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MEDICAL EDUCATION IN INDIARAJKUMARI AMRIT KAUR, M.P.

I have been a social worker all my life and tenyears of office as Minister for Health in India havegiven me tangible experience in this particularsphere of service, an experience which has greatlyenriched my life.

Since a high standard of health is a nation'sgreatest asset, and since the responsibility ofserving in this field falls on the shoulders of themedical world, the education of doctors and othermedical personnel is of the utmost importance.Medical education therefore is today a subjectwhich requires serious and earnest study by allnational and international organisations, as alsoby individuals with a wide range of experienceas teachers and research workers and by distin-guished exponents of the science and art ofmedicine. Any views that I express will, I trust,be viewed with tolerance by experts. They arein the nature of an assessment of the trend ofprogress in the field of medical education in India,drawn from the experience referred to above andstrengthened and illumined by close associationover many years with experts, both foreign andIndian, in this field.

The Purpose of Medical EducationIt is conceded by all that the purpose of medical

education is to produce doctors who will be ableto undertake successfully not only the preventionand treatment of disease, including rehabilitationas far as possible of those incapacitated by variousforms of sickness, but also the promotion ofpositive health whereby the range of man's enjoy-ment of life is expanded and his usefulness to thecommunity strengthened and rendered moreeffective. The medical educator must perforceunderstand the needs of the people. The morecorrectly he is able to envisage the prospectivegrowth of health needs in the community, themore purposeful will be his planning of the pro-gramme of medical education and its translationinto practical action directed towards the pro-duction of the desired kind of doctor.

The Expanding Role of Medicine andSelection for Medical EducationThe role of medicine has been enlarging con-

tinually and a wide variety of specialisations usefulto medicine has therefore grown up over theyears. Apart from doctors who became generalpractitioners or specialists in particular branchesof the healing art, we find others increasinglyinterested in the physical and biological sciences.Advances in these sciences have a direct bearingon the growth of medical science and research.Further, as man's ill-health and well-being arelargely influenced, not only by his physical andmental equipment but also by his social andcultural environment, the social and behaviouralsciences, even though their processes of investiga-tion and of quantitative expression of results maytoday lack precision to the extent attained by othersciences, are becoming increasingly utilised bymedicine to study and deal with the patient inhis social setting as well as to interpret problemsof disease and health as community phenomenato be tackled progressively on a scientific basis.The quantitative approach that is needed formedical studies of all types, whether they be inthe laboratory or in the wider field of communitylife, has brought to the forefront the need fordoctors to learn the elements of statistical science,so that they may bring to the tasks which facethem some knowledge of the methods of reasoningand of the process on which scientific data are tobe collected and analysed. With the conquest ofcommunicable diseases and control over man'sphysical environment, which science has madepossible, a study of the role of heredity in thepropagation of defects and of ill-health is gaininggreater prominence and must begin to receiveincreasing attention, if the steady rate of successfulprogress in combating disease and in promotinghealth is to be maintained and accelerated.Medicine and genetics must therefore collaborateto a growing extent to achieve these results, andthe future will no doubt see that genetics becomesanother field for specialisation for medical men.

The Special Needs of IndiaThis expanding task of medicine in promoting,

along with other sciences, a steady advance on abroad front towards a progressive realisation ofimproved health and working conditions for all

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October I960 KAUR: Medical Education in India 593

mankind is one which India will undoubtedlyshare with other countries to an increasing extentin the coming years. Nevertheless, there are todaycertain urgent needs of India which differ fromthose of the more advanced countries and ournational programme of medical education mustmake provision to meet those needs. For example,there is the field of undergraduate training andits reorientation, there is the emphasis which hasto be laid on the preventive aspect of medicine,there is the problem of promoting a rapid expan-sion of medical personnel without producing anundue loss of quality in the training programme,there are the preparation of the prospective doctorfor rural health work and the creation of conditionsduring the training period calculated to developin him a social outlook and a spirit of dedicatedservice to the people.

Although this article is intended to deal withmedical education and not with the problems ofemployment of doctors after their training, itcannot be too strongly emphasised that the twoare closely inter-related. India being a land ofvillages, a rural bias in the curriculum should beencouraged so that our young doctors may earlyhave some experience of work in villages. More-over, the production of doctors, unless it is linkedwith adequate opportunities for gainful employ-ment, will create an extremely unsatisfactorysituation, of which there is abundant evidenceeven today due to an unhealthy concentration ofdoctors in the urban areas. While the needs ofthe rural population are undoubtedly the mostimportant factors to reckon with in a nationalprogramme of medical care, inadequacy of pro-vision to make rural medical service sufficientlyattractive has resulted in making it difficult to filleven existing posts under the present schemes forexpanding medical relief to the inhabitants of ourmore than half-a-million villages. Our citiesprovide a lucrative practice to those who are atthe top, but there is a large and growing numberof others for whom the prospect is one of con-tinuous struggle through a process of severe com-petition, which often leads to a lowering of thestandards of professional performance and aneglect of professional ethics. Under our presentconditions, adequate medical care to the peoplecan be organised only on the basis of a broad-based system of provision mainly from publicfunds. Our rural communities are too poor andtoo sparsely distributed to give much financialsupport towards a medical service of a reasonablyhigh level of quality. Even in urban areas, theproportion of those who are just at the sub-sistence level and of others at the sub-subsistencelevel is so great that the State must take the majorshare in the organisation of health protection to

these people. Moreover, modern medicine, whileit has become tremendously effective in curingdisease and in rehabilitating the sick, has alsobecome exceedingly costly from the point of view ofthe equipment, trained personnel and otherfacilities required by a group consultative practicefor its successful functioning. When even anadvanced country like Great Britain has found itnecessary to establish and maintain a NationalHealth Service, which offers to the people medicalcare on a broad basis at a minimum cost to theindividual, it seems to me obvious that in Indiathe goal must be the same as that of GreatBritain, even though for financial and otherreasons it may not be possible for us to reach itexcept by successive stages of planned develop-ment.

If the accepted objective is to fit the prospectivemedical practitioner into a national scheme ofmedical service to the people, properly organizedand developed at various levels territorially andwith reference to the different types of servicesthat are to be rendered, then the scheme ofmedical education will acquire a meaning and apurpose which may be somewhat different fromthat of just producing doctors who will providemedical care to the people on a purely contractualbasis between the practitioner and the patient.

Emphasis on Prevention in the TrainingProgramme

In the progressive countries of the West thecontrol of communicable diseases has been estab-lished to a remarkable degree and a high level ofenvironmental hygiene has also been attained bothof which have contributed to a large extenttowards reducing the rates of incidence of suchdiseases. The result of such control over in-fectious diseases has been to prolong the life ofthe people in a manner undreamt of in the pastand the disease pattern in the community hassimultaneously undergone a change, giving promi-nence to cardio-vascular-renal conditions anddiseases like cancer. In India the picture of ill-health among the people is different, infectiousdiseases still playing a predominant role incausing morbidity and mortality.

Control of infectious diseases and the preventiveaspect of medical practice should therefore receivespecial emphasis in India. In the wide ruralareas of the country a combined preventive andcurative medical service can alone meet the needsof the inhabitants. Therefore the training pro-gramme for the undergraduate must be so designedas to equip him for this dual function. The role ofthe department of Preventive and Social Medicinein the training of the medical student is one of

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paramount importance in India, as indeed in allAsian countries.

Until recently the teaching of preventive medi-cine had confined itself to environmental hygiene.This is of course an important subject, but whilethe doctor should have some acquaintance with theproblems of providing a sanitary environment forthe community, the main tasks in that directionare really the responsibility of the public healthengineer. The doctor should be concerned indealing with the preventive aspect of disease withproblems of two types, namely, those relating tothe individual patient and those which relate tothe community. As regards individual patients,the preventive outlook demands of the doctordiagnosis of the condition of ill-health at theearliest possible stage, a speedy application ofappropriate measures, promotion of the conserva-tive methods of remedial care as far as may bepossible and the adoption of measures designedto facilitate the rehabilitation of the patient so asto enable him to retain his working capacity andability to enjoy life unimpaired to any great extent.In relation to the community the doctor should betrained to take all the necessary steps to preventthe spread of infectious diseases from the patientto others. Such measures may include appropriateadvice to the members of the family of the patient,enforcement of segregation of the patient wherenecessary, immunisation of those who are likelyto be exposed to infection and such other steps asmay be deemed desirable in respect of individualdiseases. Unfortunately, it is all too commontoday that a doctor called in to see a patientsuffering from enteric concerns himself mainlywith the treatment of the patient without recog-nizing that the preventive duties his professionenjoins on him to perform are even more im-portant from the standpoint of the communitythan the saving of the life of a single person.

Disease and health cannot be properly under-stood and assessed without considering the indi-vidual in relation to his total environment, physicaland social. An essential part of the teaching pro-gramme for preventive medicine should thereforebe to acquaint the student with the home condi-tions of the patient. In providing for such oppor-tunities he should be as much under supervisionand guidance as he would be when dealing withpatients in the wards. The programme of homevisits should be carefully prepared and the studentshould normally be accompanied by a trainedmedical social worker. Further, it will be usefulif, as occasion demands, the student is accom-panied by a professional member of the Depart-ment of Preventive and Social Medicine, a memberof the staff of the ward to which the patient has

been admitted, or a specialist such as a psychiatristor a paediatrician.

In the college and hospital there should be thefullest possible collaboration between the Depart-ment of Preventive and Social Medicine and otherdepartments. The main responsibility for theorganisation of teaching communicable diseasescan be taken over by the Department of PreventiveMedicine. But it is always an advantage if theteaching programme is itself made a collaborativeeffort between departments as has been stressedby the General Medical Council of the U.K.For instance, in dealing with typhoid fever, theDepartments of Medicine, Microbiology, Pharma-cology and Preventive Medicine may all take part,so as to present to the student a compositepicture of the disease including its causativefactor, the modes of spread, clinical signs andsymptoms, complications, the action of drugs anddifferent forms of treatment as well as the measuresto be taken to prevent the spread of the disease.The department of Preventive and Social

Medicine stands to gain considerably by closecontacts with clinical departments. The clinicaldepartments too will have their horizons widenedby opportunities to participate in visits to thehomes of the patients. These visits should helpto emphasize the fact that, in seeking to under-stand the natural history of disease and in pro-moting measures to cure the patient and torehabilitate him, it is wrong to isolate him fromhis environment and consider him as the victimof a number of specific pathological conditions.

The Problem of Quantity versus QualityThe number of medical colleges in India has

grown at a rapid rate during recent years. Withina period of less than fourteen years the numberhas risen from I7 to 52. This expansion has beenin response to the rising demand for medicaleducation which is today so great that those whoapply for admission constitute three or four timesthe total number of vacancies that are available.The rapid increase in colleges, however urgentand imperative the need, has been accompaniedby grave dangers in respect of the standards oftraining that are essential. A fall in standards hasbeen promoted by a variety of causes, of whichsome of the more important are the following:

i. Inadequate preparation of the entrant formedical training.

ii. Insufficiency of facilities for training, in-cluding accommodation, equipment and staff.

iii. Unattractive scales of emoluments and condi-tions of service, which fail to secure andmaintain teaching personnel of high qualityin a manner likely to enable them to devote

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adequate time and attention to teaching andresearch.

iv. The time lost in holidays and vacations,which reduces substantially the number ofworking days in the year; and

v. Examinations and the large percentage offailures in them.

This is by no means an exhaustive list, but thecauses mentioned above constitute importantfactors in lowering the standards of medicaleducation in the country as a whole.

General education up to matriculation is nowgiven in the regional language all over the country,English occupying only the status of a secondlanguage. At the university level the medium ofinstruction suddenly changes into English andthen the student often finds it difficult to followand understand what he is taught. Moreover,there is reason to believe that, with a large increasein the number of institutions for general educa-tion, there has been a definite fall in efficiency.A levelling up of general education in the pre-university stage is an essential step if the traineesfor higher education in the university, in scientificsubjects in particular, are to be brought up todesirable standards of proficiency.The rapid increase in the number of medical

colleges has been carried out, in some cases, with-out due regard being paid to the sufficiency ofaccommodation, equipment and teaching staff.In some cases, the number of clinical beds avail-able to individual students has fallen short of thedesirable minimum. The emoluments paid toteachers have generally been low and they havebeen permitted to supplement their incomesthrough private practice. In consequence therehas been a tendency for both teaching and researchto suffer. The view has recently been gainingground that every department in a medical collegeshould have a unit of full-time workers from theprofessorship downwards, so that this team maybe expected to become the *core from whichradiates a high level of performance in teachingand research. Financial and other difficulties havestood in the way of speedy attainment of thisobjective. It is however hoped that the trend willbe in this direction and that, in due course, themuch needed improvement will take place. Itmay be mentioned here that, in the All-IndiaInstitute of Medical Sciences, every teacher fromthe highest to the lowest is on a full-time basisand is not permitted to have private practice.

There is ample room for shortening the periodsspent on holidays and vacations and for lengtheningthe time spent in active study.

Examinations, the pressure they bring to bearon the students and the unduly large percentageof failures they produce are an unfortunate feature

of medical education in India, the ill-effects ofwhich need to be remedied at an early date.Proper and rigorous selection of students foradmission to medical colleges and a raising of thestandards of training through the process ofmaking up deficiencies in accommodation, equip-ment and teaching staff are essential. A muchsmaller teacher-student ratio than that which pre-vails at present is necessary to enable teachers topay more personal attention to individual studentsin the classroom, the laboratory and the hospitalward and a weeding out, at the end of the firstyear's course, of those who lag behind desirablestandards of performance is equally necessary. Itis understood that there is a tendency now inmedical colleges to give credit for class-workduring the courses and to take into account suchcredit along with the marks obtained at examina-tions in making a total assessment of each student.This is all to the good and a general aceptance ofthis procedure is much to be desired.

In spite of the difficulties that have had to befaced in expanding medical education, a fairamount has been done since independence toreduce the ill-effects, indicated earlier, of suchexpansion. For a period of three years a medicalscholarship scheme sponsored by the Governmentof India helped to provide postgraduate trainingfacilities for some two hundred persons selectedfrom different parts of the country. Later, inter-national organizations such as the specializedagencies of the United Nations, including W.H.O.and U.N.I.C.E.F. as well as the Colombo Plan,T.C.M. under the Bilateral Agreement with theUnited States and, above all, the RockefellerFoundation have helped to award annually fellow-ships for overseas training of Indians in medicine,nursing and allied fields. In the country itselfpostgraduate training facilities have been developedby the establishment of the All-India Institute ofMedical Sciences, the upgrading of selecteddepartments in medical colleges distributed overthe country so that they may serve as teachingand research institutions in special subjects forthe benefit of all the States, and the creation ofspecial centres like the Leprosy Institute inMadras, the All-India Institute of Mental Healthin Bangalore, and the Virus Research Centre inPoona to serve similar training and research pur-poses. There is also a scholarship programme forplacing students, who are carefully selected, in allthese centres of postgraduate medical education.

In the field of undergraduate training, underthe five-year plans the Central Government bearsa substantial share of the cost of establishing newmedical colleges in the States, is prepared to meetthe expenditure on the creation of whole-timeunits in individual departments of medical col-

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leges, has been giving grants for equipment tothese institutions and, through the Indian Councilof Medical Research, the funds of which arederived practically wholly from the CentralGovernment, has also been giving grants forpromoting research in medical colleges and forthe training of special teams of young researchworkers.

In this brief and rather perfunctory survey ofattempts to improve medical education and pro-vide facilities for research, I must not fail to giveadequate recognition to the magnificent role thatthe Rockefeller Fundation has played in this fieldduring the past forty years. In fact, if the wholeprogramme of health development in India overthe past dozen years is taken into account, thepicture that emerges is one of a closely linked,collaborative effort between India and the inter-national bodies mentioned earlier to reach out.toward an increasing fulfilment of the country'surgent needs in such diverse fields as the trainingof health personnel, control of the more importantcommunicable diseases and research into varioushealth problems, including those of environmentalhygiene.

Certain SuggestionsWhile making this survey of what has been

attempted in the past, I do not want to minimizein any way the importance of taking stock of thesituation and of forming an unbiased and inde-pendent assessment of achievements and of thedeficiencies which have to be made up. I feelthat such an assessment may with advantage betaken up by the Health Survey and PlanningCommittee, which was recently established by theCentral Government under the distinguishedchairmanship of Dr. A. L. Mudaliar, than whomI can conceive of no one more suitable for thisonerous and important post. I have no doubtthat, under his guidance, the Committee will giveconsideration to all the more important problemsassociated with medical education in, India.Nevertheless I venture to put forward certainsuggestions in the following paragraphs which Ifeel should not be lost sight of when the Com-mittee applies its mind to this subject.

It has already been stated that medical collegesare springing up. with a rapidity which seems todefy the organization, on a sound basis, of thenecessary resources which alone can enable theinstitutions to function properly. In the absenceof an adequate number of trained teachers newcolleges have been brought into existence byutilizing the services of medical men with noteaching experience or of retired persons, whoseavailability is based on the fact that the age ofretirement is generally 55. The question of

extending the retirement age of teachers at leastup to 6o years appears to be one of great im-portance, especially during this transitional periodof urgent need for more trained personnel andthe shortage of the requisite numbers.While the need for producing doctors in suffi-

cient numbers to meet the requirements of thenational health programme is no doubt urgent andimportant, it would be a terrible mistake to con-centrate on quantity to the extent of permitting asubstantial fall in quality. The matter is one ofconsiderable importance and I do hope that theCommittee will face boldly the task of puttingforward practical proposals for utilizing the funds,equipment and personnel that can be made avail-able in a manner calculated to promote the maxi-mum production of medical manpower withoutany loss of efficiency in the training that isimparted.

I hope the Committee will also give considera-tion to the problem of defining as clearly aspossible the relative roles of the Medical Council'of India and of medical education in regard to theestablishment and maintenance of desirable stan-dards. The Council and the universities bothhave statutory functions assigned to them in thisfield, and a harmonious growth of medical educa-tion will require a clear demarcation of theirrespective roles. The functions of the Councilwere originally designed mainly on the same linesas those of the General Medical Council in GreatBritain. In the changing conditions of India,rethinking on this matter is desirable. Moreover,it was pointed out during the Medical EducationConference in November 1955 that a broaderbasis than that now provided by the Council maybe desirable for the discussion and formulation ofproposals for promoting improvements in thetraining programme of the medical student andthat the teaching profession itself should be closelyassociated with developments in this field. Theestablishment of an Association of Medical Col-leges was therefore suggested. I feel that theseare all matters which may with advantage receiveconsideration.The University Grants Commission has been

developing, during the past few years, a pro-gramme of financial support to universities andto the institutions affiliated to them, for animprovement of their standards of education andfor promoting research. Medical education hasso far been outside the purview of the Commission.In view of the variety of problems to be dealt within the field of medical education, it is for seriousconsideration whether the creation of a body onthe lines of the University Grants Commissionwould be desirable.

Teaching is a specialised art, and in the field of

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general education, prospective aspirants for anacademic career are required to undergo a courseof training in teaching. Insofar as medicine isconcerned, this requirement appears to have beenignored not only in India but in other countriesalso. The All-India Institute of Medical Scienceshas as one of its important functions the trainingof teachers for other colleges in the country. Forlack of funds the Institute is still in the earlystages of development, but its early completionis of the utmost importance. The manning of ourmedical colleges with competent teachers andresearch workers will depend largely on the pro-vision of adequate postgraduate training facilities.Our expanding national health service requiresincreasing -numbers of specialists and consultantsin the different branches of the medical care pro-gramme. All these point to a stepping-up ofpostgraduate training facilities.

There is yet another important matter which,in my opinion, is vital to the proper developmentof medical educationi and research in India.The vast majority of our medical training and

research centres are maintained by the Centraland State Governments. Along with the financialsupport which Governments give there has beena growing tendency for governmental interferencein the working of these institutions. Medicaleducation with the need to promote its develop-ment on lines best suited to meet the needs of thecountry requires experimentation with new ideasand methods of training, and educational authori-ties are the best persons to discuss among them-selves the approaches to such innovations and toinitiate the necessary programmes of action. Thatis why I feel that a broad-based forum such asmay be provided by the suggested Association ofMedical Colleges would be welcome. Simul-

taneously a wide measure of autonomy must begiven to teaching and research institutions.Control exercised by governments through theirsecretariats proves more often than not to be notonly irksome to those in direct charge of suchinstitutions but also detrimental to their properdevelopment and functioning on sound lines. Thedeadening hand of precedent and of departmentalred tape may even help to kill initiative in theinstitutions, and their growth may become stuntedby the development of a tendency for those incharge of such centres to lean more on the judg-ment of lay administrative officers in governmentthan on their own initiative and independentviews. The killing of scientific initiative will bedisastrous from the point of view of the develop-ment of medicine as a science through researchand of establishing sound training methods forthe creation of future doctors.

Institutions, like individuals, can develop instature and fulfil themselves only in an atmosphereof freedom and of responsibility. I would urgethat there should be boards of high academictalent, including members of the staff of eachtraining and research institution and that, by adelegation of powers, these boards should beenabled to function with a wide measure ofautonomy. All academic matters, including thepromotion of research and the selection andappointment of employees in these institutionsand their disciplinary control should be vested inthe governing boards.

India has still a long way to go in every depart-ment of life. She has begun well in the field ofhealth and I do sincerely hope that wiser counselswill always prevail and that nothing, howevertempting, will be done to lower standards ofmedical education.

A Clinic for the diagnosis and treatment of Internal Diseases (except Mental or Infectious Diseases). TheClinic is provided with a staff of doctors, nurses, technicians, modern Radiological and Physiotherapydepartments.

The surroundings are beautiful. The climate is mild. There is central heatinvg throughout. The annualrainfall is 30.5 inches, that is less than the average for England.

The Fees are inclusive and vary according to the room occupied.For particulars apply to THE SECRETARY, Ruthin Castle, North Wales.

Telegrams: Castle, Ruthin. Telephone: Ruthin 66

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