What we knew all along (Part 2): Postgraduate admissions

The previous post on the TOI report on MBBS seats being barely exposes the tip of the iceberg. Here’s the next one:

The scam gets bigger, and more brazen as medical graduates embark on specializations that are necessary for a successful career.

The price this year for a post-graduate seat in radiology in most leading private colleges across the country is Rs 2 crore while in cardiology, gynaecology and orthopaedics are priced around Rs 1.5 crore.

We always knew that postgraduation seats were available for a hefty price. And if you had to succeed in your career, you had to get an MD or an MS after your name. The sad part is that a ‘plain MBBS’ is a nobody in Indian society today.

The main reason for such high rates is the dearth of seats for PG programmes. The average ratio of undergraduate (MBBS) seats to those for post-graduate is 100:29. In effect, nearly 32,000 doctors graduate from medical schools across the country every year, and the number of PG seats available to them is roughly one-third of the requirement.

Across India, there are 9,085 seats for clinical courses like cardiology, radiology, orthopaedics and gynaecology; a mere 662 seats for pre-clinical courses such as anatomy and physiology, and 1,303 seats in para-clinical programmes like pathology, micro-biology and forensic medicine. Of these, a large percentage are in private institutions which enjoy the freedom to charge hefty donations — which means, a bright MBBS graduate with no means to pay has few options.

Overall, less than 10% of the graduating medical batch gets PG seats through the general (government) pool. Most PG seats, in simple terms, are auctioned or sold to the highest bidder. It’s a system of exploitation that finds its eventual victim in the patient.

Another senior expert, who has held prestigious posts at the national level, says he has urged the UGC to hold centralized examinations like JEE for admissions to both MBBS and PG courses. “It’s a national shame to commercialize education. Besides, death of merit affects the quality of medical education. When money is paid, these colleges ensure that the exit is definite. The students pass, qualified or not,” he said

In a country which needs more doctors who will serve in rural areas and more family doctors; MBBS doctors are denied the prestige offered to their postgraduate counterparts. And in any case, being a general practitioner is far more difficult and requires a lot of ‘people skills’ than being a specialist is.

My own view is that general practitioners ought to be accorded more dignity, prestige and monetory benefits to attract more medical students to the profession. Look at the UK- they produce doctors in accordance with what they need. India’s strange policy means we have seats in specialities according to the number of guides. And quite obviously, the number of guides are more in subjects which are more paying. We need more community specialists than superspecialized doctors in medicine or surgery. Our needs assessment has never been done.

Until we treat MBBS doctors at par with postgraduates, this mad scramble for seats will continue.

India’s worst kept secret: Payment seats

Another tehelka style operation. This time by Times Now. Something we already knew. Just documented now for posterity.

It is a fact that merit takes a back seat in India. You can buy your way into becoming a doctor or an engineer. If you have enough dough to pay for your seat, your career is guaranteed.

Dhanya Rajendran’s report says it all (Watch) :

Less than a week after the Tamil Nadu state government put in place a system to curb the collection of capitation fees by private medical colleges, a TIMES NOW-Times of India joint investigation has caught the officials of two leading medical colleges demanding money to admit students.

In one of the most reputed deemed medical universities in Tamil Nadu, Sri Ramachandra University, the price of a seat here is anything between 40 and 75 lakh rupees. But we found out that is just the money to secure a seat. The advertised tuition fees of 18 lakh rupees is over and above this.

Now this is one of India’s worst kept secrets. And this is not the only college where this murder of merit occurs. These educational business places are in all the states. And yes, the people running them are bigshots- politicians, medical administrators, filthy rich people. With the right connections. Very influential and very powerful. Not very easily pinned down.

And we are all to blame. Not just the administrators in these colleges. The students and their parents who are willing to go any extent to secure seats are equal party to this ugly practice. And yes, we do know the kind of doctors that are being produced from these markets. What would you expect from a student who has paid so much for his education? Wouldn’t his first priority be to ‘recover’ that amount from his patients? Where does ethics, professionalism and transparency go now— out of the window, of course. My head hangs in shame. But till we accept this as a normal practice in society, I expect nothing to change.

The scourge of leprosy

“You are a leper!”, he screamed at me, “Don’t even touch my child! We will not eat anything prepared with your hands”. I looked up, first startled and then stunned, not knowing how to react (It sounded worse when said in Hindi). This was a graduate, net-savvy professional’s idea of a joke. I didn’t find it funny then. I still don’t find anything funny. What struck me was the viciousness and the vileness with which these words were flung at me.

No, I do not suffer from leprosy. I am afflicted with a skin ailment which causes the skin on my palms to thicken abnormally and then break up into painful deep fissures. But that is not the point. What if the ailment I have was actually leprosy? Wouldn’t that person’s reaction have been the same?

The whole issue is the insensitivity with which patients of leprosy are treated by society. The word ‘leper’ has become synonymous with being unclean. It is ridiculous in these times given that leprosy now has a cure and is just other infectious disease which can be treated. The disfigured hands and feet can be a thing of the past if the disease is diagnosed and treated early. But what cannot be cured so easily is the disease in our own minds.

The stigma of leprosy is hard to erase. Patients are ostracized and shunned by society and their own families. One patient summed it up like this, ‘We can endure losing fingers and toes, eyes and nose, but what we cannot endure is to be rejected by those nearest and dearest’.

I have seen an excellent effort at rehabilitation of patients of leprosy, at Anandwan in Warora in Chandrapur district. The dream village set up by Baba Amte continues to function even after his death. As a child I met him a couple of times. I always remember him saying “Work builds, charity destroys”. He used to shun charity and has taught thousands of patients to live independent lives with dignity. Each time I visit Anandwan, the cleanliness of the place never fails to catch my attention. And the beauty of their self sufficient enterprise is amazing- the grow their own crops, make their own furniture, weave their own cloth, print handicraft paper, create beautiful footwear, and grow lovely flowers. And you always come back ashamed of humanity when you hear how each person there was thrown out of their own houses and earned a life of respect at Anandwan.

As a pathologist, in a leprosy endemic area, I come across these cases regularly, and I can never forget my teachers telling me to label them ‘Hansen’s disease’ instead of leprosy. I don’t know how much of a difference the altered nomenclature made, but it is an indicator of how deep the stigmatization of leprosy has percolated. The way you teach medical students about leprosy also affects our mindset. My favorite teacher in dermatology used to take his patients into an area with bright sunlight and examine his patients carefully. And he did it with so much sensitivity. I remember overhearing a comment from one of my fellow students- “Look! He isn’t scared of touching his patients when he can avoid doing so.” There are these unsaid things– and my teacher was a perfect role model— teaching by example to empathize with your patients. Sadly, the same cannot be said of all medical teachers and doctors.

Health Education Library for People

I had a few hours to stroll around the station, before it was time for my train from Mumbai to Sevagram. And just outside CST station, across the road, I spotted a tempting sign saying ‘the largest collection of medical books’. And that is how I discovered HELP, which is an acronym for Health Education Library for People.

It is a small quiet place, but it houses around 10000 books all on various facets of medicine. I spotted some wonderful titles as I browsed through the organized shelves. I was amazed at the manner in which books ranging from topics as wide as Parenting, Death, Public Health and Gynecology were neatly laid out. The friendly librarian also came forward to show us the amazing audiovisual library of video and audio CDs and DVDs.

This library is the brainchild of Dr Aniruddh and Dr Anjali Malpani. It is a veritable collection of health related resources. And the unique fact is that all of the books are for the layman. None of them are medical jargon. Belonging to the medical field, I for once, wanted some of my favourite textbooks there. But I realized that the target audience was not medical personnel,but the common man. And the small but interested readers in the reading room of the library showed that the idea was working.

I also found that that HELP regularly organizes seminars and health education talks for people on topic related to health, healing, yoga, ayurveda etc.

A marvellous effort indeed. To find out more visit http://www.healthlibrary.com/index.htm where they also have a blog.

The address of HELP is:

Health Education Library,Excelsior Business Center, National Insurance Building, Ground Floor, Near Excelsior Cinema, 206, Dr.D.N Road, CST
Mumbai 400 001.

Timings: Monday – Saturday, 10.00 am – 6.30 pm.

DNB now equivalent to MD/MS/MCh/DM degrees

The Diplomate of National Board (DNB) degrees have finally been equated with MD/MS and DM/M.Ch for teaching jobs. The DNB degrees in broad specialities will be completely equivalent to the MD/MS degree; and the DNB degree in super-specialities will be equivalent to the DM/M.Ch degree.The latest notification from the Government of India can be downloaded from here.

The Union Ministry of Health and Family Welfare (MoHFW) and the Medical Council of India (MCI) were earlier in a standoff. The MCI guidelines were formulated by the Post-graduate Medical Education Committee (the PG Committee) constituted under Section 20 of the Indian Medical Council Act, 1956. It was on the basis of the recommendation made by the PG Committee in 1993 that the Government stipulated in October 1994 that for teaching appointments in broad specialities, a DNB degree holder was required to have at least one year’s experience as tutor/ registrar/ demonstrator, or an equivalent post, in a recognised undergraduate medical college. Similarly, for teaching posts in super specialities, a DNB awardee was required to undergo two years’ training in a recognised medical college with recognised post-graduate degree course in the concerned speciality. The Health Ministry had said that its Diplomate of National Board degrees will be treated on a par with the MD/MS and DM/M.Ch degrees awarded by Indian medical institutions for the purpose of all appointments including teaching posts in medical institutions.

Every year, there are about 25,000 medical graduates of whom 9,000 obtain MCI-approved post-graduate degrees and about 3,000 qualify with DNB degrees. But employment opportunities in medical institutions were significantly limited for DNB degree holders because of the MCI guidelines. There was also scope for at least doubling the number and also institute national programmes in areas where there is shortage of faculty. But the MCI directives prevented many institutions from offering their facilities for training DNB students.

While the Indian Medical Council Act only mandates the MCI to prescribe under-graduate courses and degrees, as well as approve the corresponding institutions offering them, it has only advisory and recommendatory powers as regards post-graduate courses and degrees. However, according to the NBE, the MCI had in recent years begun to impose guidelines for post-graduate education as well. These guidelines, as formulated by the PG Committee, rendered a whole cadre of DNB-qualified post-graduate medical students ineligible for teaching posts in medical institutions. This assumed authority, the NBE contended, went beyond the provisions of the Indian Medical Council Act.

The requirement of additional experience was reasonable earlier because DNB students did not do any dissertation for their degrees. But now since DNB students also have to do dissertations, there is no rationale any longer for insisting on additional teaching experience. Moreover, all over the world the paradigm of medical education has advanced and today it is integrated with clinical science.

In 2003, the MCI enumerated specific reasons why it could not accept the equivalence of DNB degrees with MD/MS and DM/M.Ch degrees. However, both the Government and the NBE find no merit in the MCI’s arguments and have rejected them. In August 2004, and again in September 2005, the MoHFW notified that institutions conducting MCI-approved post-graduate courses were also permitted to run DNB courses. However, in November 2005, the MCI unilaterally instructed all medical institutions to refrain from this practice without seeking the Government’s consent as required.

The National Board of Examinations (NBE) was established in 1975 with the aim of elevating standards of post-graduate medical examinations and ensuring uniformity across the country. The NBE became an independent autonomous body under the MoHFW in 1982. The Board has a system of accreditation of hospitals and institutions having adequate trained manpower and infrastructure for training students towards post-graduate and post-doctoral degrees of the Board.

Entry to the DNB programme is through a very stringent qualifying Central Entrance Test and an institutional-level speciality-specific aptitude evaluation. Qualifying for the degree is through an extremely rigorous evaluation both in theory and clinical knowledge in which the pass percentage is only about 30-35 per cent.

Medical experts say that, by enabling the large number of NBE-qualified post-graduate medical students to enter the country’s mainstream health care system, this move would help offset to a great extent the shortage of teachers in medical institutions that could arise as a result of the envisaged expansion. In fact, this shortage is in some sense artificial because the guidelines of the Medical Council of India (MCI) rendered a whole cadre of qualified doctors ineligible for teaching posts.

Multiple choice questions: the right choice?

Most high stakes entrance exams are conducted on the basis of results of multiple choice questions (MCQ). In a study published by the Economic and Political Weekly, Shobhit Mahajan and Pramod Shrivastava reveal that a candidate’s performance is governed chiefly by chance.

Real-life samples from an entrance examination, which had 57,000 applicants attempting two papers of 100 marks each were taken. Since the number of applicants was so large, there were instances when more than one person got the same score and rank. Says Mahajan: “We chose one of these question papers (which had 100 questions) and manufactured 10 other question papers created by randomly picking 50 questions from the 100 questions. As a result, we had 11 question papers for each student – the original paper and 10 fictitious ones. Since we had prepared the fictitious papers from the original paper, the scores of each student in each of the 10 fictitious papers were known. When we ranked them again, we took one rank, say 1,000. Now we took the 162 students who ranked 1,000 in the original exam. The rank 1,000 was chosen because in most exams, 1,000 or 1,500 is the usual cut-off rank. We took their marks in the 11 papers that we now had with us. And what we found was that the candidate who ranked 1,000 in the real exam was equally likely to have got a rank of say 650 or 1,400.”

What this study essentially says is that MCQs have a huge sampling error. It is an inherent limitation of this assessment tool. Agreed, that it is practical and feasible to use MCQs when the number of students is so low. But, the predictive validity of MCQs is pretty low. Does a student who scored cent percent in a MCQ test have any traits to be a competent doctor? Does this tool even test those qualities? A judicious mix of assessment tools needs to be used in selection examinations.

Technorati Tags Medical Education, Medical Education in India

The cost of producing a doctor in India

This report says that over the last three years, the tuition fees paid by an aspiring doctor in India have almost tripled.

Across India, while fees in private unaided medical colleges are still way below Rs 3 lakh, the Nagpur-based NKP Salve institute charges Rs 4.75 lakh, the highest in the country. Karnataka may have the largest pool of medical seats in India but Maharashtra by far charges the highest fees.

The annual cost of an MBBS course in a private college in Maharashtra ranges from Rs 4.75 lakh at NKP Salve to Rs 1.68 lakh at ACPM, Dhule, with the bulk of the colleges — most of them run by politicians — charging in the range of Rs 2.5-3 lakh. The annual fees of the only private college within Mumbai, K.J. Somaiya,went up from Rs 1.89 lakh to a whopping Rs 3.72 lakh between 2003 and 2006.

The main reason for this state of affairs is that the government committee responsible for regulating fees in the state has been approving hikes proposed by the managements of these colleges every year. The question that we need to ask is, when students from these colleges finally reach society what will prevent them from extracting their pound of flesh from their patients. Whither the spirit of service in their minds when they have themselves been victim of these money-minting schemes.

Welcome to the Med-Ed Blog!

Medical education has traditionally been one of the most neglected areas in medicine. Thankfully, today things are changing and awareness of its importance is increasing. Teaching technology has acquired scientific dimensions. The profession of being a medical educator has gained respectability and credibility. But there is still a long way to go.

Through the medium of this blog, let us join hands to speak the common language of walking together– in a common quest to make medical education better and more fulfilling- for the students and for the teachers.

Technorati Tags Medical Education