help to
the students was given through paramedical workers posted in
the Field Practice Area, as these workers were always in
good lai son with the community. Over the years this
exercise started losing its importance at Field Training
Centres for two reasons:
i. Repeated visits by novice medical undergraduates to a
limited number of families
always in afternoon
became a source of annoyance for family members.
ii. A limited number of paramedical workers who were
helping students became tried of these repeated
exercise. Subsequently at Medical College, Ajmer,
students were given the liberty to chose the families
at their own. Most of the time students selected the
family of their domestic servants or a known
acquaintance amongst the poor persons who usually have
a medico-social problem. Hostellers usually select a
family living in college/Hospital campus, often of a
wardboy or class IV of the college. This system is
so far, working well (JLNMCA).
IV. NTTC Collaboration
Medical college, Ajmer, is regularly receiving a circular
from PGI-Chandigarh (twice a year) for the course on
Educational techniques for Health Professionals. Over
last eight years only four teachers had gone and attended
this course. First teacher who has gone to NTTC managed
to call the NTTC faculty to hold a workshop on
Evaluation. This was attended by about 25 teachers.
Since the course of NTTC lasts for 10 days, most of the
teachers express their inability to leave the town for
such a long duration. Eventually one more workshop was
organised in collaboration with NTTC, Varanasi. This
led to lot of stimulation in the faculty about giving a
facelift to the teaching programme (JLN Medical College,
Ajmer) .
. .46
46.
V.
ASSORTED EXERCISES
1. A seminar for freshers entering in Medical College was
conducted on the subject of expectations from Doctors by
Society vis a vis why a new entrant wishes to become a
Doctor. This seminar had two parts - first part being
lectures by people representing various section of the
society. This included a professor from academic college,
an administrator, a paramedical worker, a trade union
leader and an ordinary member of society like a
rickshaw puller. Second part of the seminar was
expression by the newly entering medical students on
their perceptions on Medical/Health organisations and
why have they opted Medicine as a career. This exercise
proved a tremendous exercise and was replicated
subsequently at anothei Medical College within the
State (SMS MC, Jaipur/JLNMCA, Ajmer).
ii. In 1991, a debate was organised on the subject of
"Private Practice amongst Medical Teachers: Promotor or
Inhibitor in Medical Education" involving a wide range
of medicos starting from undergraduate to senior
professors. An equal number of entries were received
for and against the matter. This debate was chaired
by a very senior (retired) professor of the faculty.
About 14 speakers placed numerous episodes and
experiences to prove their contention. It was brought
out through this debate that a combination of a good
teacher and good practitioner is not so common but
this was a fact that many teachers in Medical Colleges
are not good teachers and it often happens that many
times Teachers indulging into practice gain a
reputation as good teachers. Therefore all that is
required from a medical teacher is a teaching aptitude
(JLN MCA, Ajmer).
This presentation of Dr.Shiv Chandra
is marked by great realism and
frankness and it highlights some of
the obstacles to change highlighted
earlier by the Study. However inspite
of the constraints, the fact that ever.
in government colleges (mainstream)
some changes are being tried cut is
very hearteninc.
- Ed
. .47
S-E.
CHRISTIAN MEDICAL COLLEGE, LUDHIANA
Dr. Mohan Verghese, Vice Principal presented a few highlights of
Christian Medical College, Ludhiana's, attempts at innovation.
These included:
i. The college has set the goal of making its graduates socially relevant, professional1y competent and spiritually
alive.
ii. In the selection procedures at undergraduate level,
sponsorship from or commitment to go to a mission hospital
is given preference in addition to academic qualifications.
iii. In the postgraduate selection - 75% of the weightage is
given fcr rural work.
iv. Workshops for college faculty have been held in skills like
problem-based learning. Inter collegiate workshops involving
Dayar.and Medical College, have also been held. While
preclinical departments were initially resistant to P3L
end other ideas, they have now changed.
v. Recently a WHC sponsored workshop on PEL for colleges of
Mort' India (north of Delhi) was organised.
vi. the college has been wanting to move to a new curriculumnot just a parallel track.
vii. During 1st MEES, a months rural / hospital posting has been
introduced to give students an opportunity to feel and
solve problems of- tie community.
viii. Samaritan Medicine - an initiative to improve the listening,
communication and inter personal skills cf the students
has been experimented with.
ix. The college has adopted a slum on the ash heap in the city
for a new multidisciplinary community orientation end action
programme. Medical,nursing and para medical students are
posted together in batches to undertake several studies of
the community and plan and initiative responsive action.
A more detailed report entitled "An
educational experiment in Community
Oriented Medical Education (COME:) through
Issue-based Learning Activities'.',
is available on request from Principal,
Christian Medical College, Ludhiana-1.
S-F. THE CONSORTIUM OF MEDICAL COLLEGES (INDIA)
The consortium of Medical Colleges in India is a process
facilitated by Centre for Education Development, Illinois, since
June, 1985. It follows the principle of evolving strategies
through research enquiry.
(Since two participating colleges in the meeting (CMC-Vellore and
SJMC-Bangalore) were members of the consortium, the dialogue
participants were given some orientation to the history,
objectives and process of the Indian Consortium and the evolving
role and initiatives of some of the participating colleges.
This note is based on the OHP sheets presented by
Dr. C. Kirubhakaran of CMC-Vellore, and Dr. Ragini Macaden of
St. John's, Bangalore.)
The Indian Consortium of Medical Colleges facilitated by CED
Illinois (Chicago) was the outcome of a request and linkage
established by Prof. V. Ramalingaswami with CED Illinois in
June, 1985, to help initiate curriculum innovations directed
towards the new goals of Primary Health Care and 'Health for All
by 2000 a.d.'. Dr. Mohan Garg of CED Illinois visited four
institutions in India. In November, 1986, the consortium was
formed with AIIMS-New Delhi, CMC-Vellore, JIPMER-Pondicherry
and BHU-Varanasi as participants. A symposium was organised in
March 1987 and ‘Medical Education and PHC Need' - successes and
failures.
The symposium recommendations outlined four major steps:
i. Initiate health service research;
ii. Identify health care needs to reform curriculum planning;
iii. Identify innovations based on inquiry;
iv. Develop strategies for implementation.
Phase - I
A consortium strategy was evolved which included the following
logical steps:
i. Each institution will identify core faculty;
ii. This core will be enlarged within the institution;
iii. Some innovations will be identified, planned and
introduced;
iv. These innovations will be evaluated.
In the first phase the four founding institutions developed
certain instruments for Health Services Research:
i. AIIMS-New Delhi, studied the perceptions of patients and
GPs role of doctor;
BHU-Varanasi, identified core abilities perceived by
students, postgraduates and faculty;
. .49
49 .
iii. CMC-Vellore, studied the morbidity and mortality patterns
at PHC, Secondary and Tertiary care levels and also studied
the perceptions of students, recent graduates, faculty and
medical superintendents of peripheral hospitals;
iv. JIPMER-Pondicherry, studied the perception of faculty about
Health For All and Primary Health Care.
Based on the above enquiry, certain innovations were planned by
each institution.
The innovations introduced by CMC-Vellore have been mentioned
earlier. (Please refer 8-A) .
After the first phase the consortium of four would grow by the
addition of four more institutions. Each founder member would
identify and work closely with another medical institution.
This linkage will be operationalised through regular site visits.
This will form the Phase II of the process.
PHASE II
After the successful •completion of Phase I, the next phase was
initiated by the four founding members identifying their twins.
These are St.John's Medical College-Bangalore (by JIPMER);
Siddartha Medical College (by CMC-Vellore); Cuttack Medical
College (by AIIMS-New Delhi); and Gwalior Medical College
(BHU).
The next process will involve the four new institutions in
studying their present department wise curriculum and then
planning, implementing and evaluating innovations which will
be scrutinized and supported by the cere-twin throughout the
process. This will be done by site visits and meetings and
the comments on reports submitted on a regular basis.
In May, 1992, at Delhi, a meeting was to be held when each of
the four new members were to present:
i. Morbidity/mortality data of region to determine Health
needs;
ii. List of skills expected of a medical graduate;
iii. List of topics considered redundant in each discipline; and
iv. a innovation each eg., SJMC-Bangalore, has selected the
introduction of Clinical Ethics as its innovation.
The survey of skills in St. John’s Medical College included
i. the skills learnt/taught presently;
ii. the skills required to pass the examinations;
iii. skills required in a primary health care situation.
. . 50
50
From these lists the mismatch of what is taught and what is
needed was determined.
List of lectures, practicals, tutorials and bedside teaching
topics from each department including redundant topics provided
insights into how we could integrate.
The topics and curriculum on clinical ethics was to be developed
by the results of a questionnaire.
Outcome: Based on these enquiries each institution was requested
to:
i. prepare a core curriculum;
ii. list of skills as decided at consortium to be used for
training;
iii. study graduates and teachers perceptions of skills and
how to implement it;
iv. to prepare a modular approach to the teaching of Jaundice.
Progress
At SJMC-Bangalore, the progress of this effort will be:
i. Meetings with preclinical/paraclinical and surgeons/
physicians on the faculty tc sensitise all faculty to
National Health Policy, MCI Regulations and the Draft
National Policy for Health Sciences Education (Bajaj
Report)
ii. Preparation of core curriculum based on National Health
Policy;
iii. Preparing a module on jaundice and implementing the
teaching of it and evaluating the use of the module.
The findings will be submitted at the meeting in December, 1993.
A meeting in February, 1994 at CMCVellore is scheduled. Core curriculla
developed by the 'North group1 and the
'South group' will be integrated and
presented for consideration. For
further information, write tc Centre
for Medical Education Technology,
All India Institute of Medical Sciences
Ansari Naoar, New Delhi - 110 029.
. . 51
51.
8-G« VHAI1S ROLE IN RATIONAL DRUG USE EDUCATION IN MEDICAL COLLEGES*
VHAI's (Voluntary Health Association of India) involvement with
Medical Colleges, their students and faculty has been mainly in
relation to Rational Drug use as part of the activities of the
Department for Peoples Education for Health Action and the larger
Rational Drug campaign.
For long we had attempted to draw in faculty members and medical
students into some of the major debates related to drugs and
health policies, as these were being formulated.
It has become evident over time that medical colleges kept aloof
from all these issues resulting in the pharmaceutical industry,
trade etc., influencing drug policies to safeguard their own
vested interests.
1. The initial interactions had been with certain medical colleges
faculty concerned about Rational Drug use and we worked closely
with them:
i. AIIMS-New Delhi: Dr. O.P. Ghei, (Paediatrics Department)
organised a National workshop on the Rational use of
Drugs in paediatrics. The issue of Rational Drug Policy
was discussed with the Drug Controller etc., and drug
activists to highlijht the complexities, the priorities
and areas requiring urgent intervention.
ii. Gorakhpur Medical College: With Dr. G.P.Mathur
(Department of Paediatrics) a workshop on 'Protecting the
Child consumer1was organised in Gorakhpur Medical College
to focus on Baby foods and pharmaceuticals and the need
for policy intervention and the linking up of medical
colleges with health and consumer groups.
2. Role of Medical Colleges in EP campaign & EP Hearings
In the campaign against high dose Oestrogen-Progesterone
combinations (being used for pregnancy testing for inducing
as well as preventing ebortion, bringing on delays and
regularising periods) it was basically the health consumer
and women's groups that had played the leading role.
Except for- the involvement of a few medical faculty members
to support the consumer stand during the EP hearings in
Calcutta, in most other places the Obstetrics and Gynaecology
faculty members besides academic bodies, members of FOGSI
(Federation of Obstetrics and Gynaecological Societies of
India) were brought by the pharmaceutical Industry to support
the industry stand.
■
■
;
,
-
.............
.
i .
.......................
.
‘Dr.Mira Shiva, Peoples Education for Health Action, VHAI, New Delhi.
The drug was ultimately banned but the process of getting it
banned clearly showed the relationship of medical colleges and
faculty with the pharmaceutical industry, who often sponsor the
conferences. VHAI has attempted to get these institutions to
look at their relationship with the pharmaceutical industry,
which can undo what is taught by way of pharmacology and
therapeutics.
3. Involvement with issue
of Iodine Defficiency Diseases
We have been focussing on the IDD problem in the endemic areas
of East Uttar Pradesh, Bihar, Garwhal area. An attempt was
made to link the community medicine department of AIIMS with
the peripheral institutions for iodised salt testing and for
helping out in training and field study.
4. Rational Drug Use Workshops in Medical Colleges
These were organised in the past 3-4 years.
The objectives were:
i. To involve medical colleges in societal issues related to
Rational Drug use and Rational Health Care;
ii. To link up socially conscious medical college faculty with
consumer and health activists, NGOs in health, socially
conscious journalists and lawyers to form a local core
group of concerned individuals to provide support to such
efforts;
iii. To encourage medical colleges in being involved with policy
intervention activities and communicate their views, and
stand on issues related to Rational Health Care;
iv. To recognise the major problems related to so called
‘scientific medicine' sc as to seriously consider
alternatives;
v. Strengthen state VHAs by linkages with medical colleges to
help build resource centres/pool - by way of information
clearing house in different regions and in regional
languages.
Experience has shown that rather than dealing with medical
colleges in different parts of the country, it was better to
focus on different regions where linking up with other support
groups was possible - eg., where the State VHAs were willing
to be involved in follow up work and where linkages with drug
activists, health activists and consumer activists was
possible. We therefore decided to focus on Andhra Pradesh and
Karnataka.
In Andhra Pradesh, Rational Drug use
workshops were conducted
along with Community Medicine Departments, Pharmacology
Departments and in one place with the Students Union as well.
The colleges were:
i.
ii.
iii.
iv.
v.
Csmania Medical College-Hyderabad;
Gandhi Medical College -Secunderabad;
Kakatiya Medical College-Warangal;
Tirupathi Medical College-Tirupati;
Siddartha Medical College-Vijayawada.
In Karnataka meetings were held in Government Medical College,
Bangalore and Al Ameen Medical College, Bijapur.
The learning experiences from these meetings/workshop were many.
1. Most institutions and faculty themselves had never been
exposed to issues related to Rational Drug Use and Rational
Drug Policy and hence expecting then; to incorporate the
issues in MediCai Education did not arise.
2. A few socially conscious individuals existed in every
institution who felt intellectually isolated and wanted to
do something socially relevant. They needed to be linked
up with like minded people outside the medical college, to
build a critical mass for collective action.
3. Interaction with field personnel is very important to
inject a dose of social reality and issues such as
Rational Drug Use opens up the very rigid medical structure
to recognise the existence of some of these broader
concerns.
4. It was very important to involve medical students in some
of these issues as some of them were quite idealistic eg..
Public Health Activist Group from Coimbatore Ayurvedic
Medical College.
5. It also became clear that some of the health related
concerns must be dealt formally or informally by medical
colleges - so that some of the distortions must be
handled by the institutions themselves.
6. Increasing dissatisfaction by the public of the medical
professionals was becoming abundantly clear and in view
of the failure of MCI etc., to look into these issues,
consumer concerns would have to be dealt with in
consumer forums and consumer courts. The medical college
faculty must be challenged to address this lacunae.
7. The resistance from colleagues from clinical departments
I
. .54
. .54
whose prescription practices are questioned can be extremely
demotivating and therefore these individuals must be linked
up not just with alternate drug and health but other networks
as well.
8. Whenever medical students were involved in prescription
analysis, promotional material analysis, they were much more
receptive to the analysis results.
9. Use of video films, slides,samples of drugs rather than
writing materials was appreciated. eg., use of Newstrack
documentaries on Kalazar, Japanese E enceptialities, IV
fluid tragedy in Delhi, Sura tragedy in Delhi, Blood banks
and professional donors, loperamide issue, etc.
10. Involvement with institutions such as JIPMER-Pondicherry
and CMC-Vellore as part of the campaign for Rational Drug
Use has been very useful and we welcome more, such
meaningful institutional linkages.
“Eternal vigilance is required to ensure
that the health care system does not get
medicalised, that the doctor-drug-producer
axis does not exploit the people and that
the abundance of drugs does not become a
vested interest in ill-health"
- - ICMR/ICSSR (1981)
Health for All - An alternative
Strategy
. . 55
55.
8-H .
THE MIRAJ MANIFESTO *
I. PREAMBLE
Many of the causes of the glaring deficiencies in the health
care system in India lie outside of the traditional domain of
doctors. Yet, one of the factors that could promote a change
for the better is a purposeful training of the medical
graduate for the provision of health care appropriate to the
needs and socio-economic realities of the Indian situation.
Previous attempts to evolve such an alternate pattern of
medical education have had limited success and some of the
limiting factors can be identified. Well-established medical
colleges have a formidable inherent resistance to radical
reorientation. Most of the Indian medical colleges are
funded and administered by the government. In such an
interlocked system, it is difficult for even new colleges
to acquire sufficient autonomy in the selection of suitable
students and in the selection, training and retention of
faculty, guided only by the objectives of the new programme.
In the light of these considerations, the management of the
Miraj Medical Centre has now committed itself to develop a
new, self-funded medical college with the necessary
independence in the selection of students and staff, with
the objective of training "appropriate" doctors especially
for service in the network of Christian hospitals.
This Manifesto is a preliminary working document summarising
the present perceptions of the small faculty currently
available in Miraj. It is prepared as a basis for further
discussions among the staff and the management at Miraj and
for eliciting the suggestions and support of others
interested in the development of "appropriate" medical
education in India.
II. OBJECTIVES
A. The primary objective of the training programme will be
to produce a doctor able and willing to play his role
in appropriate health care in the disadvantaged rural
and urban communities of India. This orientation should
not exclude the graduate from any of the other avenues
currently open to Indian medical graduates, including
specialisation and research. The major desired change
is a commitment to the promotion of health and the
* Dr. P_Zachariah, Co-ordinator, Medical Project, Miraj-416 410.
. .56
56.
prevention of illnesses in the community, while also
being proficient in curative care thoughtfully adapted
to the limitations of resources and facilities. At least
50% of our graduates must be inclined to serve in this
way, for a major part of their professional lives.
They should:
1. be able to:
a. identify the health problems of the community they
are connected with;
b. resolve them through planning, implementation and
resource mobilization; and
c. evaluate their progress.
This will include effective health education,
motivation and managerial or team leadership skills.
2. be familiar with, and reasonably competent in, medical
care at the secondary level outside the teaching
hospital, in rural and disadvantaged urban situations.
3. be competent and proficient in delivering sound
scientific medical care, their knowledge and skills
being prioritised by considerations such as prevalence
and harmfulness of diseases, and availability,
affordability and cost effectiveness of the therapeutic
measures.
4. be used to incorporating socio-cultural and
behavioural aspects in analysing the causation, and
in deciding the management, of illnesses.
5. be skillful in problem based, self-directed learning,
able to identify the knowledge base necessary for
solving unfamiliar health/medical problems and to
acquire it on their own.
B. In addition, the new curriculum should also aim to
reinforce the following capabilities which are inade
quately emphasised at present:
1. Recognition of the proper place of prevention,
referral end rehabilitation in clinical management.
2. Awareness and utilization of the whole work team
as the effective instrument, the doctor himself
assuming leadership where appropriate. Inclusion
of the patients/family/community as active
participants, rather than passive beneficiaries.
. .57
3. Skill and sympathy in both listening to, and
communicating with, patients and others.
4. Personal and professional integrity; concern and
respect for patients and colleagues.
5. Aptitude for recognizing, and seeking solutions for,
unidentified or unresolved problems in patient care,
community work or in the health care delivery system.
III. METHODOLOGY
The following methods are considered necessary for achieving
these objectives, especially the ones under I Al above:
A. Student Selection
Selection of candidates has to be entirely by the
Institute based on criteria most likely to fulfil cur
objectives; 'one criterion could be performance in a
pre-selection, training programme.
*
B. Staf f
1. Orientation of staff to the objectives by initial
and ongoing training will be important. In the
selection and promotion of staff, suitable weightage
should be given to proficiency in, and commitment to,
their "teaching" responsibilities.
2. Medical and non-medical staff in the periphery will
also be "faculty".
But faculty from the tertiary
centre will also give not less than 25% of their
time to teaching and service at the periphery.
3. Development of source material for "problem
presentation" and for learner-centred study will be
an important initial and ongoing responsibility of
the faculty.
C. Duration of the course
*If necessary, the duration of the course may be increased
by upto twelve more months, perhaps also as a pre
selection training/orientation programme.
D. Curriculum and training
1. From the beginning of the course, the students will
be exposed to and involved in medical/health care
situations at all levels, but specially at the
periphery.
2.
The students will be introduced, as early as possible
.. 58
58.
to self-directed and learner-centred education with
progressive reduction of teacher-centred transfer of
knowledge.
3. Learning will be organised increasingly around problems
and situations, rather than disciplines.
4. Fifty per cent of the "practical" work of students will be
outside the teaching hospital, in health facilities at the
primary (25%) and secondary (25%) levels. Development of
this peripheral network should be the first task in
starting the Institute.
5. A major emphasis in all the learning situations will be
the development of competence and proficiency rather than
mere acquisition of information. For this, the curriculum
will provide for increasing participation of the student
in professional activities at all levels of health/
medical care.
E. Evaluation
1. Every module or type of learning experience should be
evaluated by the students and faculty against the
objectives. Also, the participation and progress of the
students should be continuously monitored with adequate
feedback to them.
2. There should be periodic evaluations of the progress and
effectiveness of the whole programme by an external agency.
*The Preselection Sandwich Programme
The present position of the Medical Council of India is that
even innovative programmes should conform: to the pattern of the
subject-based I? II and Final MBBS examinations. So the croup
favoured a one year preselection training/orientation course
preceeding the 4^ years MEBS programme. Only students who
fulfil the minimum requirements for admission to the MBBS
course should be selected for this sandwich course. During
this selection course:
1. The students should receive a good exposure to what community
oriented Medicine really means and what the role of the
doctor is in such an approach. They can then decide with
greater understanding whether they wish to be trained for
such a career.
2. The college can also assess the candidates for their
suitability for such a programme in terms of their
maturity, motivation and commitment.
. . 59
3. Tne candidates should also acquire the following knowledae
and skills to prepare them for the proposed "innovative"’
MBBS programme:
a. Working knowledge of local language
b. Knowledge of English sufficient for acquiring necessary
information from standard sources.
c. Basics of the following three Bs:
i. Behavioural Sciences;
ii. Biostatistics;
iii. Biology (human) - This is to facilitate
problem-based, student-centred learning
from the first year of MBBS.
The CHC Project was a preliminary step to
identify and collate researched resource
material for a faculty development process at
the proposed new Medical College at Miraj
which got the green signal in June, 1992.
However due to the capitation fees medical
college related crisis, the Supreme Court
cases and the aftermath including the new
Central Ordinance, this Project could not
start up. We however hope that the 'Miraj
Manifesto' and all the publications of the
CHC Project will be resource materials for
all those who are keen to initiate an
alternative track (experimental parallel
curriculum) - sometime in the future when the
climate for such an experiment evolves.
-Ed
60
60.
8-1.
THE NIMHANS INITIATIVES IN MENTAL HEALTH TRAINING
Dr. Mohan Isaac shared that though NIMHANS was not a medical
college but an autonomous National Institute of excellence , it
had been concerned about the problems of mental health at the
community level for a long time and equally concerned about the
inadequacy of Cental health / psychiatry teaching in present day
medical education.
There was adequate evidence that Mental Health related problems
was an important unmet challenge in Primary Health Care.
20-25%
of attenders of a PHC clinic were somatizers with psychosomatic
- emotions - psychosocial problems. Epilepsy was as common as
15-20 / 1000 and psychotics about 2-3 / 1000. This implied that
doctors, nurses and health workers involved in Primary Health
Care should have some preparation and skills to deal with these
problems.
Many medical colleges did not have a Department of Psychiatry
as yet and some who had them - had a cne perscn department.
Most students got 15 days posting at a Mental Hospital.
Examinations in psychiatry were most often just a short note in
the Medicine paper.
NIMHANS had over the years systematically launched a pilot
community mental health project; then extended it to a district;
then evolved the National Mental Health programme; then evolved
various training programmes for health professionals and workers
at various levels; and prepared manuals for different grades of
workers. In addition it had facilitated some meetings on the
content of psychiatry in Medical Education and mace
recommendations.
NIMHANS welcomed requests by institutions and organisations
for reorientation and skill training in Community Mental Health.
* * *
* *
Manuals on Mental Health Orientation and
Training for all levels of Health Care/
t'-’oes of health workers are available
from: The Director, NIMHANS, Hosur Road,
Bangalore - 56G 029, on request.
* NIMHANS - National Institute of Mental Health and Neuro Science,
Hosur Road, Bangalore - 560 029.
61
8-J.
AN ALTERNATIVE MEDICAL SCHOOL
THE GONOSHASTHYA MEDICAL COLLEGE PROJECT
Dr. Zafarullah Choudhury of Gonoshasthya Kendra Project, Bangladesh,
shared the background in Bangladesh in the context of which the
idea of alternative medical college had been evolved and also
shared some of the salient features of the suggested framework of
the strategy.
* The poor were getting poorer. The state was preoccupied with the
political instability and the frequent breakdown of lav; and order.
Health care services had deteriorated due to bad planning, growth
of commercial sector and in the bargain even a small sickness was
becoming a major crisis in the lives of a person or a family.
Due co human greed, malpractice and corruption had increased and
some 'unthinkable' forms of private practice had become common.
The World Bank and IMF pressures to privatise and globalise the
economy was worsening the situation further.
* Against this background GK Project had initiated a action to
evolve a scheme to train students selected from already existing
nurses and paramedics cadre for the role ano function of doctors.
* The students would live in the community and be responsible for
some aspects of health work.
* Collecting learning would be stressed.
* The students would work as nurses for 3 months in 1 year.
* Preventive medicine would not be taught in isolation but
integrated with all other aspects.
* Communication skills will be developed.
* The political role of the doctor would be emphasised.
The Project had been on the anvil for a long time but due to
various local problems and some resistance from the medical
professional lobby - it could not take off as yet. he expressed
his enthusiasm for all the ideas and resource materials generated
by the CHC Project and looked forward to utilizing them as a
complementary support to their ongoing planning.
6
8-K. THE CHRISTIAN MEDICAL COLLEGE NETWORK
Frof . V. Benjamin presentee a short review of the evolving CMC
Network giving some background and the key issues discussed at
the meetings of the Network.
* The Christian ‘’-edical Association of India (CMAI) is the oldes
network of health institutions and hospitals in the country.
It has two medical colleges as members and numerous training
centres for nurses and the allied health professionals. More
recently the Miraj Medical Centre (Wanless Hospital) has been
initiating a process to develop the third Medical College in
the Network (see S-H).
* The Catholic Hospital Association of India is the second
oldest network of health institutions established in 1943.
Cne of its earliest objectives was to set up a medical college
to propogate Christian values is health care. St. John's
Medical College was established in 1963.
* In 1986-87, the CMAI initiated a process tc explore the
possibility of CMAI and CHAI and the four medical colleges
under 'Mission1 auspices tc come together in a spirit of
dialogue and to reflect on the past, present and future
together in the context of the health situation in India,
the emerging needs and the increasing challenges to be
socially relevant and community oriented.
* The first meeting of this informal network was in August, 1989
Dr. Ravi Narayan cave the keynote address in which he presente,
a birdseye view cf Medical Education in India and the attempts
at reform and initiatives towards an alternative. .-.e also
presented some key issues and challenges for the consideration
cf the Network.
* The first meeting also had presentations of
reflective and
interpretative histories of
each of the 4 CNCs and their
own initiatives, directions and experiments,to help the
participating colleges to get a deeper understanding of their
goals.
* The second meetinc in March, 199C, was devoted to exploring
together what was 'Christian' about a Christian Medical
College (in other words what was the mission of a college
under church auspices). The meeting also explored the
concepts of Health, healing and wholeness.
The third meeting in March 1991, explored Ethical issues in
Health care Including in clinical practice and more recent
dilemmas such as organ transplantation.
The fourth meeting in March, 1992 explored the ethical
responsibility of medical colleges especially in the ethos
of unequitable distribution of resource including health care
in the community. A collective statement on Health Care
ethics was prepared called the Whitefield document. At this
meeting St. John's Medical College also presented its
experience of teaching Ethics to medical students.
This Network has initiated a process of questioning of the
roles and goals of medical education in the Christian
Medical Colle.es all of which are among the top medical
colleges in the country kn wn fcr excellence and quality of
medical education. lihile the ethical dimensions have been
adequately focussed upon, the social justice dimension has
not yet been adequately considered.
The Network offered peer support to the CHC Project which
incidentally arose ~s ar: offshoot of the first meeting since
many CMC Network members discovered,they knew sc little
about the Indian experience, which the keynote address had
described. The Miraj Medical Centre was particularly
interested since it wanted to build its alternative experiment
strongly on Indian experience and on ideas that had been
tested out in reality. The C'-iC Project therefore emerged
as the preparatory and preliminary step fcr a Faculty
Development ‘"recess for such an alternative/experiment.
For further informition regarding Network
meeting minutes and background papers,
write to:
Christian Medical Association of India,
Plot No.2, A-3 Local Shopping Centre,
Janakcuri, New Delhi - 110 058;
or any of the Christian Medical Colleges.
SESSION
IV
9. REPORT OF DAY ONE - JUNE 20, 1992
- By a participant
Medical Educators Review Meeting organised by Community Health
Cell started at 9.30 A.M. At the very outset Dr. Ravi Narayan
requested each participant to concentrate on the talisman by
Mahatma Gandhi - "Whenever you are in doubt recall the face of
the poorest and most helpless man whom you may have seen and ask
yourself if the step you contemplate is going to be of any use
to him
will it restore to him a control over his own
destiny?".
This way of opening a meeting sensitised every participant on
the seriousness of the subject they were going to discover
and explore together.
Then in a self introductory session, participants expressed
their feelings and expectations of the workshop.
It appeared
that Medical Education was a cause of concern for each and
every individual and everybody in his own or her own way was
comitted to bring a change for good in Medical Education.
The other heartening thing about the croup was that there was a
representation from most of the disciplines of faculty of
Medicine starting from basic science like physio and Micro
to superspecialities like Cardicthoracie and Plastic Surgery,
Feathers in the cap of this CMC meeting was added by the
presence of senior Professors who had been involved in Medical
Education for 3-4 decades and also by persons from related
health organisations working for the Development of Health Care
and Human Power Training Strategies in the voluntary sector
in India.
The group of 29 participants was joined by three more
participants who arrived after the first session.
Dr. Ravi Narayan then introduced the subject of the meeting
briefing the participants on the medical education scene in
India. He emphasised the need and relevance of a ballonistic
research which helps to build an overview of the problem and
the situation. Also the need to identify responses and
solutions to turn off the tap of diseases and bring a
community health orientation in the transplanted
Western model of Medical Education in this country. He
outlined the process to study the situation and explore the
responses by medical educators in India.
Dr. Thelma Narayan highlighted, through transparencies, the
sectors of innovation in medical education, their
65.
contribution to orthodox Medical Education and the emergence of
alternatives. She stressed that organisation engaged in the
advancement of medical education need to be re-energised
mentioning IAAME in particular. This was possible by greater
focus on Indian experiments and promoting greater networking in
the efforts.
In succession Dr. Shirdi Prasad Tekur placed his lucid and comic
illustrations on the subject through caricatures/cartoons
depicting the ills and challenges of Medical Education. It
reminded me of the book of dialobue by David Morley, entitled
'MY NAME IS TODAY' - an interesting document often utilised in
the training of health professionals. Many of these drawings of
Dr. Shirdi Prasad were going to be used to animate the CHC
publications arising cut of the Medical Education Project.
Then Ravi Narayan reviewed the finding collected from 25
Medical College who responded to the letter of CHC. He
outlined the examples of pace setters, the obstacles tc change
and set out some challenges before all of us. This was followed
by a discussion.
In the post lunch session different participants shared the
experience of different institutions/organisations.
i. Dr. Kirubhakaran from CMC-Vellore, presented the innovations
proposed through consortium of inquiry driven strategies in
Medical Education focussing on CMC-Vellore's efforts.
ii. Dr. Shubha Desai from Smt.NHL Municipal Medical CollegeAhmedabad, highlighted how a small group of trained
teachers from NTTC formed a cell to renovate curricular
and academic programme in that college.
Dr. Mohan from Christian 14edical College-Ludhiana, Dr. Shiv
Chandra from Jawaharlal Nehru Medical College-Ajmer and
Dr. Dara S. Amar,(St. John's Medical College-Bangalore and
Dr. Vasundhra from Government Medical College-Bangalore, then
presented the experiments performed or being conducted in
their institutions. The Chair person Dr. Alfred Mascarenhas
summarised the session at the end by stressing
i. that experiments are more possible where one has
relative autonomy, but it is heartening to note how
much has been attempted even in the absence of it;
ii. that unless we share our failures and not only our success
we
cannot learn from each others experiments and
initiatives.
In the last session of the day,presentations were made by
. .66
66.
people who were not in medical colleges, but were representing
the organisations who were highly concerned about broader
health and social issues including the production and utilisation
of Doctors. They included:
1. Dr. Mira Shiva, VHAI-New Delhi, who outlined the efforts to
promote Rational Drug Therapeutics education in Medical
Colleges.
2. Dr. Zafarullah Chowdhry, Gonoshasthya Kendra Project,
Bangladesh, who shared about Gonoshasthya Kendra's efforts
to evolve a more relevant doctor/medical education course
for Bangladesh.
3. Dr. P. Zachariah (MMC-Miraj), who shared the key process of
evolving the Miraj Manifesto - which was the blue print for
a alternative medical education project initiated by
Miraj Medical Centre (A request was still pending with
Maharashtra Government) .
4. Dr. Mohan Isaac (NIMHANS-Bancalore) shared about their
efforts to improve the community mental health knowledge
and skills of existing health human power at all levels.
5. Some reflections on the Consortium of Medical Colleges
evolving curricular change by research inquiry (by
Dr. Ragini Macaden on St. John's Medical College).
6. Some reflections on the CMC Network that has been meeting
annually since 1989 (by Prof.V. Benjamin, Ex. CMC-Vellore).
The sessions on the first day provided all the participants
with a rich, stimulus of inspiration and information.
--
Dr. Shiv Chandra, Ajmer.
. .67
"THE GREATEST CHALLENGE TO MEDICAL EDUCATION IN OUR
COUNTRY IS TO DESIGN A SYSTEM THAT IS DEEPLY ROOTED
IN THE SCIENTIFIC METHOD AND YET IS PROFOUNDLY
INFLUENCED BY THE LOCAL HEALTH PROBLEMS AND BY THE
SOCIAL, CULTURAL AND ECONOMIC SETTINGS IN WHICH THEY
ARISE".
- SHRIVASTAVA REPORT, 1975.
"THE ENTIRE BASIS AND APPROACH TOWARDS MEDICAL AND
HEALTH EDUCATION AT ALL LEVELS SHOULD BE REVIEWED
IN TERMS OF NATIONAL NEEDS AND PRIORITIES AND THE
CURRICULAR AND TRAINING PROGRAMMES RESTRUCTURED TO
PRODUCE PERSONNEL OF VARIOUS GRADES OF SKILL AND
COMPETENCE, WHO ARE PROFESSIONALLY EQUIPPED AND
SOCIALLY MOTIVATED TO EFFECTIVELY DEAL WITH DAY TO
DAY PROBLEMS WITHIN THE EXISTING CONSTRAINTS".
- NATIONAL HEALTH POLICY, 1982
68
68.
SESSION - V
10-A. GRADUATE FEEDBACK ON MEDICAL EDUCATION - AN EXPLORATORY STUDY
Preamble
Eversince the freedom movement in India and the attainment of
national Independence in 1947, it has been the stated intention
of national level professional bodies, expert committees and
several medical colleges to mould medical education to suit the
specific needs and circumstances of the majority of the
population in India.
A study undertaken by the Community Health Cell of Bangalore in
1990-92, reviewed the past four decades of Indian experience in
evolving and implementing strategies to make Medical Education
socially relevant and community oriented. As an integral part
of this exercise, feedback from medical graduates who had work
experience in peripheral health institutions (PHIs) in the
country was obtained. This was to elicit their opinion
regarding the adequacy of the undergraduate medical curriculum,
as preparation for the professional work that they had to
carry out at the PHIs.
This aspect was undertaken as an exploratory study the therefore
used an open-ended approach. The goal was to identify broad
areas that could be studies later in greater detail, possibly
by each of the different disciplines as part of a process of
evolving relevant curricular change based on a method of enquiry
and on data collection. Thus it was done with the hope that
medical educators would take note of the findings and develop
them further. It is an effort to link up experience in the
health services and feedback arising from involvement in health/
medical care, with the system of medical education, so that in
the natural process of growth and evolution they could be
mutually supportive in the common search to be relevant to the
health needs of people.
The following is some key aspects of
the Study as presented by Dr.Thelma
Narayan on OHP sheets at the Meeting.
For further details and findings,
you can refer to the Report entitled:
'Evolving Medical Curriculum through
Graduate Doctor Feedback' by
T.Narayan and R.Narayan, published in
March, 1993 (Now available from CHC).
-Ed
. . 69
69.
Obj ectives
The objectives of the exploratory study were as follows:
a. To elicit feedback on all the major aspects of the under
graduate medical course;
b. To identify in the undergraduate medical curriculum,
i.
ii.
iii.
iv.
areas that were useful, relevant and adequate;
areas that needed further strengthening;
areas of lacunae;
areas that could be reduced or deleted.
:
Methodology
a. Questionnaire
As an instrument of study a questionnaire was developed.
The different aspects of medical education on which it
elicited feedback were:
I
i. all the preclinical, paraclinical and clinical subjects,
including medical ethics;
ii. additional skills in patient care and hospital work
like nursing, management, communication and training;
iii. other related aspects like selection or admission
procedures, teaching methodology or pedagogy,
curriculum structure, examination system, base of
teaching,etc.
A total of thirty seven (37) different aspects were covered
through open ended questions.
Information was also collected about the respondents work
experience viz., location of the peripheral health
institution, nature of medical/health activities, type of
facilities available, distance from nearest referral centre,
etc. This was to build up a profile of the background of
work experience based on which the feedback was being given.
The design of the questionnaire, including choice of aspects
to be studied, was based on previous experience of a
workshop on Medical Education held in 1984 for medical
graduates working in PHIs. We also held a group discussion
at the onset of the study for this purpose with a group of
ten medical college teachers who had all worked in PHIs
earlier. Several other personal interactions and
experiences were also useful.
. .70
70.
The questionnaire was pilot tested on 10 respondents.
Modifications were made based on this, as well as on
comments by the advisory committee.
b. Sample
The criteria for the respondents were as follows:
i. That they had graduated from any Indian medical college
during the decade of the 1980s. This was to ensure
that feedback received related to contemporary medical
education. This was considered important, as over the
decades several modifications have been made.
ii. That they should have completed a minimum of two years
working experience as a doctor in any peripheral health
institution in India. This included work in Government
Primary Health Centres or in community health
programmes/small peripheral hospitals run by VoluntaryOrganisations. This was to ensure that they had first
hand experience of understanding and responding to the
health needs of people in rural areas and urban slums
and had worked for a sufficiently long time to put
their knowledge and skills to use in these circumstances.
The sample was not statistically chosen to represent any
particular region or college. Finding respondents who
fitted into the criteria given above was not easy and
building a sampling framework was much less so. This was
also at this stage only an exploratory qualitative subunit
of a larger study. However we did try arid get a mix -of
graduates from several different colleges.- Eligible
respondents were identified from applicants to postgraduate
medical entrance exams where rural service was given
special recognition, and from a meeting of a national group
called the Medico Friend Circle (mfc).
Anonymity of the individual respondent as well as the
medical college was maintained as we were wanting to
study' issues in the different disciplines along with other
aspects of the undergraduate medical curriculum, and were
not studying or evaluating any particular college.
The questionnaire was given/sent out to 120 eligible
respondents. Of these, 78 were given out by the
researchers and the remaining through contact people.
The latter attempt was not very successful. One reminder
was sent after a period of a month to the 78.
. .71
A profile of the respondents work experience in PHIs in India
1. Year of graduation
- 40%
- 57%
1980 - 84
19S5 - 88
2. Geographical distribution
S ou th I nd i a
Rural
- 73.5%
- More than 90%
3. Years of experience
- 2 years, 10 months
- 152.4 person years
rt
(D
Q
0
h
(n
rt-
Qi
(D
io
Average
Total
Less than 50 beds
51 - 100 beds
More than 100 beds
- 65%
- 20%
- 15%
5. No. of Departments
1 (mainly general)
2 departments
3 departments
4 departments
- 51%
- 14% I combinations of
- 14% I obstetrics and
- 7.5% I gunaecology, medical
surgery, paediatrics.
6. Total No. of Doctors in PHI
1 Doctors
2 doctors
3 doctors
4-6 doctors
More than seven doctors
-
29%
20%
19%
11%
19%
7. Diagnostic facilities
Simple lab
Simple lab + X-Ray
Simple lab + X-ray+ECG
- 30%
- 44%
- 12.5%
8. Nearest referral facility
Less than 12 k.m.
13-25 k.m.
26-50 k.m.
51-100 k.m.
More than 100 k.m.
-
30%
19%
26%
14%
5%
..72
72.
9. Average workload
A. Average outnatlents/day
i.
ii.
iii.
iv.
Less than 30 beds
31-50 beds
51-100 beds
More than 100 beds
49 per day
85 per day
115 per day
207 per day
Average inoatients admissions per day
3,12, 17, 25.
C. Community level programmes
i.
ii.
iii.
iv.
community health
TE control
Leprosy control
Disability
-
60%
30%
24%
11%
Overall Impressions
1. Need for skill development
in emergency medicine
basic nursing procedures
minor surgical procedures
obstetrics
local anaesthesia
running a simple lab and pharmacy
management
communication
assessing community health needs and evolving
simple strategies to meet them.
2. Suggestions regarding curriculum strategies teaching
methodology, etc.
- Integrated teaching with focus on clinical application,
and common problems;
- Reduce details in theory - preclinical phase
(anatomy, physiology, biochemistry) to 1 year;
- Introduce/strenythen psychology and sociology;
- Need to develop experience in basic nursing procedures;
- Responsibility and decision making capacity during
ward work;
- Remove concept of 'short postings' as being relatively
unimportant;
- Posting during final MB/internship to pathology lab,
blood bank, pharmacy, MRD, accounts;
- Involvement during final MB/internship in training of
health workers.
7.7 3
73.
3.
Comments on examination system
"We are getting more and more exam oriented, while exams are
getting less and less patient oriented".
Several felt that the sytem was subjective, unreliable,
outdated, irrelevant to actual medical practice, and even
unethical.
Suagested
- continuous assessment focus on common problems focus,on
approach to diagnosis, liCQs for theory.
- several■short cases with discussion.
- assess basic, necessary knowledge and skill
Feedback on Pre-clinical disciplines
1. Need for strong clinical orientation
- to compare normal to the abnormal.
2. To integrate teaching
- between preclinical subjects
- and with clinical subjects.
3. To reduce time period from 14 to 1 year
- by deleting unnecessary detail
- reducing time in Anatomy.
4. Intrcduce/strengthen teaching of sociology.
5. Intrcduce/strengthen teaching of psychology.
6. Introduce students to patient care in wards
- learn basic nursing procedures.
7. Learn practical skills even at this stage
- as above
- first aid
8r Biostatistics - considered not very necessary.
9. Need to reinforce pre-clinical subjects during clinical
years.
10. Need to develop healthy attitudes, life styles and
values at this stage.
. .74
74 .
Feedback on Para-clinical disciplines
1. Need to stress clinical and practical application.
2. Need ability to carry out/interpret routine investigations
in pathology/microbiology•
3. Tc be skilled in blood banking procedures.
4. Need ability to support and supervise technical staff in
laboratories.
5. In pharmacology - focus on
- commonly and currently used drugs;
- drug use in pregnancy, lactation, children;
- drug interactions;
- rational therapeutics;
- cost effectiveness;
' - need for frequent continuing education.
6. Teach these subjects in the ward/community .
7. Reduce unnecessary detail eg., histopath, of uncommon
diseases, drugs not in use, making of mixtures,
experimental pharmacology.
8. Introduce postings in hospital pathology, laboratory,
participate in blood donation camps/blood bank, discuss/
analyse prescriptions.
9. How to organize/run a small laboratory/pharmacy ?
10.
Enhance teaching of Forensic Medicine
- poisons, snakebites, accidents, injuries;
- certification of wounds, death, cause of death;
- this aspect is becoming increasingly important.
Feedback on Clinical disciplines
1. Emergency Medicine.
2. Skill in procedures.
3. Clinical acumen, not high tech diagnostics.
4. Focus on common problems in India and how to manage
them in PHI.
5. Student involvement and responsibility in patient care.
6. Integrate preventive and curative aspects.
. .75
7. Use periferal institutions for teaching - OPDs/mobile clinics.
8. Enhance study of paediatrics.
9. Concept of "short postings" to be removed.
10. Importance of psychiatry, dermatology, orthopaedics,
ophlthalmology, ENT, radiology, dentistry.
11. All four primary clinical departments are very important,
especially obstetrics, which is also the most tension
producing.
Feedback on Community Medicine
1. Very imoortant to work in PHIs.
2. Need better training.
3. More community based teaching, more field work.
4. Integrate curative aspects with PSM/CM.
5. Enhance practical training in Health Education, School
Health, Nutrition, Occupational Health, Management,
Epidemiology, Statistics.
6. Learn to assess local health problems and evolve
strategies of intervention.
7. Need to experience the functioning of feasible programmes
in the field.
8. Establish special cells to maintain links with doctors
in PHIs.
9. Need committed staff with field experience.
10. Involvement in training health workers.
General Suggestions
1. Career guidance cell and preparation/orientation of
graduates opting for rural service .
2. Sharing of experiences with undergraduates by those who
have worked/are working in PHIs.
3. Visits of specialists to PHIs.
4. Internship postings to PHIs.
5. Introductory lectures on Ayurveda, Homeopathy,
traditional health practices.
6. Sessions on different religious scriptures and their
positive features regarding health.
76
76.
SESSION - VI
11-A. MEDICAL EDUCATION IN THE CONTEXT OF BHARATH (THE REAL INDIA)*
The trend of instability, unevenness and fragmentation of
political development in India has shaped up with a vengeance at
this point of time. A very conscious ideological
and political
strategy is at work, deliberately shut out from’ our people. We
need a realistic understanding of what has gone wrong with our
polity. There is a grim consensus that India is passing through a
period of major crises : economic, political, social,cultural and
religious The system has become inequitable and incapable of
serving the people of India. Millions are unemployed
and
unchecked population growth continues to increase the number
of
hungry, desperate Indians.
India is a
DbvpIoping
Country
Whatever be the promises and the rosy picture painted of our
country's growth and progress by our politicians and those in
positions of’ power, we have to accept that India is still a
developing country. Though it has good potential prospects for
using more capital,
labour and other available resources to
support its present population at a high level of
living, yet
th^t’e exists in it an exploitation so oppressive that the vast
majority of its people live at a sub-human level.
It is very
clear that more than 40 per cent of Indians, numbering more than
350 million, are living below the poverty line. Many are tumbling
every year below this line, and one of the major reasons is. the
constantly rising prices of essential commodities.
What is the "poverty Line" which is the yardstick used to
measure poverty? The Central Pay Commission has defined it has
the "minimum required diet for a moderate activity". According to
1978 prices, the Bonthalingam Commission had determined it to be
Rs.53 per head per month. Today, in 1992, it will definitely come
to at least about Rs. 200 per head per month. This is what would
provide the minimum amount of calories, proteins. and other
nutrients that one needs in India to work normally.
Looked at from the perspective of economics, the people in
India constitute a pyramid. At the top of this pyramid are the
"rulers of India" made up of about 1 per cent of the households
in our country. These are the financial kings of the country who
decide or influence every decision made by those in political
power so that their own vested interests can be served. These are
served and sustained in their position by the technological and
managerial elite who constitute 4 per cent of the population. The
organised sector of the Indian economy, comprising the blue
collar and white collar workers organised in powerful trade
unions constitute 5 per cent. According to the Central Statistics
Organisation estimates, this sector appropriates 33 per cent of
* Mr. Desmond A. D'Atreo, St.Joseph's Highlands,
Lower Bendur, Mangalore - 575 002.
■ -77
77
the national income. Adding to the black income as well as open
and hidden perquisites, the share of this total top ten percent
of the Indian population may come to about 40 per cent of India's
national income.
In the middle of this pyramid are 40 per cent of Indians who
live around the poverty line. Each of these people can afford to
have only 2,500 calories of food intake per day and the barest
requirements of clothing and shelter, if at all. Down below at
the base of this pyramid are 50 per cent of the Indian people,
who cannot even afford to have a single square meal per day. They
are the least a/ticulate in the political, economic and social
fields.
All the Five-Year Plans, and scores
of
special
programmes,
like the Twenty Point Programmes, are framed for
them, but they do not benefit from them, because whatever gains
they may have made in terms of monetary earnings have been more
than neutralised by the constant rising prices and by the
exploitation
practiced
on them by
politicians,
traders,
government officials, etc.
We really seem to be living in two Indias : One is the India
of the 10 to 15 7. per cent, the "ones who have made it",
basking
in luxury-oriented growth in advanced and privileged regions,
comprising the.caste, class and ethnic elites. The other is the
poor, backwards, marginalised, people on or below the poverty
line, living in the backward and consciously neglected areas, the
Dalits, tribals and the landless labourers.
Eros ion of Ya lues
The onslaught of Capitalism and Modernisation have brought
in a new set of values from the West which are in total
opposition
the human values that our Indian culture
has
inculcated for centuries. Founded on a communitarian culture, our
values
were
those of sharing, cooperation
and
personal
relationship.
Evert, though caste differences were
strictly
maintained, there was an arrangement of harmony and collaboration
among the people of a community. There was respect for nature and
for living beings. But the new values that have invaded our
society are competition, individualism, excessive profit motive,
disregard for nature and environment and regard for prestige.
This value system has pushed the Indian psyche towards hypocrisy
which is one of the major roots of the corruption prevalent in
our country. The tragedy is that these alien values are making
rapid inroads into our villages and have created a whole culture
of selfishness, consumerism, competition and rivalry which are
intensifying the problems of underdevelopment and exploitation OT
our masses.
The Heal th Situation of. our Poor
When we come to the health care of the people at the lower
part of the pyramid, constituting about ninety per cent of the
Indian population, we find a very grave vacuum. While we . accept
that we have a large number of doctors, nurses, midwives,
auxiliary nurses,
health inspectors, hospital
beds and PHCs ,
these persons and institutions are not really serving the poorest
sector of society. Our health standards are still extremely low
and the great majority of our people are vulnerable to disease.
Communicable diseases are still rampant and the mortality rate is
still 15.1 per thousand!
To be born poor in India means to be born unhealthy or to
become unhealthy. One out of every four • persons unnecessarily
suffers from disease; this could have been prevented by improving
the environment and by timely immunisation. The miserable health
standards of the masses are a reflection of 'the
overall
conditions of life. Those who are living below the poverty . line,
ill-clad, undernourished, homeless, without sufficient drinking
water and no sanitation at all, cannot avoid diseases ranging
from T.B., leprosy, mental retardation due to ma1 nourishment .
The medical personnel in India are not trained to cater to
the masses, as one doctor recently confessed, "We are trained to
practise abroad!" At the time of Independence, the Government of
India decided to subsidise the training of medical graduates to
the extent of 90 per cent so that there could be sufficient
doctors to attend to our poor and unhealthy population. However,
very many doctors migrate after obtaining their degree so that
they can feather their financial nests beyond possibilities open
in our country.
Medical aid is not within the reach of our poor, especially
those who live in villages. The poor man has to walk miles before
he can see a doctor or a poorly equipped or rarely manned health
centre. SO per cent of the doctors and 97 per cent of the
hospital
beds of our country are in the urban areas which have
only 20 per cent of the total Indian population. The remaining 80
per cent are left to manage without any medical personnel or
med ic a laid.
Very little attention is given to providing the rural people
with facilities of drinking water. Till recently, cut of 5.76
lakh villages, 4.55 lakh villages had some kind of water supply
like hand pumps, conserved wells and springs. But in 1.16 lakh
villages, water is still not available within a depth of fifty
feet or a distance of a mile.
On the other hand, 83 per cent of the total urban population
is provided with drinking water. A concrete example of the
shocking disproportion of concern for city over village is a
recent scheme for the renewal of the water supply in one of our
major cities, which cost over thirty crores of rupees, while in
that same time, absolutely very little is spent for providing
water for Indian villages, in which the majority of our people
are living!
To talk of sanitation would be still more meaningless, for
while 38 per cent of the urban population are provided with a
sewage system, there is practically no sanitation system for the
80
the poor children of our country will bear the scars of the
crisis in the social sectors. They will suffer from the. cutbacks
of the nineties in their bodies and in their minds well into the
21st century.
,
If the majority of our children are to exist in a childhood
that is not worthy of that name, but rather is a period with
inadequate education, if they must go through a period of severe
malnutrition, not have effective health services to go to,
then,
I am afraid, they will grow up as a people less prepared to be
fully affected adults. Even more important, mothers, who grew up
as girls through a period of malnutrition are more likely to
suffer higher rates of maternal mortality and themselves pass on
these problems to their children.
There is a lot of tragedy in store for the future because we
in the majority world (I refuse anymore, after having seen the
machinations of the elite world in the World summit of Rio, to
give our part of the world the obscene title of Third World.
Rather would I it what it really is: the majority world) — we
have bowed down to the elite world and created for our country an
economic policy that is utterly neglectful of the poor majority.
Our rulers may call this an economic policy with a human face.
But it seems to be a mere mask offering only lip service, even as
we have observed in the last few months since the economic policy
was promulgated.
Medical Education for the Rea 1 India!
In this bleak scenario, we ask ourselves, "What is the role
of Medical Education?" We cannot deny that it is responsible to a
very extent for the elitism in the medical profession. The
subjects that are emphasised are more oriented to the medical
care of the well-to-do than towards the majority of our people,
and certainly in contradiction to ths, intention of the Indian
Government at the time of Independence when it decided to
subsidise medical education so that the poor can be primarily
he 1 ped . •
There is no real education conducted in our Medical colleges
that is built on the actual situation and needs of our country.
The education purveyed in these institutions is what Paul Freire
calls a "banking system of education". In it the teachers decide
and the students follow. The syllabus is constructed by the
teachers,
rather,
we
may
say,
by
the
pharmaceutical
multinationals with a view to popularising and selling their
products, and in no way is related to the actual needs of the
students or the majority of the people of our country whom they
should serve. The teachers plan,
the students follow. The
teachers do, the'’students see and accept. Even where the students
are enjoined to involve themselves in actual work in laboratory
or field, there is not much scope allowed them for initiative and
creativity, but they are bound to follow the textbook and
professor rather blindly.
81
81.
82
82
speaking here of a spirituality that is linked with any religious
sentiment or practice. We are referring to a spirituality
which
involves a faith in one's fellow human beings, however suppressed
they may be, a hope built on their potential to discover their
own health care practices and orientations and a love for those
who eke out their living in subhuman conditions but are equal to
us in everything that is authentically human. It is essential
that one recognises these people as worthy of equal dignity as
oneself.
It is only when one is able to discern the divinity in
the other, be he or she poor, neglected, less knowledgeable than
oneself that one's spirituality will provide the elan and
leading
vitali ty to keep on working in this noble profession of
others to take care of the health of those who need it.
Consequent
on
this
is
the
realisation
that
institutionalising of the health education is a dangerous trend
that causes the depersonalisation we have been referring to
above.
It is urgent that we give primary importance to persons,
whether they be our co—professors, our students or even the rural
poor who frequent our hospitals. This importance will lead us to
a deep humility, which will enable us to be ready to learn even
from the poorest with whom we come in contact.
These poorest must be awakened to the deficiency, nay,
the
exploitative nature of the health system prevailing in our
country. They must be helped to rediscover the health system that
is indigenous and very effective, because related to the very
life situation culture and ambiance in which our people live. We
would not be exaggerating if we say that the members of the
teaching staff of medical colleges should realise that the people
the
can find their own health system.They must be given
enthusiasm to build up their own health system, in which they are
the primary planners, the real implementers and the authentic
result of their health care, founded on their innate sense of
community, their traditions, their simplicity of life style, and
their seif-re1iance.
This seems to be asking for much. But it is an ideal
cannot be denied. And ideals are meant to be striven for,
though in our life-time we may not achieve them!
that
even
83
SESSION - V/VI
10-B/ll-B. DISCUSSION
The presentation by Dr. Thelma Narayan on the feedback from
graduates on various aspects of Medical Education in the context
of their experience of the needs and challenges in Health Care
in small rural hospitals and health care institutions (see
section 1C-A) was well received and stimulated much discussion
and comment. However due to shorta e of time, the reflections
by Mr. Desmond Abreo on the challenges of Medical Education for
the 'Real India' (i.e., the large majority of poor and underorivileced and marginalised) was introduced as a supplementary
input in the discussions (See 11-A) and then the discussion on
both these presentations was taken together. Though this was
not part of the original plan, the complementarity of the two
presentations - one based on rigorous study of actual feedback
of younc doctors from the field and the other based on
'inspirational reflection' from years of grassroots development
training experience helped to make the session a very
enthusiastic and spirited event.
The participants made many interesting observations and
relevant comments while at the same time raising significant
questions. These included:
i. The polarisation of the ‘haves' and 'have nots' in the
country and the polarisation of the health care to these
two groups was a significant perception ranging from
cvermedication of the rich to near total neglect of th.'
very poor.
ii. The commercialization of medicine and the phenomenal
impact on market forces in the development of medical
malpractice should not be underplayed.
Infact this has
had a major impact on staff and student values who are
part of the larger social system and internalise and
reflect those values. Therefore professional prestige,
maximisation of profits and competition become very
dominant values.
iii. For those who opt to work in underserved and marginalised
areas there is need to have structures for support and
nurture. We need to recognise their need for facilities,
recognition, companionship and remuneration.
iv. Inspite of the growing awareness of the dichotomy
between medical professional goals and goals of medical
education vs the primary health care needs of the people,
changes and responses have not emerged adequately. This
is due to the professional stranglehold on the medical
system and also reflects our social structure.
84
v. If what is needed and what is given is so different why
dont we close down some medical colleges instead of
starting more?
vi. There should be an increasing awareness that changes will
not come about just by attitudinal change but also by
political change. Hence while training can make some
contribution to skill development and attitudinal change,
the political economy of health and the politics behind
expansion of medical education in the country must be
seriously analysed and countered.
vii- We need to reflect seriously, have we failed as teachers?
The situation around us is known to us. Why is it we
feel more and more unable to change things? Are we
willing to confront our students with the realities?
Do we ask ourselves whether what we are offering them
makes any sense to the realities in the field?
viii. While welcoming the contribution of pacesetter colleges,
we must recognise that change must come in the government
sector that is the larger and quantitatively the greater
challenge. This means that wre must involve this sector
more - and have more representation from this sector in
our meetings and dialogue. We must also be sensitive to
the increasing demoralization that is taking place among
the students and staff of this sector while at the same
time support the innovations that are also being attempted,
within government institution by some motivated staff, as
has been presented at this meeting.
ix. The growing political interference in Medical Education
is also a serious problem, affecting fall in standards and
the morale of staff and students. What can we do about
x. There is good evidence that what is really needed are good
role models for the students to emulate in their career
aspirations. Are our faculty such role models? Are we
providing the environment in which they can become role
models?
During the discussion, a group of young interns from one of the
local participating medical college were present and they were
invited to share their reactions and responses to the ideas on
challenges and feedback from peers,that they had heard about
during the session.
The very frank sharing by these young interns, many of whom had
completed their rural internship was a good indication of the
changing values in our social ethos and the dilemmas that
young doctor face when they are faced with career options in
85
the changing ethos. This was particularly significant since
these were interns from a highly motivated and community
oriented medical college. Two dilemmas that were very thought
provoking were:
1. Are highly trained people like us really required for the
type of village work that is required? Cr that we have
experienced during internship?
2. Hew do we handle the stresses created by the life style
changes that such work calls for? We do not get what we
are used to in our daily life? Are we prepared for thes
The dilemmas were presented by graphic personal anecdotes but
the message was clear to the group of teachers after the
initial shock. Are we doing enough to prepare them emotionally
as well as professionally to meet the challenges of community
work? Have we been toe preoccupied with knowledge transfer and
skill development but neglected value development?
e sharing by the in
understand the phe
e required to .move
cial
of oi
helped, tne
ommitment
and
society.
nagging doubt th at while
ion left us all wit?
content, the bas
.es towards changing
ulum would be su
in the c
the soci
the overall goal much more
er
yolitLeal-economic-cultural system as well as in the
goals of the broader educat cnal system are required
REAL CONCRETE CHANGE has tc be sustained. As enthusiastic
medical educators what will be our role in
'.e
NOW..... MMATjS
THE
^AP ?
COMMUNITY ORIENTATION - THE MEDICAL STUDENTS DILEMMAS
IS ANYONE LISTENING?
86.
12.
IN
CONCLUSION
One of the key goals of the CHC Medical Education Project was to
stimulate and support the formation of a critical mass of
medical educators to commit themselves individually, institutio
nally and collectively to reform medical education to make it
more socially relevant and community oriented.
The Medical Educators Review Meeting was a culmination of this
effort. However, as mentioned in the section on Background,
at the beginning of the proceedings, while the meeting marked the
end of the formal project, it also symbolised the beginning of a
new phase leading hopefully to action at various levels.
While the CHC had facilitated and played the key role during the
two year study phase, it was now upto the collective of 1 medical
education enthusiasts' representing various medical colleges
and other organisations to play a more active role in lobbying
for change and in experimenting with further action.
At the concluding session of the meeting, the following
suggestions were put to the participants as component actions
of the next phase and as a stimulus for follow up.
The participants were requested to:
1. Read the background materials, articles, circulated and
send comments and suggestions, that would help the
evolution of the project publications especially the
Faculty Resource Book.
2. Share materials and ideas picked up at the meeting with
other colleagues in each participant's parent organisation.
Continue to share the enthusiasm and experiences with each
other and with CHC as well.
3. With atleast two possibilities of alternative experiments
being shared at the meeting, all participants who were keen
to join the new ventures as volunteers/participant faculty,
were requested to keep in touch with those organisations:
a) Dr. Cherian Thomas, Director, Wanless Hospital, Miraj
Medical Centre, Miraj, Maharashtra-416 410;
b) Dr. Zafarullah Choudhury, Project Coordinator,
Goncshasthya Kendra, Nayarhat, Dhaka-1350, Bangladesh.
CHC was keen to support either or both of these initiatives
and had already volunteered to be an available resource to
the process.
. .87
87.
4. if any group are serious about organising a pre-selection
course which brings together as much of the wealth of
experience in the formal and informal Health training sectorthey could get in touch with CHC about the interest/initiative
since we were keen to help this process in particular.
5. The publications of the reports of the Project and the
proceedings of the Meeting will be completed in the coming
year and CHC welcomed ideas, responses, suggestions on them.
CHC would also be interested in their use for lobbying for
change within a institution, in a region or at national level
and would request participants to keep us informed about
such developments.
6. The participants were also requested to keep all the others
whom they had meet at the meeting informed about ideas, and
experiments that any of them or their institution would
initiate in the future. This informal communication could
lead to many forms of linkages between institutions and
between project initiatives, developing a healthy peer
support and peer review process. Those, who had experimented
longer, may have much to offer those who had just begun.
Those who had just begun may stimulate through their
inquisitiveness, the more experienced ones to evaluate
their own experiments with greater rigour and openness thus
producing mutually beneficial effects.
7. If any individual or group was organising a meeting/
workshop/dialogue to spread this enthusiasm for change and
required support, encouragement, help or a dose of
enthusiasm, it was hoped that the Medical Educators Review
Meeting had put people in touch with adequate number of
enthusiastic and infectious resource persons for such a task.
8. Finally, since the interaction was too packed, there was not
enough time to seriously discuss whether there was need to
develop this informal group (who had gathered at CHCs
invitation to discuss the project findings and share their
own enthusiasm and experiences) further into a more formal
alternative medical educators network. It was noted that
already we have atleast three fora where such sharing and
joint action could take place:
i. The Indian Association for Advancement of Medical
Education was such a forum though in recent years
it had lost some of its original inspiration and
collective style;
. .88
ii. The Network of Medical Colleges - called the Consortium
was another development which could be stimulated to widen
its membership and perhaps even allow for associate members
who could be observers at the meeting; (See Section 8-F).
iii. The Christian Medical College Network which had been
facilitated by CMAI since 1989 was another forum which
could also cater to a large and more secular group of
colleges and individual enthusiasts by widening its circle
of linkages. (See Section 8-I<).
Many of the participants were already members of one or more of
these fora. However many felt that all of them focussed on the
orthodox medical college sector and were not open adequately to
inspiration and interaction with other sectors such as Community
Health Trainers of the Voluntary sector, Development trainers,
students and health workers and so on, so a more broad based
open ended informal network was necessary.
However it wes felt that it may be good idea to keep the CHC
initiated precess an informal association ana linkage ana allow
the collective enthusiasm or the group to build up gradually.
See Post Script
-to Wet work
{o
f to Change
89.
13.
PARTICIPANT FEEDBACK ON MEETING
At the end of the workshop all participants were given a
participant feed back form to get a frank feedback on the meeting.
They were requested to assess the strengths and weaknesses of
various aspects of the programmes including the preparatory phase,
the technical sessions and the facilities. 6 forms were received.
Though the number of replies were a bit disappointing, those who
handed the forms gave a lot of interesting and thought provoking
comments and suggestions.
The following is a collation of the feedback from Dr. Shiv
Chandra-Ajmer, Dr. P. Zachariah-Vellore, Dr. Mira Shiva -New Delhi
Dr. Prem Pais-Bangalore, Dr. Deepak M. Kamle-Miraj, Dr.C.M.FrancisBangalore.
Dr. Shiv Chandra - Ajmer
1. The preparation was satisfactory.
2. Duration: Two days have proved shorter since it appeared that
many more ideas/feelings remained unexpressed.
3. Expectation:
a
copy of Faculty Resource Manual.
4. Facilities: I wish arrangements for transport/mobility would
have been provided.
Dr. P. Zachariah - Vellore
1. The preparatory communications and facilities were appropriate.
2. Composition: It might have been good to involve more
government colleges. Some not directly related to medical
education could have been omitted, if necessary.
3. Programme: A certain amount of meandering was inevitable though
I felt uncomfortable with it.
4. The technical quality of the presentations by the Cell could
have been improved.
Dr. Mira Shiva - New Delhi
1. What I liked best was the kind of people that had been
invited - it was such a joy to be with people one admires
and respects in this day' and age.
. .90
90
2. The CFC team was very helpful and kind and the conscious
selection of a simple place was really a very good thing
to do.
3. The schedule and content were very well organised.
a lot.
I learnt
4. I did not like the way the students intervention was handled.
I felt we were all becoming defensive and pacifying. It
would have been good to have these views exchanged in a
student debate at a national level inviting participation
from all colleges about 'personal rights'vs'social
responsibility'of medical doctors?
5. Since there was no central room to meet after formal sessions,
everyone tended to return to their rooms, missing an
opportunity for interaction.
6. The Community Health Cell team has put in a lot of efforts
and the labour of love really shows. Would you all be
willing (off and on) to travel a bit, if needed, to
introduce some of the new concepts. All of us will help in
the exercise.
7. If we try to get the different medical college people
together on Rational Drug Policy theme, then Rational
Health Care and Rational Medical Education can also be
introduced in those sessions.
8. At a time when there is so much burn out an paralysis and
dystonia - your constructive efforts - really mean a lot
and are more relevant today than even before.
9. Thanks a lot and my dream is that all the forces of good
will join together forming a critical mass and work
together. The issues are secondary bethey drugs, medical
education or economic policy related; be they in India or
across the border in Bangladesh.
10.
Thanks once more.
all of you.
I felt very very happy being with
Dr. Prem Pais, Bangalore
1. On the whole the meeting was useful.
2. I felt the majority of participants were no longer involved
in teaching medical students and had no concepts of how
medical students feel and react.
3. How can all that was discussed, begin to be implemented?
■-------------------- . .91
91.
. .92
92
Dr. C.M. Francis, Bangalore
1. The Medical Educators Review Meeting was very useful.
2. The preparation was really good, with the background
information being given to the participants.
3. The facilities were ideal for a meeting like this:
i. it was a quiet atmosphere;
ii. the style was simple with respect to meeting room
and the food;
iii. the atmosphere was informal and friendly.
4. The sessions were good.
The presen cations were appreciated.
5. There was not enough time for discussions.
As all the
participants are knowledgeable in one way or other, more
time should have been made available.
6. The final sessions of action plan is important. If people
begin leaving in the middle, it detracts from achieving
the objectives fully.
★
w
★
★
93
93.
POST SCRIPT
It is over 18 months since the Medical Educators Review Meeting
was organised by CHC as a final event of the CHC/CMAI/CHAI project
on "Strategies for Social Relevance and Community Orientation in
Medical Education - building on the Indian experience". Many
developments have taken place in the wider context of Medical
Education in India as well as in the context of ideas and
initiatives shared by participants at the review meeting. While
apologising for the unavoidable delay, in editing and collating
the proceedings,these developments and events are presented as a
process of continued information and interaction since June, 1992.
1. The Project reports of the study and the report on Graduate
Feedback was completed and sent in draft format to the
following for comments before finalisation
i. Project Advisory Committee and CMA1 , CHAI
(July, 1992);
ii. Prof. V. Ramalincaswami (prof. Emeritus-AIIMS) and
Prof. D.K. Srinivasa (NTTC-Jipmer) as independent
reviewers (August, 1992);
iii. ICMR, IAAME, li'.A and MCI
(September, 1992);
iv. The four CMCs and medico friend circle (November, 1992)
Some comments received were incorporated into the final
manuscripts before publication.
2. The outline of the Faculty Resource Book (see Appendix H)
was circulated to all the respondents of the Medical Education
Project and a large list of peer and medical education
enthusiasts for comments and.further suggestions. Various
responses received are being added to the faculty resource
book.
3. a) Miraj Medical Centre (Wanless Hospital) had been given
an indication in June, 1992 that the Maharashtra
Government was keen to approve its long pending request
for a (Alternative Track) Community Oriented Medical
College. The initial project proposal had been outlined
by some groundwork done by Dr. C.M. Francis and
Prof. P. Zachariah in 1989-90. In August 1992,
Drs. Ravi and Thelma Narayan of CHC visited Miraj to
explore the option of giving full time to a Medical
Education Cell for faculty development from January,1993
(if the final permission was granted). The Society had
agreed to release them for this assignment for a period
of two years. However during the visit, the implication
of the newly proclaimed Central ordinance on new Medical
Colleges was discussed and Miraj project has now been
temporarily postponed due to this new development.
. .94
94.
b) During Dr. Ravi and Dr. Thelma Narayan's visit to Miraj
in August, 1992 the Staff Research Society of Government
Medical College, Miraj and the local chapter of the
Maharashtra Medical teachers association organised a special
meeting on the Medical Education giving an opportunity f,
present the study findings to an enthusiastic audience of
staff of a government medical college.
4. The Supreme Court Judgment on the capitation fees Medical
College problem and the subsequent writ petitions and stay
and the newly promulgated Central ordinance regarding the
need for Central Government permission for all new Medical
Colleges, led to an interesting and effective break on the
growing commercialization and mushrooming of private medical
colleges in the country. This has led to an intense public
debate on privatization/comrercialization and the role of
the state in Higher Education. While the capitation fees
lobby is very very strong, partly because of its linkages
with big business and 'political party funding' it has not
been able to stall the court cases and the judgments about
allotment of seats and related procedures for payment and non
payment seats which has put the state governments,particularly
of Karnataka, Andhra Pradesh and Maharashtra in a quandry.
This is a good example of legal measures that are required to
make some aspects of Medical Education development more
relevant to out needs and realities.
5. August 1992 : The Medical Council of India circulated a
draft report of a special committee set up by it in
Cctcber, 1991 to draft recommendations for the evolution of
a revised curriculum (The .acker Committee Report). Cne of
the highlights was an Alternate Track after preclinical,
paraclinical training. It was stated that,"the focus of
the training in these courses will be on general practice,
in community setting, with capabilities of providing primary
and secondary care. There will be a significant component
for training in Mother and Child Health Care and family
welfare programmes. Input will be provided to work with a
health care team to achieve fulfillment of national health
programmes and to participate in health education activities
in the community. The opportunities for those who elect this
track will be equivalent to those who continue as physicians
to be specialists or to take postgraduate courses.".
A workshop on Need based curriculum for undergraduate
medical education was also organised 28-29th August, 1992.
6. An extract from the Graduate Feedback survey raw data on
basic skill requirements for Doctors working in peripheral
health care institutions was sent to St. John's Medical
College for a survey they were carrying out in the context
of a consortium initiative.
. .95
95.
7. The final recommendations of the MCI Workshop on Need Based
Curriculum in August, 1992 was circulated a few months later.
With reference to the Alternate Track, the recommendation
noted: "Having debated at length the suggestions for providina
an alternate track for the MBBS course, the workshop
recommends that the proposed changes in the MBBS curriculum
would take care of the kind of competency suggested in the
alternate pathway, as such there is no need for the same.
However the MCI may permit and encourage innovative educational
reforms for providing inputs for introducing curricular
changes'1. A disappointment no doubt for all of us who believe in
the "alternative track conceptl
Significantly the only relatively new recommendations were
(i) 'the establishment of a medical education unit in every
college for faculty development1.
(ii) 'the senior faculty
may also be enthused in participating in the educational
activities in the district, taluka and rural health centres
to ensure their exposure to the realities of community
health care'.
(iii) One month of the primary care training
during internship may- be in the form of preceptorship with
a practising family physicians or voluntary agency or other
primary health care provider approved by the faculty, aw these
three de provide new opportunities as well to all of us'.
8. Dr. Mohan Garg, Consultant-Medical Education from CED-Illinois
who has been one of the key facilitators of the Consortium
of Medical Colleges (see section 8) was in Bangalore in
December, 1992 in connection with a consortium related visit
to St. John's Medical College. During this visit, the CHC
Project coordinators (RN S TH) were able to meet him and apprise
him of the study/ and the related process as well as the
Medical Educators Review Meeting in June, 1992. He was
particularly interested in the Graduate Feedback Survey,
since there was a renewed interest in reaffirming the role of
General Practice/Family Medicine in the USA and various
prcjects/discussions were underway- to operationalise their
s: if t of emphasis. The Graduate Feedback survey- greatlyemphasised the content and nature of this shift. The need for .
the consortium initiative to tap other sectors was also emphasises
9. An unsuccessful attempt was made by the CHC project
coordinators to get IAAME to provide sometime for the
presentation of the study findings at the annual conference
held in Madras, in January 1993, on the theme"physician for
the Twenty First Century". Inspite of being IAAME members,
having sent full manuscripts of the pre publication reports;
and being in touch since February, 1992 after the
preliminary papers from the Project were presented at the
Bombay Conference (IAAME annual meeting - January, 1992)
an opportunity could not materi alise ,which was a. disappointment ’.
10. Prof. V. Ramalingaswami, Chairman, Task Force on Healt?
Research for Development, Geneva, sent a very' interesting
.96
96.
foreword for the first publication of CHC Project in
February 93 which he endorsed that "there is a message of
hope in this monograph even as the obstacles to change are
identified clearly and the many disturbing trends in medical
education and practice are outlined. The monograph makes
a positive contribution to refers, in medical education and
the cut'• or
serve praise and gratitude".
(See rest of
for-werd in Medical Education ''reject Report, rarcb, .1993
available at CMC).
11. Prof. D.U. Srinivasa of NTTC-JIPMER sent the foreword for
the second publication, mentioning "this report, part of the
whole project focusses on the feedback from medical
graduates and covers a wide range of topics in medical
education. This study is intended for medical education.
It is hoped that they take note of the findings and mould
their t:.inking to the specific needs, expectations and
inr.cvations" .
12. The first two publications of the Cf-C/Ci'AI/CHAJ Project on
Medical Education was published in March, 1992 and available
for lobbying and sale. These were:
i. Strategies for Social Relevance and Community Orientation
- Building on the Indian Experience (A Project Report);
(Cost: fc.40-00, U.S.? 5)'
ii. Evolving Medical Curriculum through Graduate Doctor
Feedback.
(Cost: 9s. 40-00, U.S. $ 5)
A pre publication offer was circulated to all project
contacts offering a 20% reduction in the cost of the total
set. Many contacts availed of this offer and we also
received bulk orders from some croups. A post publication
handout has also been distributed and announcements of the
publication have been caried in some health bulletins and
j ournals.
13. Dr. Madhav Ram, Lecturer, Department of Community Medicine,
PSG Medical College, Coimbatore, was a short term research
associate of the CHC Medical Education Project and helped
to compile the chapter on Innovations in Medical Colleges
for the evolving Faculty Resource Book. This was the
largest section of the book and contributions and papers of
varying quality had been received,which needed both,
systematic and creative editing and collation.
14. Dr. Arvind Kasturi, who completed his postgraduation in
Community Medicine from CMC-Vellore, joined the CHC
Medical Education Project as a short term research associate
to undertake an overview - compilation of 14-15 Training
9.7
97
programmes in Community Health in the voluntary Health sector
in India. This first stage compilation was circulated as a
background paper for a planning meeting organised by
Dr. R.S. Arole of CRHP, Jamkhed, for a special three month
course in Primary Health Care being organised by him (which
is being sponsored by Pune University and Institute of Child
Health, London). This draft report will form part of a
larger interactive process that will help in evolution of a
CHC Monograph entitle 'Laying the New Foundation' (expected
completion in 1995).
15. Dr. Thelma Narayan of CHC attended the Silver Jubilee
Celebrations of The Faculty of Health Sciences, McMaster
University, which had pioneered the concept of 'problem
based learning' in the world. The three day meeting
included small group work to interact with faculty and thus
get acquainted with the learning methods used at McMaster.
The workshops covered areas of small group process,
evolution of community experiences using journal method,
faculty development for problem based learning, selecting
priority problems and designing curricula,adapting problem
based learning to different learning situations and
community based experiences. Useful discussions were held
with the team working on "Educating Physicians for Ontario".
16. The third report of the CHC Medical Education Project was
published in August, 1993. This was an annotated
bibliography of 60 key publications in Medical Education
entitled 'Stimulus'for Change*.
It was hoped that it will
prove to be a useful stimulus particularly to medical
education enthusiasts in medical colleges in the country.
(Cost Rs. 8-00, US $ 2) .
17. Dr. Thelma Narayan of CHC attended the Sth Biennial meeting
of the International Network of Community Oriented Health
Sciences Institutions at Sherbrooke in Canada in August,
1993. She also attended the International Conference on
"Student Centred Learning',1 which was linked to the meeting.
Two papers from the Project (summaries of the first two
publications) were presented at the meeting, which will
now be featured in their 'Annals'. She also participated
in a special interest group meeting on "Community
Orientation in Medical Education" and presented some
reflections and data from the study.
18. The Consortium of Medical Colleges have been undertaking
Phase II of their process (see Section 8). St. John's
Medical College was selected as one of the four newer
entrants to the Network and a twin of JIPMER-Pondicherry .
After the surveys on skills and also on relevant and
redundant portions of the curriculum,the meetings have
98
98.
progressed towards the development of core curriculum by a
North group and a South group within the Consortium, which
are scheduled to be integrated at the next meeting of the
group in February, 1994.
19. The fourth publication cf the CMC Project (Key to Change)
and the fifth publication (Faculty Resource Book) are in the
final stages of being edited and published. There were
unavoidable delays in the work. In response to many of our
communications and circular letter more material was
received and our attempts to integrate them caused further
delays. They are new scheduled to be out of the press by
March 199 and the delay is regretted.
20. Finally,Dr. Tamas Fulop, one of the originators of the
International Network of Community Oriented Educational
Institutions for Health Sciences and the author of the
recent report "Crossing ^Frontiers'1 - Reflections on the
Networks post and future, wrote a very interesting letter
sharing his assessment and comments on the first two
publication of the CHC Project which was a real morale booster
"As to your two brochures, I first certainly would like to
congratulate you and your colleagues, for a job well done:
they both reflect a highly intelligent, timely and most
relevant peice of work. They provide a lucid and daring
analysis of what is the Indian reality in Medical Education
in the 90s based on fate obtained by well chosen, valid
methodology. The results are most interesting and revealing.
They certainly are worth publication in a widely read
journal as their international validity should be in no
doubt, and this in addition1 to your planned book/s whose
readership will unavoidably, be rather small. The
recommendations are all well-based, important and feasible...
After sending detailed critical comments to sharpen our
analysis and future initiatives he also mentioned that
"Finally, a good solution to the problems, listed in the
two brochures, could be, what you also propose, to organize
just in a very few, volunteering schools (may be in some of
the so called "pace-setters") "parallel tracks" with all
the characteristics of CCME/CBE and PBL, properly adapted
to the Indian reality, and with appropriate monitoring and
evaluation. May be that would be more feasible than
trying to propagate large-scale, institution-wide
innovation/change .
Among his suggestions for future complementary studies are:
Examination
i.
of content of medical education against the
Indian demographic and epidemiologic situation;
ii. Examination of the same against the Indian health
system reality (structure, function, etc.);
iii. Examination of the same against the opinion of other,
may be the real, consumer groups: the public (patients
M
as well as healthy people) and the health system managers.
4.
.99
99.
A ver^ thought provoking suggestion from someone who has done
similar overview studies on alternatives at the global level and
we hope that all of us in this informal network will take up these
roeas seriously in the years ahead.
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fMEPICAL EDUCATORS j__
Review MEETING
JUNE 1992 - WAS IT INDIVIDUAL RHETORIC OR COLLECTIVE REALISM?
A CHALLENGE TO ALL PARTICIPANTS OF THE MERM.
. . 100
100.
A Note
These appendices include some of the key resource materials that were
distributed before and during the Medical Educators Review Meeting.
Appendix A
This is a compilation of an opinion survey conducted among the
potential participants which identified 56 changes needed in medical
education and 40 innovations that were ongoing in the country.
Appendix
B and C
These are two articles circulated as background stimulus for the
dialogue.
(i) Dr. N.H. Antia, Founder of The Foundation for Research
in Community Health, Bombay, makes an urgent plea to prevent 'Health
Care' and medical education, from remaining a chimera and a mirage
for the vast majority of our people.
(ii) Dr. Thelma Narayan presents
an overview of the Medical Education situation in India - highlighting
the problems and the new initiatives.
Appendix
D and E
Represent two key examples of serious reforms in medical colleges
(i) The primary health care oriented, four-phase, training module of
CMC-Vellore representing the NGO sector (ii) The evolving process
in NHL Municipal Medical College, Ahmedabad, symbolising the
'optimistic' possibilities within the government sector as well.
Appendix F
A chart from David ■'■erner and Bill Bower's book 'Helping Health
'•■'orkers learn1 was circulated to stimulate participants to consider
how 'conventional medical education' can move towards more
progressive and liberating directions.
Appendix G
A self assessment guide was prepared and circulated to all
participants to help them assess the level of their knowledge on
the Indian experience of Medical Education. The guide was based on
the premise that after all the project outputs were available,
participants would be able to mark 'yes' for every item and have
access to enough detail to be able to write some notes on each.
Appendix
H
This note was circulated to all participants to seek their response
to the evolving manual which would be the culminating effort of the
two year project and was available in its pre final format for
perusal.
Appendix
I
Is a list of the key documents and publications identified by the
project as important resource materials for medical educators in
India. An annotated bibliography of all these 40 items was
distributed at the meeting (see publication 'Stimulus for Change' -
101
APPENDIX - "A
*
BDIIDING COLLECTIVITY
- h Preworkshop opinion £O_ll
As part of the preparatory process for the Medical Educators
Review Meeting to be held on June 20th and 21st (1992) an opinion
survey was conducted to explore the views of the participants on
i. The key changes which should be introduced into the present
medical education system to make it more relevant to our
social/community needs.
ii. The key.innovations/experiments currently in practice which
will help this reorientation process.
As of 1st June, 1992, 12 participants had sent in their opinions
which has been collated for circulation. These two lists of
issues enclosed in this first collation give a very interesting
picture of the key issues of concern of the participants and the
salient experiences that they bring to the review meeting.
It also gives a birdseye view of the key challenges that face
medical education in India as well as the wide range of
experiences that are a cause for optimism, in the midst of the
increasingly disturbing situation of medical education in the
country.
This compilation includes responses from Dr. Ulhas Jajoo(MGIMSSevagram), Dr. Varsha Patel (NHLMC-Ahmedabad) , Prof.S.V.Rama Rao
(formerly SJMC-Bangalore) , Dr. Asha Oumachigui (JIPMERPondicherry), Dr. Ragini Macaden (SJMC-Bangalore), Dr.M.J.Thomas
(formerly SJMC-Bangalore), Dr. Shirdi Prasad Tekur (CHC-Bangalore),
Dr. Deepak Kamle (MMC-Miraj), Dr. Mani Kalliath (CHAI-Secunderabad) ,
Dr. S.K. Das (KGMC-Lucknow), Dr. Shiv Chandra (JLNMC-Ajmer) ,
Dr. P. Zachariah (formerly CMC-Vellore).
NOTE - 1
This compilation may be used as an instrument
of self assessment and preparation for the
meeting. You can tick off all those that
you agree with. Reflect why? You can tick
off all those that you do not agree with.
Reflect why?
NOTE - 2
i
It can also be used to initiate an
exploratory discussion with a group of
faculty in your own institution.
102.
A. Key changes that should be introduced into the present medical
education system to make it more relevant to our social/
community needs. (I)
Preparatory
01. Reeducation of policy and decision makers to see medical
education in the present context.
02. Reeducation of Medical Teachers to wean them away from the
traditional and conventional miseducation.
03. Must develop a consensus on objectives and priorities.
04. Mechanism or opportunity for providing 'recognition' or
'affirmation' to the product of an alternative track.
(As this person would be working against prevailing cul.ture
and values).
05. Medical education should be taken away from elitist grip
by doing away the admission on donation/privatisation basis.
06. Education must become a more conscious goal of medical
faculty.
07. Reorganisation of MCI.
Objectives
08. a. Define clear objectives at all three levels i.e.,
primary, secondary and tertiary health care accordingly change the methodology and evaluation
strategy.
b. The objectives should include:
i. - able to understand social reality and processes;
ii. - able to use clinical skills and preventive
methods to meet the needs of the people;
iii. - have technical and managerial skills and
ability to integrate various programmes;
iv. - be able to identify areas of relevant research
and carry out such research programmes.
Selection
09. Selection should be based on aptitude to take up medicine.
10. Selection criteria to be more broad based and opening up
to health personnel at-various levels of the health care
system.
11. Candidate sponsored by a group committed to primary
health care.
103
103.
Teachers (Selection / Preparation)
12. All the teachers should be oriented to the need for relevance
in education through workshops and meetings.
13. The reforms in medical education should begin from teachers
so that they can become role models for the trainees.
14. Reorientation of the 'key' teaching faculty to innovative
approaches to teaching. This will facilitate the programme.
15. Training medical teachers on teaching techniques.
16. 'Rolemodels' among teachers or guides who can inspire and
who hold different values.
17. Selection of teaching staff who would be role-models, and
providing facilities for them to fulfil their needs.
18. Private practice amongst Medical Teachers should be curbed.
19. Selection of students at the undergraduate level for taking
up teaching as a career and offering them special courses
e.c., pedagogy.
20. Incentives / rewards for teachers contributing to these
changes.
Curriculum (General)
21. Teaching should be integrated, not compartmentalised.
22. Introduce the concept of 'holistic' approach through
integrated teaching and learning programmes.
23. Eliminating compartmentalisation in teaching by various
departments and integrating teaching with a built in system
of evaluation to eliminate competition and studying for
examination.
24. Curricular content (syllabus) to be made more relevant.
25. A periodic update on the morbidity - mortality data of
diseases prevalent in our country. This becomes the
reference point.
26. Teaching priorities/methodologies to be modified to be more
relevant to present situation.
27. Curriculum to be relevant to the community needs.
28. Altering the curriculum to suit the need of the recipient
population (student centred).
29. Teaching process should increase the student's learning
capacities.
Curriculum (Detail)
30. For each discipline in pre, para and clinical section to
make a conscious effort to present topics in
i) INTEGRATED;
ii> PROBLEM BASED MANNER.
..104
104.
31. Reduction in courses and the period spent in Basic/Non clinical
sciences, eg., Anatomy/physiology/pharmacology/bio-chemistry/
pathology etc. Applied aspects should not be taught during
core training in these subjects but may be taught later on
during clinical classes as revision/reinforcement.
32. Deletion of superspeciality training eg., Cardiology or
Cardiothoracic surgery from MBBS curriculum. These subjects
should be taught as part of Medicine/Surgery by Department of
Medicine and Surgery and not by Cardiologists/Cardiothoracic
surgeons.
33. Public health engineering should be deleted from PSM subject
of Medical Curriculum and should be taught as a speciality
subject in Engineering colleges.
Exposure / Experience
34. Actual exposure to the exploitative (economically, socially,
politically) social structure, with special focus on exposure
to poverty, as it operates at the grassroots.
35. Exposure of students to patients, hospital and community right
from their entry.
36. Training the students in an ideal Primary Health Care Hospital
where he is taught to put his knowledge and skills to maximum
use.
37. Venue of practical training must shift to general hospitals
and peripheral settings.
Skill Traininc
38. To develop in the student sufficient laboratory and clinical
skills to enable him to function effectively in a Primary
Health Care situation.
39. Spend more time on helping students to acquire clinical
skills/practical skills.
40. Need to stress on communication skills and managerial skills.
41. To aim at behavioural modification, development of
communicating skills and perfection in delivery of peripheral
health care.
42. Improvement in practical training and stress on ‘hands on1
experience.
Additional Subjects
43. The curriculum to include study of ethics, behavioural
sciences, social sciences, management, economics and ecology
as related to health.
44. Ethics of professional work to be emphasised.
45. Make students aware of ethical issues in medicine and health
care.
. . 105
105,
46. Inclusion of al ternatives/indigeneous systems of health care
prevalent in the community as a major subject of study.
47. Adequate emphasis on value education such as team work,
social responsibility, etc.
Examination
48. Critical evaluation and change in examination.
49. Examination / Evaluation system to be more 'self-evaluatory'
and with practical slant.
Internship
50. In view of emphasis on pre PG-senior housemanship, internship
should be done away(l).
51. It should be mandatory to get full registration as a
practitioner to serve in rural area for minimum three years.
Evaluation of Innovations
52. Evaluate the results of these changes from time to time by
teacher-teacher and teacher-student interactions.
Certification and Continuing Education
53. To lay down,' minimum qualifying .criteria before getting
certification of practice which must be reviewed on regular
basis by appearing in programmes of continuing education.
Postqraduation
54.
Postgraduate Medical Education (specialist) should be
de-emphasised.
55.
Greater emphasis and postgraduate training in general practice.
56.
Career guidance should be introduced at different levels.
It is interesting to note that though the
overall changes seem to be moving towards
a consensus in direction, there was a
diversity in the opinion survey which led
to a rather comprehensive list of ideas.
B. Innovations / Experiments currently in practice which will help
this reorientation process. (I)
01. Formulating Educational Objectives - Institutional,
Departmental and instructional.
02. Identifying core curriculum.
03. Formation of a core group of faculty tc reappraise modify and
enthuse the reorientation programme (frequent meetings which
are alive, vibrant, determined).
.. 106
106.
04. Sponsorship of students by groups to whom the candidate has
a commitment after graduation.
05. Exposure to existing health care delivery system - beyond the
teaching hospital.
06. Selection of students to include methods to assess values,
motivation, team work, social orientation etc.
07. First hand experience of living with village households.
08. Rural/community orientation camps for medical students and
nurses in preclinical year.
09. First MBBS examination after 15 months and three months for
preclinical orientation for community medicine, nursing and
support facilities and orientation to hospital.
10. Faraclinical teaching;
i. integrated teaching;
ii. reduce didactics to 30 minutes and leave 30 minutes
for discussion and learning;
iii. involve relevant pre/para/clinical faculty to reduce
danger of compartmentalization.
11. Train students in simple lab tests and give confidence in
verify/investigating clinical problems on own.
12. Community health care should become a compulsory ingredient
of all clinical department teaching.
13. General practice clinics in outpatients for undergraduate
and interns teaching.
14. Integrated Teaching/learning sessions in OBG with surgery
and medicine.
15. Competency based curriculum for labour room posting of
Final MBBS.
16. Making student record book more comprehensive.
17. Community block postings in clinical years with specific
objectives and tasks.
18. Project allotments to undergraduates.
19. Involving medical students in evaluation surveys in
immunization and family planning.
20. Extra rural postings of students to peripheral hospitals in
prefinal year.
21. Educational trips to good primary health care projects.
22. Involvement of community in their own health care system.
23. Teaching/orienting medical students to alternative systems
of health care.
24. Involvement of students in running a primary medical care
hospital.
. .107
107.
• . 108
APPENDIX /B!
Medical Education: In Need of Cure
N H Antia **
While the medical profession has played an important role in
determining the health status of the country, it has also been
responsible for the distortions in the health care system. What can
be done to change the situation?
THE aim of professional education in the
field of health must be the production of
a cadre of professionals who would have
both the competence as well as the
motivation to serve the health needs of the
country and its people as a whole The
number and type of health professionals,
their recruitment and training for the
various functions at various levels and
locations must be determined primarily by
the actual problems of health in both the
rural and urban situation, the prevailing
pattern of diseases, the available health
technology, all this in keeping with the
human and financial resources available
to the country.
Unfortunately the production of the
number and various categories of person
nel as well as their training is entirely
disproportionate to the actual needs and
has to a great degree been dictated by the
perceptions and needs of the medical pro
fession whose values and aspirations are
more in consonance with those of the
prevailing western mode! rather than the
entirely different needs of the vast
majority of our own people. Hence the
larger number of doctors than nurses and
paramedicals, the emphasis on expersive
specialised curative medicine in large
urban hospitals for non-communicable
diseases rather than the far more effective
yet lower low cost preventive, promotive
and basic curative services for the rural
population and urban slums.
The crucial role played by the medical
profession (and especially of the private
sector which now commands two-thirds
of the country's medical manpower as well
as the health expenditure) in reversing the
health priorities can no longer be ignored.
Their influence in determining the type
and quality of the country’s health
services, either directly, or indirectly as
physicians to the rich and influential, far
outweighs that of those who seek to
develop the health policy and services
along rational lines for the good of our
society as a whole. The medical profes
sion has equated health’ with illness,
doctors, hospitals, drugs and westernised
medical technology and converted illness
into a lucrative business and industry.
Medical education plays a key role in
perpetuating this system. The vast increase
in the number and size of medical colleges
from 25 to 125 in four decades has
Economic and Political Weekly
resulted in an increase in the annual pro
duction of doctors from about a thousand
to over 13,000 during this period. The
majority are still government colleges
funded by the public exchequer but lately
there has been a rapid increase in the
private colleges. The struggle to secure a
seat in a government medical college is
demonstrated by the mark list of the can
didates and by the high capitation fees
paid in the private colleges by those who
fail to get entry into the government ones.
In both cases the advantage is for the
children of the affluent. Those few who
are admitted in the seats reserved for the
backward castes are at a considerable
disadvantage due to their different
cultural and educational background.
Despite this after qualifying they too have
the same aspiration as the rest. Bar excep
tions the reason for the choice of medicine
as a career is the assured high level income
with a high social status.
The values of the medical profession
are, therefore, determined even before the
student enters the portals of the medical
college. These values are reinforced
throughout the five and a half year course
and later during post-graduate specialised
training. While the honorary system at
tracts the elite of the profession, the train
ing they impart is biased by the specialised
expensive medical technology they prac
tise Even worse are the values of lucrative
private medicine that they subconsciously
inculcate into the receptive young mind.
With the increasing disparity between the
earnings of the private and public sector.
where a surgeon in a single operation in
private practice can earn the equivalent of
one or two months salary of his full-time
counterpar,, it is difficult to retain good
motivated teachers and doctors especially
in the clinical subjects. This has led to a
funner deterioration in both the technical
aspects of medical education as well as in
the values that are imparted to the
student.
The values of the vast majority of
students is reflected in the importance
they assign to the various subjects and
even more so in the choice for post
graduate training. The glamorous high
tech and lucrative fields like medicine and
surgery and their subspedaiities like
cardiology and plastic surgery are the first
choice while preventive and social.
medicine and community heaftlfahe at tire
bottom of the ladder a choice inversely
proportionate to their usefulness in deter
mining the health of the nation. These im
portant subjects in medical education also
suffer from a vicious circle for they by
and large also fail to attract the best
teachers. The fossilised methods and
nature of basic science teaching combined
with glamorised teaching of technology
in the specialised clinical subjects has
resulted in the failure to produce medical
scientists and basic doctors. While the vast
majority will perforce have to eventually
gravitate to general family practise it is
anachronistic that there is not a single
general practitioner as a teacher in the
' medical college especially when the
majority of outpatients are flooded with
simple common ailments from the local
vicinity which are then referred to
specialists for lack of a family physician.
The reorientation of medical education
(the ROME scheme) is a farcical exercise
in a vain attempt to sensitise the student
trained for five years in high tech clinical
medicine to the entirely different rural
health problems of our people in a period
of three months. The Lemin Commission
has also demonstrated the chaotic ad
ministrative and bureaucratic manage
ment of these hospitals and their specia
lised units, revealing that even the socalled best medical colleges and hospitals
are mere caricatures of the western model
they choose to emulate
The aim of the medical student after
qualifying is to specialise and get theo
retical if not much practical knowledge
with the hope that this may help him/her
to secure a job abroad or in a five star
private institution in a city. Since these
avenues are limited, the majority perforce
gravitate to small private nursing homes
or general practice for which they neither
have the training nor even basic facilities.
Over-production has now driven them to
seek government posts which were dif
ficult to fill a decade ago. Unless posted
in a city or district hospital they perforce
have to serve in a rural primary health
centre where the requirement is chiefly of
a managerial physician to cater to the
health of a population varying from
30,000 to over I lakh with about 30 to 60
paramedical staff under their guidance
and supervision. Besides management
even the medical functions are chiefly of
preventive, promotive and of a social
medicine nature, the lowest in the
hierarchy of medical education. There is
little time and even lesser facilities for
clinical medicine for which alone he/she
is trained. The most important aspect of
our health system, the primary health
centre which has to cater for the needs of
the 70 per cent of our rural population
July 21. 1990
Director, The Foundation for Research in Community Health,
84-A; R.G.Tnadani Marg, Worli, Bombay - 400 018.
1571
109
is theretore encumbered with a leader effect of this on the poor masses in a
whose training and values are almost country with limited resources is far
diametrically opposed to the health needs worse. The health debate even in the
of the majority of our people and the affluent countries is now centred in the
functions to be performed.
containment of cost with control of the
Under the circumstances the prevailing medical profession as the key factor.
system of medical education is almost
Since the profession as it exists today
entirely divorced from the health nerds of has failed to shoulder their responsibility
the majority of our people, both in the the inevitable result is that society has
public as well as in the private sector. The perforce to undertake most of these func-.
over-production of doctors and of drugs tions by itself and define the role of the
because of their lucrative nature has medical profession in serving its needs.
invariably resulted in a form and extent This must perforce lead to the control of
of malpractice which now poses a new the profession in the interests of the
threat to the health of our nation, both society at large Since self-regulation is not
a part of this new order in India and since
the poor as well as the rich.
'
The question arises that if the vast the people must be provided with
majority of both the non-medical as well adequate basic health care, alternative
as the medical functions of health can be means have to be devised to regulate the
best managed by the people themselves medical profession and define their role
with the help and support of the para in the health care system of the country.
The regulation of the profession must
medical workers then why not concentrate
on this aspect of health and ignore the start even before the stage of medical
medical profession which has gone so education by determining the human
awry. This unfortunate attitude continues power required at each level in a graded
to prevail not because of the failure to decentralised system based within the
appreciate the needs for the increased level community. The gross distortions in the
of skills and facilities which are essential present set up where there are more
for certain aspects of technical medical doctors than nurses, more nurses than
care, however small it may be of the totali ANMs and more ANMs than community
ty of health, but because of a feeling of health workers will have to be corrected
helplessness when confronting the entren for any meaningful health system. This
ched and extremely powerful bastion of will invariably result in limiting the
the medical profession which it has built number of medical schools and the
for itself through various means. These
vary from offering the lure of an ex
trcmclj lucrative professional career.lo thi
children of the rich and influential at
public expense, high level of monetary
gains to both the promoters and the politi
cians who run private medical colleges
under the guise of producing doctors for
the rural poor, a good prospect of emigra
tion so attractive to the elite, by offering
the ‘latest’ western type medical care to '
the politicians, bureaucrats and the rich
who believe that ‘West is Best’ and that ,
too often free of cost in major government :
and five star private hospitals, by
glamourising expensive technology and
mystifying health into an illness business
which the people are told is too dangerous
to be left to anyone but the allopathic
trained medical profession.and preferably
those who are specialised..
......
. Unfortunately health is too important ,
a commodity to be left to the tender mer
cies of a profession whose chief interest,
like most other professions in capitalist ,
market economy, lies in the maximising
of monetary gain regardless of Bother
scruples. The nation’s health, bothfef the
rich as well as of the poor, is now threa
tened by the burgeoning health industry
with its insatiable appetite based on self
created demand and consequent rising ,
costs without concomitant benefit The ■
1572
annual production of doctors. It is dearly
unacceptable that the two-thirds who
enter the private sector be trained at the
cost of Rs 3 lakh per head at public
expense in government hospitals.
Since over-production invariably leads
to malpractice, especially in a fidd where
consumer resistance is at its lowest, the
opening of private medical colleges can
not be justified on the basis that this does
not involve public funds and that over
production will automatically provide ser
vices to the rural poor. The majority of
graduates even of these colleges choose to.
practice in urban areas and even if under
economic duress are driven to rural areas
they practice a form of curative medicine
without even minimal facilities and which
is highly dangerous, like the widespread
practice of giving of unnecessary and even
harmful injections. This has diverted the
meagre income of the poorest from nutri
tion to such necessary and unethical
medical expenses with little benefit even
for the actual care of their illnesses.
The present form of medical education
which is based on an ad hoc importation
of western medicine also needs a radical
reorientation to meet the entirely different
needs of our people The teaching of basic
sciences like anatomy, physiology, bio
chemistry and pathology are outdated
even by the western standards they imitate
Economic and Political Weekly
July 21, 1990
110
As a result of the vast increase and rapidly tion of the technical aspect of the medical
changing nature of knowledge the need education are the values that are in
is for the teaching of broad principles, culcated during the entire period of train
stimulating curiosity and teaching the ing in the young and receptive mind. As
intelligent retrieval of information and stated previously the influence of the
utilisation of the libraries and other dominant values of the society at large
documentation facilities; to inculcate a wjll prevail. The most that one can hope
habit of continuous self-education not to achieve within this social system is to
merely to pass exams but as a lifelong inculcate a desire to combine monetary
pleasurable exercise; a process which is with job satisfaction, which has somehow
almost entirely neglected in the present got lost on the way and has led to much
curriculum.
frustration.
Since public needs demand that the vast
The present method of inducting im
majority of the graduates must undertake mature youth at the age of 16 or 17 years
general practice whether in private or at directly after SSC into medical college
the primary health centre the emphasis of cannot be condemned adequately; for
under-graduate medical education must medicine is a subject which deals ulti
be for this rather than specialised services. mately with people and the most intimate
The present clinical training is undertaken aspects of their life. Many if not most of
entirely in specialised departments, for the problems that modern medicine suf
strange as it may sound, there is not a fers from is the conversion of a science
single general teacher of family medicine dealing with life into an exercise in mere
in our entire medical educational system. technology. This has resulted in the com
As a consequence the young MBBS mercialisation of health into an ‘illness
doctor sees the patient as a series of dis business’, from ‘caring’ to ‘cure’, frustra
jointed specialist problems rather than a tion from loss of job satisfaction and
whole human being in relation with his alienation from the people.
family, job and society which is the
Some corrective measures need to be
essence of family practice. This has con taken. Five years of training is unneces
sciously or unconsciously led to over sarily long for the technical training of a
investigation, over-medication and over- basic doctor for the needs of our society.
rcfcrcncc to specialists and excessive Specialists will in any case receive ap
hospitalised care. The majority of under propriate additional training in their own
graduate clinical medicine should hence field. Much more important would be to
ideally be undertaken within the com provide the first onc-and-a-half to two
munity at the primary health centre and years of training in the general as well as
community hospital. Since this is a distant health related humanities and basic
goal there is no reason why the out sciences both which stand out by their
patients of medical colleges, which arc absence in the present medical curriculum.
mainly crowded with thousands of This should include subjects like the
patients from the adjacent locality with sociology, anthropology, economics,
common family ailments should not have statistics, demography, psychology, ethics.
a number of family physicians with simple documentation and communication. This
pathology and diagnostic facilities to may either be undertaken in the medical
attend to these problems who arc at college with a suitably inducted faculty or
present referred by out-patient clerks to in the departments of the university. This
whichever specialist they feel is the correct would help to produce a more mature and
one. This simple practical device would sensitised individual for a three-year
not only screen the majority of patients course of which one year should be in
and save much time and expense of both basic medical sciences and two in ap
patients and specialists but also enable propriate basic medical technology and
instruction of the students in the most practice.
Even in the field of specialisation the
essential and relevant pan of their under
graduate training namely, general practice. largest needs will be for the general
It would at the same time reduce the cost surgeon, general physician, paediatrician
of these expensive hospitals where some and obstetrician/gynaecologist who can
of the beds can be allotted to these be trained to carry out the common pro
cedures which comprise the vast majority
teachers of general practice
The subject of decentralisation of such of specialised care which have now been
large and inappropriate urban hospitals appropriated by the ever increasing
into community health care institutions superspecialities today. This would leave
where 95 per cent of all preventive pro only a few problems for the superspedamotive and curative services will be lities located in independent institutions.
catered to within the 1.00.000 population preferably isolated from the medical col
level as recommended by the ICMR/ leges, and acting as pure referral centres
ICSSR report will need to be dealt with for the most difficult problems. This will
ensure that in the medical colleges the
elsewhere.
Far more important than a reorienta students will be exposed to the general
Econoniic and Political Weekly
July 21. 1990
practice type of medicine and only to the
four above mentioned basic specialities
and not distracted and diverted by the
glamorous b&t far less important super
specialities with which they need only
nodding acquaintance. This will also
permit the rejuvenation of the four basic
specialities whose realm has been eroded
by the superspecialities in the present
medical colleges and hospitals.
The present system of medical educa
tion dominated by the superspecialities
has played a crucial role in distorting the
values of medicine not only among the
medical students who will be the future
doctors, but also of the public as seen by
the false demand created by these specia
lities. One of the results of this distortion
is the devaluation of most important sub
ject of preventive and social medicine
which, bar exceptions, fails to attract the
best teachers or students. This vicious
circle has to be broken by raising the
prestige of its teachers and by compulsory
devotion of more time and examination
questions to this subject. There are several
examplcs'where a good teacher has been
able to create interest in what is basically
an interesting subject which is generally
taught drably and perfunctorily. The most
important aspect of medicine, namely,
epidemiology and communicable disease
control, is a part of this discipline.
The importance of the medical profes
sion in determining tfit health care of the
nation cannot be underestimated. They
can be the leaders in orchestrating the
health services if not in health care if they
so choose. On the other hand they can and
have played a crucial role in distorting the
w hole system. Motives and values arc far
more important and must precede and not
be subordinated to technology which used
appropriately can transform the health of
our people Used inappropriately it can be
a powerful tool for their exploitation.
The Medical Council of India as the
apex body responsible for medical educa
tion has failed to fulfil its task. Leave aside
setting an example of high moral and
ethical values it has utterly failed even in
devising a curriculum in keeping with the
needs of bur country. Nor has it been able
to resist the political pressures in the open
ing of new colleges which fail to meet even
the elementary needs of medical educa
tion. A radical change in this outmoded
body with the induction of dynamic
young teachers is an essential prerequisite
for the improvement of medical education
in this country.
All this will undoubtedly require a
powerful peoples’ outcry and through
them the development of political will to
bring about the necessary changes.
Without this health care will remain a
chimera and a mirage for the vast
majority of our people.
1573
APPE11DIX
"C
Cover
Story
"Ho we ver it is from the perspective ofthe poor
nnd underprivileged — the 350 million and
more people in India — for whom health and
wellbeing still remain a distant dream, that the
training ofdoctors and Health For All (HFA)
need to be reviewed."
Training of Doctors for India
Thelma Narayan *
Community Health (.'ell.
Bangalore
Promise of a New Dawn
When one thinks ol medical care or
of health services, among the images
that come to mind, the doctor always
! seems to play a major role. Medical
professionals, pai ocularly doctors.
have held the centre stage in ihe health
care scenario. This is so particularly
I from the points of view of planners.
| administrators and diictors themselves.
i
Other points of view. based on field
; experiences, nave been gaining ground
: during the past few decades. In 1978.
the world wide acceptance of the goal
ofHeaithfor AlltHFAiby 2000 A.D..
with its concern for equity and social
justice, seemed to promise a new
dawn. It initiated fresh thinking on
several issues including that of the role
! of a doctor. It has developed
! multidimensional strategies of which
I Reorientation of Medical Education is
j one. Its terminology has now become
i pan of the consciousness and state
ments of Governments. MiO’x meoi. cai educators, health professionals.
; development workers mo 'ixriai
• Inis .irtu . '.I' \-,i: vi
activists. Even the private -ector uses it
to its own benefit!
However it is from 'he perspective
of the poor and underpriv i.eged — the
350 million and more people in India
— for whom health and wellbeing still
remain a distant dream, that the
training of doctors and HFA need to
be reviewed.
This article attempts to focus on a
few questions concerning medical
education What is the image of the
new doctor
What has been the
Indian experience ? What are the
challenges we face? What are the
positive initiatives that have been
developed 1 and. What are the
negauve trends
The need for a ’’new- doctor
The health status ot people and
populations is determined largely by
socio-economic-pol itical-culturalccoiogicai factors. At '.he family and
mvididual 'eve these 'ranslate into
income ocu joation. residence.
-vun me-upp< ri
, n<
education and a host of cultural
factors. While curative medicine plays
an important healing and supportive
role in times of disease, the other roles
that a doctor can play need streng
thening. For example, they could be
pacesetters in making available know
ledge concerning the promotion of
health and the causative factors for ill
health, using the people’s idiom and
culture. Thus they could "teach".
"educate" and "liberate" from
unnecessary illness and suffering, in
the truest sense.
Several groups play a role in
shaping health and more specifically
health care services.
People themselves are crucially
important — in making decisions, in
being capable of looking after them
selves and others, in living healthy
lifestyles if circumstances permit, and
in panicipating actively in and shaping
their own health. This calls for
different styles of functioning, different
, mmipi.p. Health Ceil Team
Health Action June 1^1
112.
perspectives, and different attitudes
especially of the health professionals.
Doctors probably require a change of
self image from being centre-stage to
moving to the periphery, to playing
catalyst, to learning from people and
building on their existing knowledge
and skills.
The contribution and role of the
silent majority of health workers is also
gaining increasing recognition. We
have a virtual army of different levels
i of health “workers” — nurses,
. pharmacists, laboratory technicians.
health supervisors, multipurpose
workers, health educators. ANM’s
trained “dais” or birth attendants.
community health guides etc. For
every medical officer of a Government
Primary Health Centre there are over
twenty workers. The GOI statistics say
that about 53,000 of all these grades of
workers are trained annually in the
country. Doctors need to be trained to
work- with all health personnel as
democratic team leaders, outside the
hospital setting as well as in it. and also
to be able themselves to provide
relevant training to others.
We have a rich tradition of
indigenous systems of medicine viz.,
Ayurveda, Siddha, Unam and also
other systems of medicine, e.g.,
Homeopathy. Acupuncture etc.
Besdes these, there is also a wealth of
local folk health practices. Doctors
need to move away from the present
condescending, superior and largely
ignorin' position to a more openminded and scientific approach
involving these systems and their
practitioners in Health Care. This can
only occur if serious efforts are made
towards integration during the training
phase in medical college itself.
As a result of far-reaching changes
: that are raking place in the phikisophy
and practice of medicine anc health
care services, there seems to be a need
for a redeSnmon and rediscovery of
the role of a doctor in this more
■ complex and decentralized scenario.
I Their formation needs to prepare them
I more adequately for the new chal
? • Health Action June 1991
lenging roles they care called upon to
play.
Prescriptions For Change
In India, reflections regarding the
type of health care services and
medical education we need, predated
the HFA declaration at Alma Ata.
They go back to the freedom
movement
The Nationalist Inspiration
The Sokhey Committee on National
Health was set up by the National
Planning Committee in 1940. It
included many medical professionals
who were active in the Independence
Struggle. A demand was made for ±e
provision of comprehensive health
care by the state to all the people. They
suggested the training of one health
worker per thousand people within 5
years. A longer term target was to have
one doctor per thousand people. This
has not been achieved fifty years later.
They also recommended that the
Ayurvedic and Unani systems should
be part of our national heal± system.
This too has not moved much beyond
apologetic rhetoric.
— Reduce didactic instruction and
increase self-learning skills
— Set up All India Institute of
Medical Sciences to train
“teachers”
— Reserve 25 — 30% seats for
women
— Provide subsidy and freeships for
30%
— Stress research for full-time
teachers
— Refresher course for GPs
— Increase training of Nurses
The Fifties and Sixties were witness
to a tremendous effort in infrastru
ctural development and expansion of
training capacity. The Mudaliar
Committee (1959) recommended the
need for consolidation and the Patel
report (1968)spe\t out in greater detail
the qualities of a “basic doctor”.
Numerous conferences and meetings
to discuss reorientation also took
place.
Rethinking Change In 1974 the
Government of India set up an expen
committee to review the Indian
medical education scene.
The report of the Group on Medical
The landmark report by the Health
Survey and Development Committee Education and Support Manpower
(Bhore Committee, 1946), recom (Shnvastava Report, 1975), made a
mended the training of a “basic very strong indictment of the system
doctor” to provide comprehensive and identified the challenges ahead
health care to the vast rural population (See box 2).
of the country. The earlier licentiate
course was closed down. Several ■
important recommendations were
(Box 2)
made which formed the blue print for Diagnosis of the Problem
change in Health Care and Medical
“the stranglehold of the inherited
Education (See Box 1).
system' of medical education,
the exclusive orientation towards the
teaching hospital,
(Box 1)
the irrelevance of the training to the
The Bhore Committee. 1946
health needs of the community,
— Expand medical education — the increasing trend towards specia
more colleges
lization and acquisition of postgra
— Social and Preventive Medicine duate degrees,
departments in metrical college
the lack of incentives and adequate
— A year’s “internship" after recognition for work within rural
community.
graduation
113.
Cover
Story
the attraction of the export market for
medical manpower,
are some of the factors..... responsbile
for the present day aloofaess of
medicine from the basic health needs
of our people"
Srivastava report 1975
of all categories of medical and health
personnel. It also stressed the need for
a National Medical and Health
Education Policy which would
move ahead with new directions, and
innovations.
At the national level therefore we
have very cledr and unambiguous
statements regarding future directions.
— chan out changes in curricular This is reinforced at the South East
content,
Asia Regional level by the WHO— assess requirement of health SEARO reflections on Reorientation,
personnel according to regional and at the international level (See box
The Committee went on to offer its
4), by the Edinburgh Declaration of
needs.
own prescription for change which
the World Federation of Medical
reinforced and went beyond the — ensure social motivation of all
Education (reprinted elsewhere in this
personnel
towards
health
services.
“Bhore" blue print (See box 3).
issue).
However the most important
and
aspect of policy is its implementation.
(Box 3)
— establish inter-relations between
What has been the experience of
health personnel of various grades.
translating polices to programmes of
Srivastava Committee 1975
change ? Are the prescriptions still
— “Humanities and social sciences in
The first attempt to have a national rhetoric or reality?
premedical
education to be level policy has been the Educational
introduced.
Policy for Health Sciences. 1989,
— Principles of “Educational (Bajaj repon) which is still in the form
(Box 4)
of a draft report. The absence of a
Science” to be utilized,
— Skills of “Basic Doctor” to be national policy or commission on TRAINING THE NEW
Medical Education/education of DOCTOR .... THESEARO
defined,
health personnel leads, to adhocism REFLECTIONS
— Community orientation — as
and anarchy at ±e ground level, with
“The new doctor will be the leader
overriding objective of change,
market and political forces playing the
— Community medicine teaching to major role, resulting in adverse effects of a health team comprising various
be joint endeavour of entire on the quality of medical education disciplines and professionals, working
in partnership wi± the community it
faculty,
and medical care. The Medical
serves. Training would prepare the
— GP’s to be involved in teaching,
Council of India, MCI, provides
doctor for the application of a limited
— Internship in District and Taluk guidelines and recognition, but lacks
technology to preventive as well as
adequate statutory powers to be a
hospitals.
curative interventions for patients
— Continuing education for all regulatory body. Health being a State predominandy from lower economic
subject, medical colleges can start and
health professionals / workers”.
and rural groups. The leadership role
function, having received affiliation by would not be symbolic but rather !
The Group considered it important a local university and sanction from based upon managing, coordinating ■
to create a structure — a Medical and the State Government.
and training skills.
.j
Health Education Commission —
Medical education to support this j
There is a Bill in Parliament to
charged with the responsibility of provide the MCI with more powers. It development would have to become
bringing in the change process.
raises issues like providing autono community-oriented, which would
Unfortunately the major part of the mous colleges and institutions to allow mean students learning about care in,
recommendations of the Sbrivastava them to innovate more freely. How of and for the community. Curricula .
report were not implemented. In fact ever, with all political instability of the would change to stress content |
presently, 15 years later, the majority past 2 years, it has not yet seen the light relevant to Health for All and Primary |
of “medical educators” (teachers) are of day. During the 1980’s a few States Health Care. Teaching methods would '
not even aware of the report or its (Andhra Pradesh, Tamil Nadu-and become more flexible, integrated, and
contents.
Karnataka) have started or initiated problem oriented. Students would
The 1982 Statement on National the process of forming a State Level work in teams and in communities.
Health Policy ofthe G. O.I.. recognised Health University to which all medical Their goal would be life-long, selfthat effective health care services colleges are affiliated. This helps in educative skills. Standards would be
depend largely on the nature of providing some standardization of competency-based and linked to local
education, training and appropriate curriculum, examinations, etc. It is priority problems. Students would be
orientation towards community health hoped that they will aso be able to selected to represent more closely the
Health Action June 1991 • 7
. . 114
114 .
Cover
Story
socio-cultural circumstances in which
their skills would be needed, and
would be strongly encouraged to take
career directions consistent with
HFA/PHC. The overall emphasis
would be upon appropriate techno
logy and comprehensive health care
management.
New demands would be made upon
administrative structures for better
coordination between faculties, profes
sional bodies and communities be
cause community — oriented medical
education is like a three-legged stool
which cannot do without any of
these".
SOURCE: Reorientation of Medical
Education, WHO-SEARO Regional
Publications No. 18 (1988).
From Rfifetoric To Reality
Over 40 years of experience are
over. Where are we today ?
Where are the Doctors?
Mere numbers do not imply useful to take a look at the G.O.I.
equitable distribution. Medical colle statistics on the doctor — population
ges are clustered in and around the ratio in different States and Union
large cities like Bombay, Calcutta, Territories. The figures for 1988 show
Madras, Delhi, Bangalore, etc. It is a wide variation in different regions.
How many Doctors?
There has been a quantum growth
in medical education and in the
training of health personnel of different
levels, since 1947. From 15 medical
colleges admitting 1.200 students
(other than medical schools) before
1946, we today have around 140
medical colleges! of the allopathic
system) in the country. These form one
tenth of allopathic medical colleges
world-wide! Unfortunately, we do not
know the exact number of colleges as
of now. With rapid growth of
capitation fee colleges and other new
colleges in the 80’s, many of which are
not recognised by the Medical Council
of India, we have only an approxi
mation — viz^ 140. The summary
picture given in the figure below
■ pertains to 125 colleges only. The
, actual numbers will therefore be
. higher.
< • Health Action June ! 00I
. .115
115.
Cover
Story
considered as “none of our business" with skills in epidemiology, sociology, ,
or impossible.
health education and communication.
The young graduates who are understanding the life situation of
trained to believe that they are the people in rural areas and urban slums
cream of Indian society, having etc.
entered medical college in the face of
The present system of medical
stiff competition and having laboured education in India was built on the
for 5 1.2 years before graduation, are British model. The curricular content.
aghast when they come face to face text books, college and hospital
with the realities They are neither structure and environment, examiprofessionally competent nor emotio pation system etc., are all patterned
nally prepared to face such a situation. and firmly set on the Western System
Trainee in a very structured, hierar as it prevailed 50-100 years ago.
chical. compartmentalised environ
A universal culture seems to prevail
ment. with a surplus of medical among medical students. Whatever
personnel and a specialist for every may be the background of the student.
organ, they feel incompetent to make a certain process of westernized
important decisions concerning life socialization occurs. While certain
and death independently. There is a aspects may be positive, it produces an
long list of jobs for which they have alienation from our poor and a
never been trained.
yearning to work in the familiar,
Being used more to “Chan Care" comfortable surrounding of a hospital
than "Patient Care", even the so called with ail its infrastructure and back-up
“good students" often find themselves services of personnel and technology.
handicapped when it comes to
carrying out basic nursing procedures.' The Challenge before us
calculating drug dosages for children.
The Shnvastava report sums up this
handling normal and complicated paradox and dilemma succinctly by
deliveries, setting fractures, treating stating that —
snake bites and a host of similar every
I How good are the Doctors ?
“The greatest challenge to medical
education in our country, is therefore.
It is the area of quality of medical day medicai problems.
is to design a system that is deeply• education, and ns relevance to the Where lies the problem ?
| health needs of the large majority of
Feedback from medical graduates rooted in the scientific method andyet
I our population, that presents the who have worked in peripheral health is profoundly influenced by the local
' greatest problem and also the greatest institutions m the late 70’s, 80’s and health problems and by the social.
j challenge to medical educators.
early 90's reveals the urgent need tor cultural and economic settings in
;
It has been the experience of people skill development during their under- which they arise. We need to develop
i and NGO's. Volags involved in health grduate years. However, unless methods and tools ofinstruction which
1 w’ork in the periphery, that doctors medical teachers themselves get have relevance to the resources and
fresh from medical colleges are ill- exposed to the realities of medical cultural patterns ofeach area. We need
equipped to cope with even the practice in the periphery and are to train physicians in whom an interest
medical problems in a rural area. themselves skilled to handle such is generated to work in the community
i Much less when it comes to issues like situations it would be wishful thinking and who ha ve the qualities for
’ being the manager of a health centre, to expect them to train young students functioning in the community in an
effective manner. In addition to
, handling accounts, running a small adequately.
. pharmacy and laboratory handling XIt is important to shift the base for medical skills, they should be trained 1
ray equipment, training health clinical training from being 100% in in managerial skills and be able to |
workers, coping with rivalries and the exceptional environment of a large improvise and innovate".
conflicts in the villages, and working in teaching hospital, to smaller hospitals.
|
differing cultural situations. Under dispensaries and health centres. This Innovations. Initiatives Within
standing and intervening sensitively should not be contused with the The System »
During the past 44 years, there have ‘
along with multidisciplinary groups in community based training under me
the broader societal "factors that Department of Community Medicine been several attempts to introduce !
impinge on neaith is most often which is essentiailv to equin students changes within the medical curriculum !
Doctors are not evenly distributed
in a State according to the population.
| but are clustered in the urban a rex'.
i with the rural areas being underserved.
: Even so. a clear pattern emerges.
i showing that the Northern States.
; including those holding the bulk oi
■ India’s population, fall into the fourth
' group.
Who are the Doctors?
We are doing fairly well in terms ot
■ the number of seats for women
students, with 36.4'- of seats in 1987
' going to girls. This trend has in fact
; been increasing over the years.
i
A compilation has been done
I regarding seats reserved for students
; from the Scheduled Castes. Scheduled
Tribes and Other Backward Castes for
the year 1984 — 85. covering 106
medical colleges recognised by M.C.I.
It revealed that 30.6% of seats were
reserved for these three categories.
As an approximation, one can also
say from Figure — that about 45% of
undergraduates complete their post
graduation.
<
Health Action June i991 •
. .116
116
to make it more meaningful to our
situation. Some of these have been at
an All-India level, through guidelines
provided by the MCT, expen com
mittee reports, and meetings of Deans
and Principals of Medical Colleges.
Some have been lobbied for by
professional bodies eg., the Indian
Academy of Paediatrics (IAP), the
Indian Association for the Advan
cement of Medical Education
(IAAME), and The Indian Medical
.Association (IMA.)
Some have been introduced at the
State level eg., through the Health
Universites of Tamil Nadu and
Andhra Pradesh. Others have been
developed at an institutional level. Yet
others have grown around particular
departments and individuals. The
MCI guidelines (the latest was
published in 1982) provide the overall
framework for curriculum and examination system and also the minimum
requirements in terms of staff and
facilities. The guidelines are of a
general nature and flexible enough to
allow for innovations and
modifications.
Some of the key initiatives have
been :
Teaching Preventive and
Social Medicine
Department of Preventive and
Social Medicine (later called Com
munity' Medicine) were introduced
during the early fifties. Field practice
areas in urban shims and rural areas
were developed for the purpose.
Programmes such as the Family
Health Advisory Service, where each
student followed up 3-5 families for
periods of 1 -2 years, climco-sociai case
conferences, and field visits to different
institutions were introduced. How
ever, in general, these efforts have not
made a dent in the situation for various
reasons. In fact medical students and
doctors always rate PSM about the
lowest among ail disciplines. Much
I worse has been the sometime counter
productive effect it results in, creating
long-lasting negative impressions and
a decision never to get involved with also has not moved ahead and has not
this sort of work or situation. Another brought about changes that were
adverse effect has been that commu hoped for.
nity orientation has got compart
mentalised into a departmental respon Training the “Teacher”
sibility, while the rest of the 22 or so
Action was also initiated to
departments of a medical college introduce the principles of educational
continue their individual patient or sciences into medical education. The
system/organ oriented work.
National Teacher Training Centre
However the PSM departments in a (NTTC) was set up at JIPMERfew colleges have done creative work Pondicherry during the 70’s by the
and have been more inspiring. Government of India in collaboration j
Foremost among them are CMC- withWHO.lt did commendable work I
Vellore. MGIMS-Sevagram, SJMC- in organizing workshops and training I
Bangalore, AIIMS-New Delhi, programmes for medical teachers from
JIPMER-Pondicherry, CMC- colleges across the country. Sub
Ludhiana and BHU-VaranasL They sequently a NTTC was also started at |
have introduced rural or community PGI, Chandigarh and later at B.H.U- I
orientation camps where students five Varanasi. Some colleges now have
and learn in villages for a period of 2-3 medical education cells with core
weeks, block postings, health educa groups of trained teachers who |
tion and child to child programmes, organise programmes at their own
socio-epidemiological projects, institutional level. AIIMS-New Delhi
actually organizing health progra more recently has developed a Centre
mmes of various types in rural for Medical Education Technology
situations, collaboration with other (CMET) with a fairly large number of i
departments etc.
teachers trained at the professor and I
Assistant Professor level.who form its
The ROME Scheme
adjunct faculty. CMET has all the
The Reorientation Of Medical equipment necessary for the deve
Education (ROME) Scheme was lopment of teaching aids. .All these
launched by the Janata Government centres are also working on making
in 1977, based on earlier expen assessment/examination methods
committee recommendations. Three more objective and rational.
Government Primary Health Centres
(PHC’s) were attached to each Socialising ‘Mother and
medical college. It was hoped that the Child' Care
entire faculty would be involved in the
The development of the concept
training of students in the periphery. and practice of social or community
They would thus develop a commu Paediatrics (child health) was also
nity orientation and also upgrade skills initialed during the Seventies.
at ±e PHC level. Over time, each Osmania Medical College, Hyderabad
college could take responsibility for an was a pace setter; so also have been the
entire District. Unfortunately, the colleges in .Ahmedabad, Trivandrum,
programme remained more at the level and Madras. The Indian Academy of
of mobile dime services provided by Paediatrics has recently published
interns and junior doctors, utilising the recommendations for the teaching of
3 large white mobile vans procured paediatrics relevant to our social
from the UJL by Raj N’arain.
situation.
These “White Elephants" cannot
Attempts have also been made
manoeuvre the smaller roads leading towards the development of social |
to the more remote villages; they are obstetrics with ±e support of WHO.
confined to the highwavs. The imple Integrated teaching of Mother and
mentation of the scheme in its entirety Child Health (MCH) by the depart -
0 • Health Acoon June 1991
. . 117
Cover
Story
ments of Obstetrics and Gynaecology, should therefore be the focus for major The group decided to be much more
Paediatrics and PSM was introduced efforts in reorientation. Another community oriented and community
in some colleges.
phenomenon is that creative and based. The manifesto articulates an
committed work usually continues as alternative vision in objectives,
Expanding medical horizons
More recently some colleges eg., long as the key person who initiated it, methodology, student/staff selection,
MGfMS-Sevagram. PGI-Chandigarh. is around. After they move on. the curriculum development, evaluation,
JIPMER-Pondicherry. CMC-Vellore work gradually reaches a different development of peripheral health
and others have been spearheading the level of routinized, meaningless facilities etc.
introduction of Rational Therapeutics functioning or gets lost to history. We Recognising the Social Paradigm
through the Departments of Phar need to develop a commitment to the
The Medico Friend Circle (mfc) is
macology. Medicine etc. The need for cause and a process rather than an all India group of people interested
a greater emphasis in the under individualized functioning and and involved in health issues within a
graduate medical curriculum to kingdom building.
broader social perspective. In a recent
Psychology. Behavioural Sciences and Networking for Change
publication entitled “Medical
Psychiatry is also gaining ground. The
In addition to changes attempted by Education Reexamined” (1991) they
development of epidemiological skills individual colleges and small groups of explore various dimensions of medical
is also being streng±ened by initiatives faculty there is an emerging trend in education, building on ±e perceptions
and networks linked to CMC-Vellore the 1980’s for networking and explo of their members who come from
and AIIMS-New Delhi. A few
ring the problems and the solutions diverse medical, social activist and
colleges are also concerned about a together.
developmental backgrounds. Using
more planned approach to training in
the framework of the 1982 MCI
Mediail Ethics. Some ground work Asking the right questions
curriculum they have formulated an
has also been done to work out a
In 1987 a symposium on “Medical innovative alternative anthology of
curriculum for the teaching of Education for Primary Health Care ideas which stresses the “societal
Management to
medical Needs — experiences in successes and causes of ill health and the community
failures” was held at AIIMS-New orientation” of the medical solutions.
undergraduates.
Delhi. One of the key resource groups
Selecting and Motivating
was the Centre for Educational The Alternative Track
In 1988. the MCI and WHO
CMC-Vellore and SJMC-Banga- Development. University of Illinois
; lore have introduced selection (USA), which has been spearheading initiated homework with a few
'■ methods, which strive to understand changes worldwide. Four participating medical colleges on the possibility of
attitudes and mouvation rather than medical colleges — AIIMS (New an experimental parallel curriculum
only intellectual ability. They also Delhi), BHU (Varanasi), CMC which would be “community ori
have a scheme through which young (Vellore) and JIPMER (Pondicherry) ented” and “problem solving” in its
graduates work m peripheral health formed a working consortium on approach. Inspite of running into “bad
institutions of the voluntary health “Inquiry Driven strategies for weather”, one member of the group.
sector for 2 years after graduation. Innovations in Medical Education in CMC-Ludhiana has gone ahead with
i Having completed this, doctors get a India. Health Services Research and preparation for change, having .
preference for entrance into post- Context Evaluation”. Each took on an received the Punjab University’s green
I graduate courses. Over the years some area of study concerning medical signal to lay the new track. As faculty
■ of these postgraduates have become education. There was sharing of and students prepare of change CMCi staff members. It is hoped that their information and views at different Ludhiana has discovered the trials
experiences in the periphery will workshops. It is now hoped to enlarge ahead with status quo forces. The
the consortium, and spread its scope process in its initital teething troubles
' influence their teaching.
Most of the experiments and wi± each of the 4 colleges taking on 4 has discovered the need for a
l innovations have been confined to a more colleges. The idea is to build ±e “voluntary incrementalism”.
relatively small number of institutions “case" and substance of change step by Searching for a value orientation
! — the “Top Ten" medical colleges. step asking the right questions and
1989 saw the Christian Medical
These colleges also attract “good” initiating studies to find answers and Association of India (CMAI) facili
tating a network of Medical College
students who tend to go in for approaches.
superspecialization. It would probably Exploring Community approaches viz.. CMC-Vellore. CMC-Ludhiana,
not be a surprise to find that most
The Miraj Medical Centre has put SJMC-Bangalore and Miraj Medical
doctors going abroad come from these up a proposal for the development of a Centre. Their objective was to learn
colleges. The mainstream colleges Chrisuan Institute for Health Sciences. from one another pioneering expeHeaith Action June 1991 • 11
. . 118
118
rience and strengthen each other. At
the same time they have been
exploring the need for greater social
relevance and a new orientation in
medical education upholding ethical
values in medical practice, research
and health care delivery.
EXPLORING NEW LINKAGES
Learning from the Grassroots
The voluntary health sector, work
ing primarily with the more under
privileged sectors of society, has been
growing during the past 3 decades.
Non-formal training programmes in
health related subjected were begun by
different groups, independent of each
other, in different parts of the country.
Some of these date back about 25
years, while others are more recent.
The motivating factor was to train
people to intervene sensibly and-^
sensitively in the situation that prevails
in each local region. There is a
tremendous variety in the types of
training that evolved from the training
of dai s and community health
workers, health educators, community
organizers, multipurpose workers, deve
lopment workers with a health
training as well, to community health
training and reorientation for doctors
and nurses. From a six weeks' course
the range of courses and alternative
courses go right up to an M.phil and
Ph.D programme in Community
Health offered by JNU University.
These programmes nave developed
their own cumctiiar content and
alternative training methodologies.
Since they were unfettered by regu
lations and accreditanons. they were
rather creative in their approach.
These programmes are a very nch
Indian resource and important lessons
could be drawn from their experience
and internalised into the medical
education system, particularly for the
community orientation ano com
munity health aspects. The Kottayam
experiment a forgotten experience is
given elsewhere in this issue.
Some newer areas developed are
social analysis at a macro-level and
also methods of understanding and
analysing local situations. Simulation
games have been developed to enable
this. Another important area is the
understanding and acceptance of
oneself, one’s needs, motivations and
aspirations.
Identifying and utilising local health
traditions, resources and medicinal
plants has been done by several groups
in different pans of the country.
.Methodologies have been develo
ped to enable and empower women
who any way are the main providers of
health care in the family and
community.
Medical skills have been demysti
fied and health workers have been
found very capable even in performing
minor surgery and tubectomies. There
is therefore an urgent need for
interaction between the classical
medical educators and this very alive
and dynamic process at the grassroots
which will be to their mutual benefit.
Recognising fellow physicians
The wealth of resources available in
the Indian and other systems of
traditional medicine which are cul
turally acceptable, closer to the people
and more holistic in approach is
gradually being recognised by health
planners. Given below is a picture of
the manpower available and training
capacity.
Fig 3 a
Total number or registered practitioners of the different systems of
medicine in India — 1987
Source Health Irrormation India 1988
Allopathy
3.31.630
51.43%
Ayurveda
2.72.800
42.31%
Unam
28.711
4 45%
Sidoha
11.581
• 30%
Total
6.44.722
12 • Health Acuon June 1991
. .119
11°
Cover
Story
: Number of Training Institutions for medical practitioners of the
i differnt systems of medicines in India — 1987
I
Private or Public ?
There is an increasing trend par
ticularly in the 1980’s towards the
privatisation of medical education, i
Private colleges today account for
about 25% of all medical colleges.
“Capitation Fee' Colleges have sprung
up as business enterprises. Upto Rs. 5
lakhs are collected as “capitation fees”
per student on entrance. The facilities
and staff requirements are more often
than not inadequate and hence the
colleges are not recognised by the
MCI.
‘
Thus a profession, that was once a
vocation, is being commercialised and
made into a business where medical
care is bought and sold like any
commodity. This is becoming
increasingly evident in the type of
doctor-patient relationships that
prevail, in prescribing practices and in '
the mushrooming of high-tech
diagnostic services and five star
curative centres.
Source: Health Information India 1988
Allopathy
14Q
53.85%
Ayurveda
100
38.46%
Unani
18
2
0 77%
siddha
6.92%
260
Source: Health Information India
1988.
Medical educators can no longer
ignore the other systems of medicine.
Western medicine trained doctors in
the community cannot ignore or their
fellow physicians from the other
systems. This calls for a courageously
new commitment to integration in a
medically plural situation, a task
which the people have already begun.
Notwithstanding the lofty exhortanons
of G.O.I. reports and the newly
converted rhetoric of WHO—this
conunues to be a sadly neglected
aspect of health care policy exposing
the deeply embedded “cultural
colonialism” of the allopathic tradition
large number — presently about 5000 a
year i.e., 40% of graduates — migrate
(R. Duggal). Even today, large
proportions of our rural population
have to make do with substandard
medical care or no care at all from the
state sector.
and the lack of an open ended
rationalism. How long can we conti
nue to ignore this plural partnership ?
Medical Education And Society In
India
The training of doctors does not
take place in isolation, but is moulded
by powerful forces that operate in
Indian Society.
Doctors at what cost
Medical education in India is highly
subsidised. Doctors are educated at a
tremendous cost to the public ex
chequer. This was done with the hope
that thev would provide medical care
to “the vast rurai population” (Bhore
Committee). However, most of the
graduates remain m urban areas and a
Unemployment in the midst of
need
The total number of qualified
medical doctors (allopathic) registered
with the various State Medici Councils
in India in 1987. was 3.31.630. In
1988. the total number of doctors
working at the Primary Health
Centre/Community Health Centre
level was 262230 i.e.. about 7% of the
total number of doctors. The Taluk
and District Hospitals and hospitals/
dispensanes/health centres of the
NGO/voluntary sector also employ
doctors. Private practitioners also
sometimes work in villages. However
even an optimistic estimate would not
be more than 20-25% of doctors
working in rural areas.
y •-•c/.i -u SELL
Healtn Action June 1991 • 13
120.
Paradoxically, wc also have
unemployment and underemploy
ment of doctors. The number of
medical graduates on the live register
of the employment exchanges are as
follows:
1986 — 25.613
1987 — 31.029
1988 — 27. 599
This is more than the number of
doctors working at the PHC level! The
actual numbers are much higher !
In Conclusion
There have been several changes for
better and for worse in ±e Geld of
medical education in India. There has
been tremendous increase in the total
number of trained personnel. Clinical
competence is on the whole good.
Over the years the varying needs at the
grassroot, secondary and tertiary level
have become more and more clear.
Opinion and pressure have gradually
been growing ar the local, national,
regional and international level regar needed is a coming together of various
ding the need for a new type of elements who are committed to the
training of the new doctor. A critical
physician viz., one
mass of these “live elements” could
— who can understand health spearhead change in the years ahead.
problems in a community context,
— who can build on the strengths of
the community, working with References
them, facilitating growth, learning, 1. Central Bureau of Health Intelli
gence, G.O.I., Health Information
— who shares information and
India — 1988 and 1989
knowledge with the patient and
the public,
2. Medico Friend Circle, Medical
Education Reexamined, 1991
— who can function democratically
within a health team, and
3. Narayan Ravi, mfc bulletin 97-98,
150 years of medical education
— who is open to different systems of
medic'ne and healing and health 4. Duggal Ravi, Radical Journal of
practices.
Health, Vol. Ill, No. 4 Medical
Education
in India : Who pays ?
Never before have we been so close
to embarking on this challenging path. 5. Ministry of Health and Family
Welfare, G.O.I., Report of the
We already have before us pioneers
Group on Medical Education and
and trail blazers. At a wider level we
support manpower, 1975
have also with us competence in
various Gelds, knowledge about local 6. Government of India, Report of
reality and a self-conGdence to
the Health Survey and Deve
intervene creatively. Perhaps what is
lopment Committee, 1944.
of their family members made to a treatment given by the doctor ? Why ?
doctor. We feel that dissemination of 13. What, according to your
the Gndings of such a survey may begin experience are the good and bad i
a process of new thinking and perhaps. practices of the medical profession i
today ? 14. What according to you, |
a process of change in medical care.
should
be done (including tightening
1. Date of visit to doctor. 2.
Doctor’s QualiGcation (degree) 3. regulations) to encourage good |
Describe nature of illness for which medical practice ?
doctor
’s help sought. 4. Number of
While responding to the above •
\ Dear friend,
days this illness lasted. 5. How long did questionnaire you need only put the
•
Medical care is an essential service you wait in ±e clinic before the doctor respective Question Numbers.
; we all need at sometime or the other. examined you? 6. How much time did
We thank you for your response ■
.Almost 80% of it is in the private sector the doctor spend in examining and and promise to communicate the |
i in our country. Of late, inspite of advising you ? 7. Cost of the visit: results to you. Kindly send your I
paving for private medical care, people Doctor’s fees, cost of drugs, transport responses to:
i
have been raising doubts about the cost and any other. 8. Without having
Medico Friend Circle (Bombay
■ quality and the cost of medical care. to demand it, did the doctor give you a
Group) 310. Prabhu Darshan. 31 SS
But are these doubts really justiGed ? receipt for the money you paid him ? 9. Nagar Amboii. Andben (W\ Bombav
i Unfortunately our research institutions Did the doctor tell you the diagnosis. 400 058
i have paid scant attention to the and give you information about the
Please write your name and address
■ medical care of consumers and side effects/ bad effects of the
adequate informs non is not available. medicines given or tests recommen along with the response. All
infonnanon given will be kept in strict
Medico Friend Circle is a group of ded? 10. Do you think that the fees confidence.
I socially conscious doctors and other paid by you to the doctor was
health acnvists, interested in knowing low/reasonable/high/very high ? 11.
Thanking you,
; consumer’s (patient’s) experiences and Do you thmk ±e doctors’ fees should
be
standardised
throughout
the
i opinions. We will gratefully appreciate
if the readers respond to the following countrv ? Why ? 12. Were you
Annie George
Coordinator I
questions for the last visit they or any satisGed with the behaviour of and the
Dear Reader
Medico Friend circle is conducting
a survey of patients' experiences and
opinions of their doctors. Reproduced
below is their letter and questionnaire.
Your answers will help you and
everyone else. (Ed)
. . 121
121.
APPENDIX
"D"
BLOCK POSTING - AN EFFECTIVE METHOD FOR COMMUNITY-BASED,
COMMUNITY-ORIENTED TRAINING PROGRAMME*
*
The teaching of Community Medicine to undergraduate students in
Christian Medical College takes place in a phased manner in four
"Block Postings": during the first year of medical school, the
first and second clinical years, and internship. Each phase has
specific objectives, and is designed to build on the experience
gained in the previous phases.
A block posting is when students are relieved from attending
other classes and concentrate only on Community Medicine. This
concept of teaching was introduced in 1975 by the Community
Health Department when they realized that the previous programme
known as Family Health Advisory Service had some serious
limitations.
The Block Posting has the following advantages:
1. It helps to get the students full attention as well as have
more time in the community. The students are not distracted
by other classes, exams and extra curricular activities.
2. They are able to spend the entire day at the village, from
early morning to late evening.
3. Living in the village or being present for the greater part
of the day enables the student to observe the life style of
the villages: their day to day activities, health practices,
work schedules etc.
4. Besides, the students are able to contact, interact and
organize programmes according to the convenience of the
community.
5. The community is more receptive as students mingle with them
freely, become involved in their daily lives and develop
friendships with some of the families.
6. The close contact with the people is an enriching experience
for the students as they discover the warmth and hospitality
of the community. They are also able to identify and meet
some of the felt needs, using the potentials and local
resources of the community.
There are some disadvantages to this system of teaching:
^1. It has the tendency to compartmentalize the subject.
* Dr. Abraham Joseph, Christian Medical College, vel1 ore-632002
. . 122
122.
2. The faculty are unable to attend to their other duties and
clinical responsibilities during this period.
3. The other departments in the medical college are also
inconvenienced as they have to reorganize their schedules for
this programme.
However, cooperation and understanding between the faculty of the
various departments has helped to organize these teaching
programmes successfully.
METHODOLOGY
PHASE - I
Upon entry into medical school, the students are introduced
through didactic lectures, case studies and simulation games to
sociology, psychology, and biostatistics. The main part of the
primary health care training, however, takes the form of a block
posting of three weeks in what is known as the community
orientation programme. This experience aims to familiarize
students with the demographic, socio-economic, and environmental
aspects of rural community health; with beliefs about diseases;
with the role of various members of the health team; with
government and voluntary organizations in rural health; and
with the principles of health education. The students, in
groups of two or three (depending on how many Tamil speaking
students there are), live for two weeks in a rural community
typical of those in the area. They use local sources of water,
which they have to draw and purify; they plan the meals in
thatched huts and use toilet facilities constructed at the
camp site.
Each group is assigned 12-15 households and asked to study
them in detail, using a form, designed by the college's
department of Community Health and Biostatistics. Interviews
and observations, help to uncover information on various aspects
of village life. In addition, special studies are made of
particular problems, such as the nutritional status of children
(through anthropometric measurements), prevalence of diseases
such as filariasis and scabies, the role of traditional
practitioners, and the social problems of old age. With the
help of the staff, the students analyse the data they have
collected, which gives them practice in using and interpreting
statistics and applying theories and methods they have learnt
in the classroom. Groups of students then present their
results to the rest of the class, using various methods of
presenting the data. The ensuing discussion is often heated
and educative and forms an important part of the learning
experience.
. .123
During the camp, the students present special case studies of
individuals suffering from common illnesses which they have
identified themselves. Senior faculty members from CMC are
invited to be pesent at these presentations, and to help students
understand both the socio-economic roots and implications of the
problems and the practical aspects of finding solutions in the
village context. The presence of specialists from Physiology,
Pathology, Surgery, Child Health, Medicine, Obstetrics and
Gynaecology departments underlines the importance of Community
Heal th.
To interact more effectively with the Community, the students
organize and participate in various other activities: games and
competitions for the village children and young people, health
education activities (particularly in Nutrition), immunization
programmes, construction of soakage pits to improve environmental
sanitation, and the conduct of medical clinic each evening. In
all such activities they work both with community leaders and
with other members of the health team. In order to help the
students understand the existing programmes in the rural areas,
officials from various government departments and agencies and
personnel from relevant private industries give talks about
their role in community welfare.
At the end of the posting period,
the students organize a social gathering for the village at
which they thank its eresidents and entertain them with songs
and dances.
The students, on their return to the college, spend three days
presenting and discussing the data they have collected, with
the help of staff members and the use of audiovisual aids. Their
learning experience includes an evaluation of what they have
accomplished.
The COP has been organized with the following objectives:
1. To bring about an awareness of the:
a.
b.
c.
d.
e.
f.
g.
h.
social and economic status of the rural community
demographic structure of the community
environmental status of the community
influence of social, economic and environmental factors
on health and diseases
existing health practices and beliefs about disease, its
causes and prevention
role of Government and Voluntary Organization and their
programmes in improving the welfare of the rural community
role of various members of a health team
principles of health education.
2. To provide the student with skill in;
A. Making a Community diagnosis by:
i. interviewing individuals and families
124.
ii.
iii.
iv.
v.
carrying out a field survey
using appropriate sampling techniques
analysis of data
interpretation of data.
B. Organizing a Community Programme by:
i. identifying leaders and enlisting their cooperation
ii. enlisting community participation especially by
working through leaders, youth and women group.
C. Carrying out health education for individuals andgroups
using appropriate health education methods such as flash
cards, flip charts, villupattu, skit, drama and songs.
D. Identifying the role of, and working with other members
of a health team in organizing community programmes.
3. To inculcate an attitude of concern and compassion for the
individual and the community.
PHASE - II
The second phase, which takes place during the first clinical
year and lasts two weeks, focusses on the principles of
epidemiology, health administration, and health planning. It
includes lectures, classroom exercises, and field exercises.
The students, working in groups of 10-12 have 2-3 villages as
the subject of field investigaticns. They conduct a crosssectional survey of morbidity and mortality and, from the data
collected, estimate the morbidity rate, susceptible ages, and
sex-specific prevalence of certain diseases; the birth rate,
crude death rate, infant mortality rate, and maternal mortality
rate; and the utilization of health services, the distances
that must be travelled to reach the services, and the cost of
treatment. The students study the various types of health
services available at the different administrative levels, from
primary health care center, through tahsil hospital and
district hospital (or community health and development hospital),
the referral hospital. Through interviews with patients they
obtain information on the distances patients have travelled,
the types of disease that are common, and the length of time
patients were ill before they sought medical aid. Information
on each of the health services is compared in relation to
types of illness, duration cf illness, and distance travelled.
A time and motion study of the hospital organization is done
to determine the waiting time and actual service time at
various points the doctor's consultation, pharmacy, laboratory
and injection room.
. .125
125.
on the basis of lectures and the data they collect, the students
plan a programme for a defined problem for a specified population.
Their knowledge of community health principles is, in turn
evaluated at the end of this phase.
The objectives of the CHP-1 are:
A. To make the students aware of the:
Principles of epidemiology
principles of health planning
Principles of health administration
National health programmes with special emphasis on
the organisation of Primary Health Care
v. Common health problems of a community
vi. Utilisation pattern of health services
vii. Role of the various members of the health team.
i.
ii.
iii.
iv.
E. To provide them with skills in:
i. Formulating a questionnaire
ii. Carrying out community surveys - cross sectional
morbidity and mortality surveys
iii. Analyzing and interpreting data
iv. Estimating vital statistics such as birth rate,
death rate, infant mortality rate
v. Carrying out observation and time motion studies and
interpreting the data
vi. Health Planning
vii. Use of various audio visuals aids, overhead projector,
slice projector, movie projector etc.
PHASE - III
The third phase comes during the second clinical year and is of
two to three weeks duration. It aims to give the students an
opportunity to apply in practice, the knowledge and skills they
have acquired in the previous two postings to implement a
programme in a given community. This is primarily a community
based, problem-solving problem. The students form their own
groups of 5 or 6 students. A defined population is given to
them. Within two weeks they are asked to make a community
diagnosis by carrying out a survey or using existing data, plan
a programme, implement and evaluate it. Each group of
students chooses a particular problem to work with. Usually
these will be common national health problems, or problems
more specific to the area under study, such as nutrition,
maternal and child health, leprosy, tuberculosis, family welfare,
environmental pollution etc. The study questions are
formulated in such a way that a variety of study designs will
also be employed by the various groups eg., descriptive study
or case control study.
i
. . 126
126.
During the implementation of their programmes, the students
make their own time schedules and use the services of various
members of the health team as required. Two staff members from
the college are assigned to each group as resource persons, but
provide only guidance. The last few days of this programme are
set apart for presentation. Each group presents the projects'
goal, objectives, methods, results and limitations of the
programme. They highlight their success and failure and analyze
the reasons for the failure. The students also give a feedback
of their data analysis to the community based on which they
conduct a health education for the community. The students have
reported that this phase of their training is the most useful,
because of the experience it gives them in actually organizing
a programme on their own and doing something for a community.
Eut its effectiveness depends on the knowledge and skills the
students have acquired in previous phases.
The objectives of the CHP-II are to provide skills in:
i. Making a community diagnosis prioritization and manpower
planning
iiT working with the members of the health team
iii. Organizing a health programme in the community
iv. Carrying out a health education programme
v. Evaluation of the health programme carried out
vi. Analysis of the data collected
vii. Presenting the findings of the study
viii. Using various audio-visual aids.
PHASE - IV
The one year compulsory internship is a continuation of
undergraduate medical education. It includes a three month
community posting that aims to prepare the intern as a "basic
doctor" and to give him or her elementary knowledge of community
health practice. As part of the health team the interns
participate in the organization and implementation of primary
health care in the area where they are posted; they also do
short evaluation studies of programmes conducted by the
department of Community Health of the college.
The "basic doctor" should be able to diagnose and treat common
illnesses without the use of sophisticated laboratory aids
and should know when to refer patients to specialists or to
larger hospitals or other facilities. He should also be able
to perform simple laboratory tests and common minor surgical
procedures, such as tubectomy and vasectomy.
The interns training in community health practice focuses on:
organizing preventive services for vulnerable population
groups, such as mothers and children; conducting surveys and
using their findings as a means of evaluation the health
status of the community; applying the basic principles of
. .127
127.
health education and the use of relevant techniques; promoting
family planning; functioning as a general practitioner (or medical
officer) in a health center, hospital, or national health
programme; identifying the various political and socio-economic
factors that influence a community's health and learning ways
of improving it by working with people in other disciplines
(eg., agriculture, education, and animal husbandary); understanding
and working with other members of the health team; and becoming
familiar with other community agencies and the help that they
have to offer.
During their community health posting, the interns are an integral
part of the health team. They make regular visits to the villages
to take part in leprosy outreach work; supervise the work of
part-time community health workers, health aides, andnurses at
mobile clinic sessions; give health education talks at community
gatherings; conduct maternal and child health clinics; and treat
common conditions and make the necessary referrals. They also
participate in all the activities at the Community Health and
Development Hospital, Bagayam, for 3-4 weeks, treating inpatients,
working in the clinical laboratory, seeing patients in the
outpatient clinic, and performing simple surgical procedures
under the supervision of a senior doctor.
culty attempt to use each patient encounter as an opportunity
for teaching. Patients are told the causes of their maladies
and how to prevent such disorders in the future. The intern
learns to view patients not simply as isolated individuals with
particular clinical disorders but also as signs of an unhealthy
physical, biological, or social environment.
An environmental
problem, for example, can be viewed as a "community disease"
and the patient as a "sign" of that disease. Treatment of the
"community disease" often requires the use of non-medical
approaches - hence the doctor's need to work with people in
other disciplines. The necessity for involving the whole
community in the solution of certain types of problem is
demonstrated to the interns.
Working in pairs, the interns conduct a special study (an
epidemiological) during their community posting. Often these
studies serve as pilot projects that subsequently evolve into
larcer-scale endeavours.
The training of the interns aims to impart the following with
regard to Community Health practice;
a. Ability to organize preventive services for vulnerable
croups in the population eg., mothers and children.
b. Ability to conduct surveys and use its findings as a means
towards arriving at a community diagnosis.
• .128
128
c. Ability to understand and work with other members of the
health team.
d. Knowledge of the basic principles of health education and
ability to use health education techniques.
e. Ability to promote family planning.
f. Ability to function as a general physician (or medical officer)
in a health center, a hospital or National Health Programme.
g. Ability to identify the various factors, social, political
and economic, which influence the health of a community; and
gain knowledge of ways by which this could be improved by
working with other disciplines eg., agriculture, animal
husbandary, cottage industries, etc.
h. Appreciation of the need to know government and private
agencies in the community and acquiring knowledge of how to
utilize their assistance.
An important aspect of the training model is evaluating it at
various stages. Students submit pre and post evaluation
questionnaires to assess their change in attitude toward rural
medical care, knowledge acquired as a result of the programme,
and the students own assessment of the programme. Department
staff members give serious consideration to the students'
evaluations, make relevant comments themselves, and try to alter
subsequent programmes accordingly.
★
★
★
★
For further information regarding each
phase including reports, proformas,
methods of evaluation, please contact
Dr. Abraham Joseph, Professor and Head,
Community Health Department, Christian
Medical College, Vellore - 632 002.
129
129.
APPENDIX "E"
RECENT CHANGES IN UNDERGRADUATE MEDICAL EDUCATION AT SMT.N.H.L.
MUNICIPAL MEDICAL COLLEGE, AHMEDABAD
A REPORT ON INNOVATIONS/EXPERIMENTS*
1. INITIATING THE CHANGE
In 1989-90 during the meetings of departmental heads arranged
by the Additional Dean, Dr. K.J. Nanavati, various problems
regarding undergraduate training programme and their possible
solutions were discussed. Some changes were suggested like:
a. Need for frequent meetings and interactions between
departmental heads, teachers from different departments
and between teachers and students.
b. Strict review of attendance of students.
c. Synchronisation of theory lectures programme between
various departments for example, between pathology,
pharmacology and medicine, also synchronisation between
theory and practicals/clinics for the same subject.
d.
Formation of a Teaching Programme Review Committee(TPRC)
to supervise these changes and give necessary suggestions.
2. THE CATALYST
To bring about changes in education in the right direction
scientific approach is necessary and the first step towards
developing a scientific approach was to orient the teachers
to the concepts of Educational Technology. Thus a workshop
on “Principles and Practice of Education, Technology in
Medical Education"was organised at the institute and
conducted by the faculty of NTTC from PGIMER-Chandigarh
(Post Graduate Institute of Medical Education and Research)
in March, 1990. The four day workshop covered two areas Educational objectives and Evaluation. Twenty-eight teachers
from the institute participated in this workshop which
used real workshop methodology (Group Discussions/Group
Work, etc.).
Most of the participants were quite impressed by this newly
acquired knowledge and were convinced that for the change
in the desired direction proper application of Education
Technology would be necessary. It was also realised that a
total reorientation and not the isolated, patchwork type
changes in education was necessary to achieve relevance
and effectiveness.
. . 130
♦Minutes sent by Dr. K.J. Nanavati, Additional Dean
Smt. HHL Municipal Medical College, Ahmedabad.
130.
3. FEW STEPS FORWARD (INNOVATIONS AND EXPERIMENTS)
A follow up meeting of all teachers participating in NTTCworkshop was called by the additional Dean (who himself was
one of the participants). It was decided to proceed for the
change using principle of Educational Technology. The
proposed change can be represented as follows:
♦DEFINE LEARNING OBJECTIVES (Relevant to society needs);
♦CHANGE TRAINING METHODOLOGY;
♦CHANGE EVALUATION METHODS;
(The group, now called Educational Technology Group(ETG)
was divided in three sub-committees) .
i. Sub-committee for conducting Education Technology
Group workshop for remaining teachers;
ii. Sub-committee for formulating Educational objectives;
iii. Sub-committee for MCQs, collection and forming MCQ
Bank (now changed to sub-committee for Evaluation).
All sub-committees worked under the leadership and guidance
of the Additional Dean.
Following is the outcome of the ETG activities over the last
two years.
3.1 WORKSHOPS ON EDUCATION TECHNOLOGY
The Sub-committees for workshops conducted a series of
workshops on Educational Technology. Main objective
was to expose the teachers of the Institute to Education
Technology and to enable them to participate effectively
in the activities like formulating learning objectives
in their department, constructing tests for student's
evaluation etc.
Total 217 teachers participated (almost all the teachers
of the institute) in 10 workshops conducted between
April 1990 and March, 1991.
3.2 FORMULATING EDUCATIONAL (LEARNING) OBJECTIVES
The sub-committee for Educational objectives worked
simultaneously with the workshop committee and so far
has completed the following tasks.
3.2.1 Formulating Institutional level objectives:
The committee obtained Educational objectives
from some premier Medical Institutions in India
and reviewed them. At the same time it also
defined priorities in education on its own
during the course of several meetings. The
draft of institutional objectives prepared by
the sub-committees was revised, after being
discussed in the meeting of the departmental heads.
••131
131.
3.2.2 Formulating Departmental level objectives:
Once the institutional level objectives were ready,
the tasks of defining objective of various departments
was undertaken. A two step strategy was adopted.
STEF I: Defining priorities - division of the subject
into three areas:
a. Core areas absolutely essential areas in which
90-10C per cent efficiency is expected;
b. Good to know - in which 50 per cent efficiency' is
expected;
c. Nice to know - least important may be dispensed
with.
STEP II: Stating the objectives - describing the
competence in terms of knowledge and skills and also
the attitudes, by referring mainly to the Core Area.
While stating departmental level objectives, their
relevance to the institutional objectives was also
being checked. So far most of the departments have
completed this exercise, and a few are in the
pipelines.
3.2.3 These objectives will be modified if necessary taking
into consideration the views/suggestions of the
practitioners, resident doctors, interns and students.
A step in this direction - two workshops/meetings
recently held with the members of Ahmedabad Medical
Associations to discuss these objectives and to get
their feedback.
3.3 INTRODUCTION OF CLINICAL TEACHING FROM FIRST MBES
Clinical posting has been introduced for first MEBS students
for the last two years. The objectives is to orient them to
the hospital set up, and to make them familiar with history
taking, physical examination of patients, bedside manners
and simple ward procedures.
3.4 Evaluation Programme for the first year was evaluated by the
students by responding to the questionnaire. Similarly
during the Orientation Programme for interns (Refer 3.6)
feedback was also obtained from them.
3.5 COMPREHENSIVE CLINICAL POSTINGS
A one week experiment of comprehensive posting was conducted
for the batch of 8th semester students, attending medicine
term. During this period, the students stayed with the
department for the whole day (9.00 a.m. to 5.00 p.m.)
during which they were exposed to the working of Radiology
and Pathology departments in addition to clinics/clinical
. .132
132.
lectures in Medicine so as to give an picture of integrated
coordinated working of all these departments.
It was felt by the teachers that although this type of posting
was possible for all the clinical subjects it required a
careful and long term planning.
3.6 ORIENTATION PROGRAMME FOR INTERNS
In February, 1992, the new batch of interns was exposed to a
three day orientation programme. The programme covered the
following:
a. Short lectures and discussions on objectives of internship
and rational therapeutics;
b. Introduction to group dynamics;
c. Project work and project report.
Students worked in groups of ten and gathered information on
the different type of formulations available for the given
group of drugs (Brand names, contents, potency, cost of a
course of therapy).
They presented the report using tables, charts, histograms,
etc. The information thus gathered was discussed in relation
to rational therapeutics.
d. Projection of a video film covering aspects of rational
therapeutics;
e. Group Exercise - three groups were formed and each
undertook one of the following three exercises:
i. Essential drugs scoring system;
ii. Evaluation of promotional drug literature;
iii. Discussion on expectations of interns from
internship programme.
The programme was perceived as 'useful' to 'very useful'
by about 85 per cent of the participants.
d.
A LONG WAY TO GO
Above is an account of a few experiments - some planned and some
spontaneous. To bring about a perceptible change, these few
steps should lead to a long journey - involving not only a few
teachers but all concerned - the teachers, the students and the
administration.
. .133
133
APPENDIX
THREE APPROACHES TO EDUCATION
This chart gives a summary of 3 approaches to teaching. It may help instructors to evaluate
their own teaching approach. But we do not recommend that this analysis be given to health
workers. Analyzing stories and role plays will work bettor. So pass by this chart if you want.
CONVENTIONAL
PROGRESSIVE
LIBERATING
Function
to CONFORM
to REFORM
to TRANSFORM
Aim
Resist change.
Keep social order stable.
Change people to
meet society's needs.
Change society to
meet people’s needs.
Strategy
Teach people to accept
and 'fit in' to the social
situation without changing
its unjust aspects.
Work for certain
improvements without
changing the unjust
aspects of society.
Actively oppose social
injustice, inequality,
and corruption. Work
for basic change.
Intention
toward
people
CONTROL themespecial ly poor working
people—farm and city.
PACIFY or CALM themespecially those whose
hardships drive them
to protest or revolt.
FREE them
from oppression,
exploitation,
and corruption.
NO
CHANGE
General
approach
AUTHORITARIAN
(rigid top-down control)
PATERNALISTIC
(kindly top-down control)
HUMANITARIAN and
DEMOCRA TIC
(control by the people)
Effect
on people
and the
community
OPPRESSIVE—ri^id central
authority allows little
or no participation by
students and community.
DECEPTIVE— pretends to
be supportive, but
resists real change.
SUPPORT! VE-he\ps
people find ways to gain
more control over their
health and their lives.
How
students
(and people
generally)
Basically passive.
Empty containers
to be filled with
standard knowledge.
Basically irresponsible.
Must be cared for. Need
to be watched closely.
Basically active.
Able to take charge
and become selfreliant.
Can and must be tamed.
Able to participate in
specific activities
when spoon fed.
Responsible when
treated with respect
and as equals.
FEAR—Teacher is an
absolute, all-knowing boss
who stands apart from
and above the students.
GRA T! TUDE—Teacher is a
friendly, parent-like
authority who knows what
is best for the students.
TRUST—Teacher is a
'facilitator' who
helps everyone look
for answers together.
Who decides
what should
be learned
The Ministry of
Education (or Hea tn)
in the cac tai.
The Ministry, but with
some local decisions.
The students and
instructors together
with the community.
Teaching
method
• Teacher lectu'es.
• Students ask ‘ew
questions.
• Often bonr^^^_^^»
• Teacher educates and
entertains students.
• Dialogue and group
discussions, but the
teacher decides which
are the 'right' answers.
• Open-ended dialogue,
in which many answers
come from people's
experience.
• Everyone educates
each other.
Main
way of
learning
PASS! V£-studenu
receive knowledge.
Memorization of facts.
More or less active.
Memorization still
basic.
ACTIVE-everyone
contributes. Learning
through doing and
discussing.
are viewed
What the
students
- feel about
the teacher
134
134
c .
CONVENTIONAL
Important
tubjacti or
COOCtptl
co v»red
Flow of
knowledge
•nd ideas
PROGRESSIVE
LIBERATING
• the strengths and
rightness of the present
social order
• national history
*
(distorted to make 'our
side' all heroes)
• rules and regulations
• obedience
• anatomy and physiology
• much that is not
practical or relevantit is taught because
it always has been
® unnecessary learning
of big words and boring
information
• Integrated approach to
development
• how to make good use
of government and
professional services
° filling out forms
• desirable behavior
• simple practical skills
(often of little usesuch as learning 20
bandages and their
Latin names).
• critical analysis
• social awareness
• communication skills
• teaching skills
• organization skills
• innovation
• self-reliance
• use of local resources
• local customs
• confidence building
• abilities of women
and children
• human dignity
• methods that tselp the
weak grow stronger
school or
health
system
school or
health
El
mostly
system
J
one
•
way
teacher
fJ \
§
• O ®
students
students 7-q^oudttschool or
leader health
system
The classroom and other
controlled situations.
Life-the class'oom
is life itse
all
one
a
1
/ 1\
students
Area for
studying
The classroom.
How does the
clan lit?
»
monocular
both ways
o
/----
a
• ® O Q O o
o © o o o a
o
•
0
Often LARGE. Emphasis
on quantity, not
quality, of education.
Often fairly small, to
encourage participation.
Often SMALL, to
encourage communication
and apprenticeship learning.
Attendance
Students have to
attend.
Students often want to
attend because classes
are entertaining and
they will earn more if
they graduate.
'Incentives' are given.
Students want to
attend because the
learning relates to
their lives and needs.
and because they are
listened to and respected.
Group
interaction
Competitive (cooperation
between students on tests
is called cheating).
Organized and directed
by teacher. Many games
and techniques used to
bring people together.
Cooperative—students
help each other. Those
who are quicker assist
others.
Purpose of
Primarily to 'weed out'
Variable, but generally
slower students; grades
tests are used to pass
emphasized. Some
/. -----some and fail
students pass.
/X
/X
others.
L
Others fail.
„
Primarily to see if ideas are
clearly expressed and if
teaching methods work
well. No grades. Faster
students help slower ones.
Evaluation
Often superficial—
by education or health
system. Students and
community are the
objects of study.
Often over-elaborate—
by education or
health 'experts’.
Community and
students participate
in limited ways.
Simple and continual
ly community, students.
and staff. Students
and teachers evaluate
each others' work and
attitudes.
At and of
• diplomas
• irregular.
police-like
supervision
• diplomas
Q O
• uniforms
• salaries
fy
• 'supportive supervision
• encouragement to work
hard and keep learning
• supportive assistance
when asked for
mainly to the health
authorities, less so
to local authorities
and the community
mainly to the
community—especially
the poor, whose
interests he defends
Class
mi
exams
training.
ttudenu
are given . . .
After training,
• health
worker is
accountable to..
SOURCE
R
his supervisor, the
health authorities.
the government
=
Helping Health V.’orkers Learn
(A book of methods, aids, and ideas for instructors
at the village level)
by David Werner and Bill Bower
135.
APPENDIX “G"
CHC/CMAl/CHAI
Medical Education
Project
i
|
135.
Please fill this form before you
come for the meeting.
It will
take you 5 minutes only. Your
participation is solicited.
MEDICAL EDUCATION / SOCL.L-COidMUNITY RELEVANCE
Indian Experie»ice
SELF ASSESSMENT GUIDE
Are you interested in Medical Education in India
Yes/No
If Yes would you like to know what your score in information
terms is as of today I
Mark tick for each item that you feel you know something
about.
Would you be able to write 5 lines on each ?
SECTION A
1. Shore Report (1946)
Yes/No
2.
Mudaliar Report (1959)
Yes/No
3.
Srivastava Report (197-4)
Yes/No
4.
ICSSR/lCMR - Health for All Report(l981)
Yes/No
5.
National Education Policy for Health
Sciences (1930)
Yes/No
6.
MCI Curriculum 1982
Yes/No
7.
Indian Association for Advancement of
Medical Education,
8.
Indian Journal of Medical Education
9.
National teacher Training Centres
.
.
Yes/No
Yes/No
Yes/No
10. Institutional Objectives
Ye s/N 0
11. Rural Internship
Yes/No
12. ROME Programme
Yes/N»
13. Basic Doctor Definition (1970)
Ye s/l'Io
14. Edinburgh Declaration (1939)
Ye s/No
15- Problem based learning
Ye s/No
Total Yes in A=________________
X 2
=
. . 136
136.
\ ?
SECTION B
16,
Patel Report (1970)
17.
National Health Policy (1982)
18.
National Educational Policy (1986 )
Y.es/.No
' Yes/lfP
Yea/No
19- Perspective Plan for Science & Technology
2001 A.D.
Yes/No
20.
Eighth Plan Document - Sector : Health
Yes/No
21.
National Medical/Health Commission
Yes/No
22.
MCI Bill in Parliament
23.
Healtli University Concept
Yes/No
24.
Family Planning Course - MCI Guidelines
Yes/No
25.
Clinical orientation in pre-clinical
phase - MCI requirements
Yes/No
26.
Integrated Teaching
Yes/No
Yes /No
27.Social Paediatrics/Obstetrics
Yes/No
28.
Family Health Advisory Service
Yes/No
29.
Epidemiology for Undergraduates
Yes/No
30.
Leprosy Teaching - MCI Guidelines
Yes/No
31.
Mobile Rural Hospital Scheme
Yes/No
32.
Objectives . of Internship
Yes/No
33.
Interns Orientation Programme
Yes/No
34.
Internship Assessment
Yes/No
35.
humanization of Preclinical Experiments
Yes/No
36.
Synchronised lecture programme
Yes/No.
37.
Community Orientation Camps
Yes/No
38.
Community Block Postings
Yes/No
39.
CPGP Units / G 0 P D
Yes/No
40.
Priority listing, in Clinical subjects
Yes/No
4l.
Core abilities
Yes/No
42.
Integrated Health Team Concept
Yes/No
43.
Clinical clerkship concept
Yes/No
44.
Health Education in Medical Education
Yes/No
45.
Behavioural Sciences in Medical Education
Yes/No
46.
Students Electives
Yes/No
Total Yes in
B1
=
X 1 =
. . 137
137.
47. Rational'.Therapeutics Course
,
Yes/No
48. Ethics course in Medical Education
Yes/No
49. Foundation Courses for Medical College
Entrants
Yes/No
50. Management Training in Medical Education
Yes/Mo
51. Teachers Training
Ye^s/No
52. Medical Education Technology
Yes/No
53. Instructional objectives
Yes/No
54. Small Group Learning
Yes/No
55. MCQs
Y e s/N 0
56. SAQs
Yos/No
57. Skill Laboratory
Yes/No
58.
Self Learning Skills
Yes/No
59. Participatory Training
Y e s/No
60. OSPE
Yes/N 0
61. OSCE
Yes/No
62. Teaching in Emergency Medicine
Yes/llo
63.
Alternative Systems of Medicine in
■ Medical Education
Yes/No
Yes/No
.
64,
simulation Gaines
65.
Low Cost Communication skills
Yes/No
66.
Kottayam Experiment
Yes/No
67.
Doctors for Villages - Study
Yes/No
68.
mfc - Anthology of Ideas
( '
Yes/No
'69. JNU - Plea for a new Public Health
Yes/No
7P.. CMC - Vellore model of Community oriented'
- ,
Medical Education
Yes/No
*
71. Miraj Manifesto
’■
v
Yes/Nc
72. Alternative Track
Yes/No
73• Inquiry driven Strategics-Indian~Consortium
Yes/No
74.
EiTCLYN Netj^rk
Yes/No
75.
EPIDMAN Network
Yes/No
76.
National System of Medicine
Yes/No
Total Yes in B2=
.. 138
77• Selection Procedures - Psychological tests/ ‘
Group Observation
Yes/No
78. Extra aural Postings for Undergraduates
Yes/No
79• Graduate Feedback
Yes/No
80.
Alternative Health Trainers Sector
Yes/No
81.
Alternative Development Trainers Sector
Yes/No
82.
SEARO booklets on Reorientation of
Medical Education
Yes/No
Alma Ata Declaration
Yes/No
83.
34. International Network of Conununity
Oriented Health Sciences Institutions
Yes/No
85. Rural Bond/Placeraent Scheme
Yes/No
Total Yes in B3 =
X 1
=
Total Yes in A + B1
+ B2 + B3
That is the percentage of information you have on Indian
experience.
If you would like to increase your score you
may like to read/use the Faculty Resource Manual which we
will be producing as an output of our study 'Strategies
for social Relevance and Conununity Orientation in Medical
Education : Building on the Indian Experience' (Due to be
published by end 1993)
z
.
Welcome to theMedical Education Review Meeting .on 20/21 st
June 1992 where you will find out more about all these’ Indian
Experiment/expo rienc es.
.___________________
—-------------•A modified shorter version of
COMMUNITY HEALTH CELL
- ‘
tills was distributed to IAA14E
Aiinpal Conference participants
1Oth June 1992
£n january 1992.
. . 139
ANNEXURE
“h"
STRATEGIES ■ FOR SOCIAL RELEVANCE AND COMMUNITY ORIENTATION IN
MEDICAL EDUCATION
- Building on the Indian Experience
I--------------------------------------------------- —
j A FACULTY RESOURCE MANUAL
VOLUME
I-III
---------------------- - ------------------------- i
'A Note and the content list of the Faculty Resource I
Manual for consideration by participants of the
1
• Medical Educators Review Meeting organised by
’ Community Health Cell in Bangalore in June 1992.
Dear Reader,
Please review the enclosed note and the content list that follows
i)
Please read the note about the manual which is in its
pre-final stage.
Do you have any ideas/suggestions
about format/presentation at this stage which would
.make its use' more easy, relevant and meaningful to your
faculty group work.
ii)
Are there any ideas/issues, experiments/innovations that
you know of, which have not been mentioned?
If so, can you give/send us further details/references
or leads on the same.
iii)
You may like to show this to some of your other colleagues
in your institution who have an interest:in medical educa
tion reform.
Please do so and send your comments after
:4
that if you like.
iv)
Please mark the couuiunication to Community Health Cell,
Attn.; Faculty Resource Manual, Society for Community
Health Awareness, Research and Action, 326, V Main,
I Block, Xoramangala, Bangalore - 5^0 Ojk.
v)
All communications/suggestions will be acknowledged in the
final publication.
vi)
All communications to us should be sent in by 31st July,
1992.
. . 140
i
A NOTE
* This manual has been put together as a resource book for the
faculty of medical colleges who are keen to be involved in
reorienting medical education towards greater social and
coiamunity relevance in the 1990's.
* It brings together a large number of ideas, innovations and
experiments that have been part of the Indian experience in
the last few decades and especially since the mid 1970's.
* These were identified through a project undertaken by a group
of researchers of the Society for Community Health Awareness,
Research and Action, Bangalore which was sponsored by C.M.A.I.
and C.H.A.I. and supported by the C.l'I.C. Network.
* The project methodology included a literature survey; a survey
of medical colleges; field visits to a few key colleges which
included discussion with faculty and interns;:a study of the
training experiences in the voluntary sector to identify issues
and methodologies relevant for professional education; and a
survey of graduates who had two years experience in a peripheral
health care institution.
* The manual attempts to put the faculty in touch with the wide
range of Indian experience so that they can build on ideas and
experiences that have arisen from a creative interaction with
local realities and no.t just transplanted from another culture,
health service or educational system.
* It also draws inspiration from different sectors of experience
which include the exports; the medical college innovators; the
alternative community health and development trainers; academes
and activists interested in the topics and young graduates wor
king in■primary health care situation.
* This manual is not a recipe book.
It does not aim at telling
you how to do it but to bring to your notice what was said and
what has been done by someone else in a similar situation.
* It is a resource manual - a reference manual to inform, to
stimulate, to, support.
* The ideas identified by the study have been grouped into
sections, so that they cover different aspects of reorientation
- different issues - different tasks.
* Ideally the resource manual could be an adjunct to the group
discussions and group work of a team of the faculty, who form
part of a for.aal or informal medical education cell of a college.
Issues and ideas suggested in the manual could be taken up and
the Materials provided used as baoKgromid reading and background
stimulus.
* Some tasks have been identified in each section or whenever/
wherever it is relevant.
Many other tasks could be evolved by
the group itself.
* The format of the manual is a file with information and ideas
in loose leaves.
The faculty team are advised to make their
own notes, include additional reference materials, modify or
update the section in any -way and as they require.
The manual will have three volumes
*
The. first is the current
volume which will include 5 key areas for reorientation :
.
a) Exploring Expert Prescriptions
b)
Lessons from History, Culture and Tradition
c)
Medical College innovations and experiments
d)
Exploring new horizons
e)
Studying the pace-setting innovations that have
relevance for the 1990's
The second volume is a detailed report of the 'graduate survey'
which was part of the study and which apart from the scientific
report of the study and its findings will provide all the key
ideas and suggestions from the graduates for reorienting
teaching in each of the subjects,ztaught in the Existing course
as well as about a wide range of related issues and aspects of
the curriculum. ■
.
The third volume which focusses primarily on the contribution
of trainers from outside the medical college sector will focus
on Laying the New Foundation for an alternative medical education
by
i) Exploring the links between Medical Education and
society and hence ■understanding the social/societal
context in which change has to take place.
ii) Explore the alternative pedagogy, ideas, content and
methodology of trainixig in'’the .alternative training
sector in India which helps trainees to locate their
action and efforts in a broader community/societal
framework.
The final, format of the first two volumes' is■being released at
this Me’dical Educators Review Meeting in Bangalore in June 1992
to get your ideas,iviews and opinions on the areas/issues covered
and to get any suggestions or feedback,that will-help us to
prepare the trial copies.
We hope that in the months ahead these trial copies will be used
by a certain number of faculty teams to undertake certain common
group tasks and exercises and provid'd 'a "feedback on the contents
and presentation of the manual. •’
'''
...
This trial phase will lead to many ideas, modifications, alter
ations and additions to the volumes of the manual and will greatly
help to ensure that when it is finally’"publi shed by early 1993., it
will be in a format for easy and more meaningful use by a wider
cross section of medical college faculty in the country.
Tne Faculty Resource Manual (three .volumes) will be complemented
by three other publications from the project,
a) Stimulus for Change
An annotated bibliography of 40 key titles around the theme
of the project.
142.
b ) Step by Step
An anthology of all the earlier initiatives towards an
appropriate medical education by the researchers bofohe
the project was initiated.
c) Evolving a Process
A detailed project report on the two year study.
V 0 L U I-l
-
E
I
This volume is divided into four sections.
'
Section I
This section provides the introduction to the manual and some
ideas about how to use it; the areas it covers; short descri
ptions of the sub-units; approaches and planslimitations of
use; format and arrangement; and other relevant background
information.
Section II
Introduces the need for strategies of.social relevance and
community orientation in medical education by bringing some
real life case studies of the challenges of health, care in
rural, tribal and urban slum situations in the country and then
provides a situation analysis and comprehensive overview of the
challenges in training of Doctors for India.
Section III
* •
'
.
This section brings together all the ideas, issues, innovations,
experiments identified by the- study organised into 5 broad sub
sections. A to E with multiple subuni,ts in-each subsection that
focuses on different issues,, groups of ideas or themes.
The detailed content list of .this section follows
Section IV
This section includes a bibliography of all the Key reports,:
articles, publications reviewed by the researchers and presents
them in an alphabetical order with a supplementary subject index
as', well.
*■ ’
The bibliography covers-over 300 references.
■<
. . 143
S E C T I 0 N
III
A-
An Anthology of Expert Recoimaandations on Medical
Education in India
A-1
A-2
A-2.1
A-2.2
A-2.3
A—2.4
A-2.5
A-2.6
A-2.7
A-2.8
Introduction
Background on expert committees/organisations
Shore Corm'iittee (i
Mudaliar Committee (1961 )
Patel Committee (1968)
Srivastava Report (1974 )
ICSSR/lCilR - Health for All study group ( 1981 )
Rational Education Policy in Health Sciences (1989)
Medical Council of India ( MCI )
The Indian Association for Advancement of Medical
Education (lAAME)
A-3
The Expert Prescription
A-3.1
What's wrong with Medical Education
A-3.2
Type of Doctor
A-3 *
3
Objectives/aims of medical education
A-3•Learning objectives for undergraduate medical education
A-3.5
Recognition and control of colleges.
A-3-6
Pre-medical education
A-3.7
Admission requirements and selection criteria
A-3•8
Duration of Course
A-3.9
Coeducation
A-3-10 Medium of instruction (Debate)
A-3.11
Modical curriculum ; Overall principles
A-3.12 Medical curriculum ; The challenge before medical education
A-3-13
Medical curriculum ; The new focus of education
A-3•14 Educational strategies
A-3.15 Nature and organisation of Teaching Hospital
A-3 • 16 Nature and organisations of community centres for teaching
A-3.17 Pre-clinical phase
A-3.18 Additional programmes (Pre-clinical )
A-3.19 Para-clinical phase (Phase II)
■•
A-3.20
Clinical Pjiase (Phase III)
A-3.21
Preventive and Social Medicine (Community Health)
A-3-22 Integration
A-3.23
Examinations
A-3.24 Internship
A-3.25
Teachers - selection/development
A—3 * 26 Research - General
A-3.27
Modical College facilities
A-3.23
General Practitioners
A-3.29
Students Health
A-3.30 Electives
A-3.31
Amenitios/lncentives for hural Work
A-3.32 Image of a doctor at the PHC's
A-3.33
Continuing Education
A-3.34 National System of Medicine and integration with ISM
A-4
Some major thrusts and approaches
A-4.1
Training of Basic doctor in Preventive Medicine and
Public Health (Bhore Report 1946)
Preventive and Social Medicine — Building the outline
and framework (Carl Taylor - -1955)
Tho Field Internship'(Carl Taylor - 1955)
Medical colleges and Health Services (Kartar Singh
Report,1974)
,
A—4.2
A-4.3
A-4.4
A-5
Medical Council of India - Reconii.iendations
A-5.1
A-5 • 2
A-5-3
The MCI 1982 curriculum - An overview
The evolution of MCI recommendations (1964 to 1982)
Co.mjunity/clinical orientation in Pre-clinical phase
Curriculum in Fa..iily Planning
Compulsory Rotating Internship (Rural Training)
A-5.5
A-6
Milestones in Medical Education
(key meetings and initiatives of IAAME, and others)
A-7
Key sources and background materials
B-
Lessons from History,
B-1
Why study History and Culture of Medicine (H.Sigerist)
3-2
3-2.1
B-2.2
B-2.3
B — 2.4
B-2.5
3-2.6
Ancient and Medieval India
Characteristic features of Medical Education
The Oath of Professional Conduct (Athroya)
Ethics of Professional conduct (Ayurveda)
Qualities of a Physician (Unani)
Instructions to students (unani)
B-3
B-3.1
Advent of Western Medicine
Lessons from this phase
Culture and Tradition
Introduction
Lossoiiij
£x'om
pHhdo
B-4.1
3-4.2
Nationalist and post independence phase
(from Sokhoy to Srivastava)
Lossons from thia phase.
.
.
National orientation to health Care (ICSSR-ICMR,
3-5
References and additional reading
C—
Medical College - Innovations and Experimentations
C-1
Introduction and oyerview
C-2
C-2.1
C-2.2
C-2.3
C-2. 4
C-2.5
C-2.6
Pacesetters of Change
The Vellore Model
Training in AIIMS
The Sevagram model
The St. John's Initiatives
The JIPMER experience
The CMC-Ludhiana experience
C-3
C-3.1
C-3.2
C-3.3
C-3.4
C-3.5
C-3.6
Initiating change in the 'mainstreamers1
N.H.L.M.C. Ahmedabad
Rangaraya Medical College, iCakinada
T.1I. Medical College, Bombay
Medical College, Kottayam
The Rohtak experience
Innovations in KMC, Manipal
c-4
C-4. 1
C-4.2
C-4.3
C-4.4
C-4.5
C-4.6
C-4.7
C-4.8
Evolving Objectives
Objectives of AIIMS, New Delhi
Objectives of IIGIMS, Sevagram
Aims and Objectives - SJMC, Bangal«ie
Objectives at CMC-Vellore
Institutional Objectives - IJ.H.L.M.C., Ahmeda ad
Instructional Objectives - AIIMS
,
fiTTMql
Instructional Objectives - RFPA - 7/
1 ®
p
\
Instructional Objectives - Pharmacology (BJMC-Pune)
B-4
'
1981 )
C -5
C-5.1
C-5.2
C-5»3
Selections/Admissions
....
Criteria for Admissions in Medical Colleges in India
- Selection/Reservation - An overview
Interviewing Philosophy and procedures (SJMC-Bangalore)
Interviewing Philosophy and procedures (CMC-Vellore)
C-6
C-6.1
C-6.2
C-6.3
C-6.4
C-6.5
Faculty Development
The Natioiial Teacher Training Centres
Faculty Development (JIPMER, IMS-BHU, AllMS) •
Teacher Training Programme ( KMC-Manipal)
Education Technology Group (IJHLMCAhmedabad )
Staff experience in peripheral hospitals
(CMC-Vellore)
C-7
C-7.1
C-7.2
Examination Reform
Objectivised Assessment System (AIIMs)
Restructuring assessment towards HFA/PHC (JIPMER.)
C-8
C-3.1
k
C-3.2
C-8.3
Electives and Research by Students
The Role of electives and participation of Students
in Research Projects
Exposure of Undergraduate students to research (VHO)
Health and Society - Reflections on a Travel elective
C-9
C-9.1
C-9.2
C-9.3
C-9.4
C-9.5
C-9..6
C-9.7
C-9.8
C-9.8.1
C-9.9
Pre-clinical phase initiatives
Rebuilding Pre-clinical Foundation (CHC, Bangalore)
Short Study Skill Course for Mew Entrants (VMMC, Solapur)
Foundation Course (CMC-Vellore )
Cliniqal Orientation in Pre-clinical Phase (KGMC, Lucknow)
Behavioural Science Teaching - A plea
Behavioural Sciences - suggestions for curriculum content
(A compilation)
Samaritan Medicine (CMC-Ludhiana)
Rural Orientation Camps - An outline (SJMC, Bangalore)
Go to the People - Learn from them ( SJMC, Bangalore)
Community orientation pro gramme (CMC-Vellore)'
C-9.9.1
Attitudes - evaluation form (CMC-Vellore)
Post Community Orientation Programme - Evaluation
(CMC-Vellore)
C-9.10
Community Oriented Training Programme (PSG, Coimbatore)
C-9.10.1 Community Orientation Programme - Evaluation (PSG,
Coimbatore)
C-9.11
Integrated teaching of growth and development AU MS, Mew Delhi - a manual
C-9.9.2
Par^-clinical Phase initiatives
Reorienting Pharmacology Teaching - An overview
Reorienting Teaching of Pharmacology (BJHC, Pune)
Synchronised lecture programme of Pathology, Pharmacology
and Medicine (1JHLMC, Ahmedabad) .
■
'
.
. - • t..
C-11
Preventive and Social Medicine Teaching
C-11.1
Fa.aily Health Advisory Service (LHMC, New Delhi)
C-11.2
Integrated teaching of PSM with para-clinical/clinical
departments (a suggestion)
C-11.3
Family Health Care Exercises (aIIMS, New Delhi)
C-11.4
Training in Epidemiology (LHMC, Hew Delhi)
C-11.4.1 Training in Clinical Epidemiology/Health Economics/
iianagerial Skills ( CMC-Vellore )
C-1 1.5
Community Block Posting - I Clinical Year ( CMC-Vellore )
C-11.5
1
*
Health Planning Exercises (CMC-Vellore)
C-11.6
Community Block Posting - II Clinical Year (CMC-Vellore )
C-11.7
Beyond PSM - A Community Health Experience (SJMC,
Bangalore)
C-10
C-10.1
C-10.2
C-10.3
146.
Integrated Teaching
Objectives of integrated teaching - An overview
Integrated Teaching (Goa Medical College)
Integrated Course of Human reproduction/ Family
Planning and Population Dynamics (sVMC, Tirupati )
C-12.4
Integrated Teaching (SVMC, Tirupati)
C-12.5
Human Sexuality Course (MC, Nagpur)
C-12.6
Integrated Training in Leprosy (An approach)
C-12.6.1 Training of UG's in Leprosy (GMLF/MCI Workshop)
C- 12
C-12,1
C-12.2
C-12.3
C-1J
C-13.1
C-13.2
C-13-3
C—13
4
*
Q-13>5
C-13.6
Clinical reform
Priority listing in clinical teaching (NHLMC, Ahmedabad)
G.O.P.D. (MGIMS, Sevagram)
Extra mural postings (CMC-Vellore)
Training in Emergency Care (JIPMER)
Student Clerkship - Medicine, Surgery, Paediatrics(.CMC,
__:j
Integrated teaching of MCH (WHO, SEARO)
Vellore)
C-14
0-14.1
Mobile Rural Hospital Scheme
Mobile Rural Hospitals - Rohtak experience
C-15
C-15.1
C-15.2
C-15.3
ROME Scheme - Guidelines
ROME Scheme - Evaluation
Implementing ROME (lottayau Medical College)
Implementation and Evaluation of ROME (Goa Medical College)
Internship Programme
Integrated Orientation Programme (JIPMER, Pondicherry)
Interns Orientation Programme Plan (G14C, Bombay)
Community Health Postpngs-(CMC-Vellore) .
Rural Community Health Clinics (SJMC-Bangalore)
Training interns in integrated GP Unit (BMC, Baroda)
Interns and epidemics (NHLMC, Ahmedabad)
Interns and Health Education (TNMC,; Bombay)
Ct16.7
Internship Evaluation (CMC-Vellore)
C-16.7.1 Internees Assessment Proforma (SVMC, Tirupati)
■ C-16.8
Other aspects
'
J
C-'.6
C-16.1a
C-l6.1b
C-lo.2
C-16.3
C-16.4
C-16.5
C-16.6
Exploring New Horizons ■
.
D-1
D-2
D-2.1
D-2.2
•
D-2.3
/
Introduction
■
Management in Health Care
Management Training needs of MO of PHC (1TIHFW, New Delhi)
Management concepts in Medical-1 Education (NTTC, JIPMER)
- Workshop recommendations
lianagement Training in Medical Colleges (MIHFW, New Delhi)
- Trivandrum Workshop recoiuaendations
D-3
D-3 • 1
D-3.2
Educatipa for Health
Learning- made Easy (TNMC, Bombay)
Health Eiucation in UG Medical Education (CHEB, New Delhi)
D-4
D-4.1
D-4.2
Medical Ethics
c
Teaching in Medical Ethics (SJMC, Bangalore) • ."
Ethical issues in Medidine - An opinion survey
(NIMHAHS, Bangalore)
Current problems.in Medical Ethics (a listing)
Medical ethics, medical malpractice and Patients
rights (mfc, Bombay)
D-4.3
D-4.4
' '
D-5
. .. . Mental Health
D-5 • 1
-Teaching methodology of.Mental Health to UG Medical
Students (AIIMS, Hew Delhi)
D-5.2
Training undergraduates in Psychiatry (NIMriANS, Bangalore J
D-5.3
Mental Health - Time table for a short course (NIMHAHS,
Bangalore)
1
D-6
D-6.1 .
D-6.2
■ D-6.3
•
’ D-6.4
D-6.5
D-6.6
Rational Therapeutics ■’
..... •
Components of art educational programme ■ on Rational”Therapeutics - A check list.(CHC, Bangalore).
Rational Drug Use (CHC, Bangalore)
'
A to Z of Drag-Policy issues and Problem Drugs
(CHC', Bangalore)
' '
•" !?
" '•
Rational Drug use in Medical/pharmacy Education, .
(lOCU Consultation)
Essential Drugs and Rationalised' Drug Use - Objectives
of teaching (NTTC, JIPMER)
J 1
Improving therapeutics■through an ADR Monitoring ”•
Centre (CMC-Vellor’e)’
•■}
D-7 '
*
D-7
1
D-7.2
Alternative Systems of Medicine
’ ■'< . t
Situational .Overview (mfc)-.
... ' .
■
', y .
Curriculum plan for an \input.on Alternative Health
Care' Systems (CHC/sJMC, Bangalore)
E-
Setting the-Pace for the 1990's
E-1
Introduction.
'
. ’
'
Pioneering . Efforts - Pre- 1980
■«
Doctors for the villages - An internship study" on
7 colleges
'
E-2,2
For a new pattern of rural medical education-Some Guidelines
E-2,3
The Kottayam experiment
E-2.3.1
Curriculum development
.
E-2.3.2 The curriculum '
E-2.3.3 Doctors or Health Educators
E-:2.3 .-4 Health Awareness and'Health Science
E-2.4
The ROME experiment - an overview
E-2.4,1’ A Study of ROME Programme (dNUj .
E-2
E-2.1 ■
E-3.
E-3.1
-' E-3.2 . ' E-3.3
E-3.4
E-3.5
E-3.6
Recent Policy Statements
The National Health Policy (1982/83)
. Health for All by 2000 A.D. - Working Group (1981 )
The New Education Policy (1936) •
The Revised Education Policy.(1939 )
A perspective plan for-2001 A.D. oh -role of Science
'
and Technolb'gy (1939)
:
‘
,
The Eighth plan Document - Sector: Health
(1990)
E—4
E-4.1
A Plea for a now Public Health (JNU ) .
Crisis in the Medical Profession in India (D. Banerji)
‘ e-5
E-5.1,
The Community Health Trainers of--the Voluntary Sector
A Statement of Shared Concern and Evolving Collectivity
(c.H. Traihers' Dialogue - October 1991 )
E-6
E-6.1
E-6.2
The mfc Anthology of Ideas
The medico friend circle manifesto
The Alternative Curriculum
E->7
E-7.1
The Health University Development
University concept of medical and health education
E-8
Emerging Networks
' E-8,1- ... ....The Alternative Track (1933)
■
■
"E-3.2
The CShsortium.of Colleges (1937)
(inquiry, driven strategies)
E-8,2.1
Synopsis’of curricular deficiencies
E-8.2.2
Curriculum reforms at consortium institutions
»
E-8.2.3 Block Posting for Community based training (CMC-VelloreJ
E-8.2.4
E-3.2.5
E-8.2.6
E-8.2.7
E-8. 2.- 8
E-8.2.9
Core Abilities (iMS-BHU)
Introduction of Problem beaming (consortium)
Introduction of Management Concepts (consortium)
Integrated Health Team Concept (Consortium)
Clinical Clerkship (consortium)
''
Introduction of Behavioural Sciences (Consortium)
E-8.3
Strengthening Epidemiological Skills
E-9
E-9.1
E-9.2.1
E-9.4.1
E-9.4.2
The CMC Network
’
f
The CMC Network - ( 19^9) .
.
The Vellore model of Community Oriented medical
education (MGR University Workshop)
.
The Challenges of Continuing Education (CMC-Velio re )
Education in.CMC - Themes and Styategies'in tho 90
s
*
CMC-Ludhiana - Process of voluntary incrementalism
Child survival through a slum, health and development
project - a multj. disciplinary training module
(CMC-Ludhiana)
The Miraj Proposal (CHc)
The Miraj Manifesto (MMC-MiraJ) - ■
E-10
E-10.1
E-10.2
E-10.3
E-10.4
Reorientation of Medical Education - SEARO efforts
Towards the New poctor
Obstacles to Change
’■
Goals Areas and Direction for'- SE Asia Region
Targets in Educational Programme Reform .
E-11
E-11.1
The Network of community Oriented Heal ch Scl'enqes
Institutions (*
979)
Lessons from ths Network (A.report)
E-12
E-1 2.1
E-12.2
The Edinburgh dEpnf'orenjcxj - An over view .
The Edinburgh Declaration
■
- ■
The Edinburgh Declaration - The questions asked
E-13
Education for decentralised Health Care (CHC,
E-1 4
References and further reading, on recent developments
E-15
A WORD OF CAUTION
'E-9.2.2
E-9.2.3
E-9 .3.1
E-9.3.2
.
'
Bangalpr
"
A teacher can novar ..frilly teach unless
he is still learning hfmseIf'.
4 lamp
c.an'
never light another lamp unless, it continues
to burn its cwn flame'. The teacher who has
come to the end. of his subject, who has no
living traffic with his own knowledge, but
merely repeats his lesson to his students can only load their minds.
He/‘cannot
quicken then.
Truth not only- must inform,
but also must ^inspire. If the inspiration
dies out, and the; information only
accumulates, then truth loses its
infinity.
'
J ■'
Rabindranath Tagore
14 9
APPENDIX
"I"
AN ADDITIONAL READING LIST
AN-01 Srivastava Report (1974)
AN-02 Health For All - An alternative strategy-ICSSR/lCMR(1981)
AN-03 MCI Recommendation on Graduate Medical Education (1982)
AN-04 National Health Policy (1982)
AN-05 Recommendations of Health and Develooment Committee
1943-1975, CEHI (1985)
AN-06 Medical Education in India - CEHI Directory (1986)
AN-07 Draft National Education Policy Baj aj J.S. et al (1990)
AN-08 Health Education in Medical Curriculum - CHEE (1979)
AN-09 Primary Health Centre Training Guide - Part I, M.HFW (1980)
AN-10 Handbook for the MCH in a Community Development Dhillon E. et al (1983)
AN-11 Manual of Mental Health for Medical Officers Isaac, M.K. et.al (1985)
AN-12 Child Health and Manpower 2000 AD - IAP and WHO (1987)
AN-13 Undergraduate Medical Education in Mental Health,
NIMHANS (1988)
AN-14 Concepts of Essential Drugs and Rationalised, NTTC (1989)
AN-15 Teaching Community Medicine, CMC Aporcach, CMC-Vellore
(1990)
AN-16 Inquiry Driven Strategies - An Indian Consortium (1991)
AN-17 Health and Family Planning - Multidimensional Analysis
- Eanerji, D. (1985)
AN-18 Medical Education - Radical Journal of Health,
March 1989, No.4.
AN-19 Medical Education Re-examined, Medico Friend Circle (1991)
AN-20 Medical EducationzWhere does it lead - Health Action,
June, 1991.
AN-21 Monsoon: A Simulation Game, SEARCH Publication (1981)
150
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