Health care and medical education in India have been going through a tumultous phase in the recent past - the crackdown on stent prices and kickbacks, the NEET MBBS - Tamil Nadu battle, the NEET / Vyapam scam, the Gorakhpur tragedy, etc. And, in several of these instances, the medical fraternity has been blamed for no fault of theirs.
While most of these reports claim prominent space in the press and visual media, the highest education sector in medicine has been witnessing silent protests and fight for 'justice' - this has largely gone unnoticed by the press or public because it involves only a few individuals - but it is of equal importance to people and medicos alike.
Medical education consists of three broad phases - MBBS - the basic medical degree which has become some sort of intermediate education in medicine nowadays because few stop after MBBS - most of them go for postgraduation - called MD / MS - which is available in about 30 broad specialities - the pre and para clinical subjects (like Anatomy, Pharmacology) and clinical subjects (like Medicine, Surgery, Gynaecology, etc.) Surprisingly seemingly specialised subjects have been traditionally included in this broad group like ENT, Ophthalmology, Dermatology.
A few among those who complete their MD/MS pursue further higher education - called sub- / super- / second specialities - e.g. Cardiology, Gastroenterology, Neurosurgery, Plastic surgery, etc. - called DM for medical subspecialities and MCh for surgical subspecialities.
The problem has arisen out of the way the entrance exam for these superspeciality courses is conducted, the eligibility criteria, etc.
Here are some of them and my humble opinions -
1. Eligibility -
Who should be eligible to take a higher course - obviously someone who has the basic knowledge and skills for the broader speciality to which that belongs to - thus for medical subject like cardiology and neurology someone with a medical degree like Internal / General Medicine shold be eligible.
Surprisingly other subjects are given eligibility like Pediatrics, Biochemistry (for Endocrinology for several years) Pulmonology (for Cardiology) Pathology (for Hematology, Oncology) Microbiology (for Immunology) etc.
Here are my objections / counters
1a. When there are sufficient persons in MD General Medicine, which everyone will agree is the most suitable and apt eligible broad speciality why should other subjects be given eligibility?
1b. Among the other subjects mentioned above, the para clinical subjects being included is the most questionable choice - how do we come to such conclusions? what is the basis? We have no answers from the MCI or other higher bodies.
1c. Okay one may argue that we should not restrict higher education to one speciality - then open it up to other specialities also - like ENT Ophthalmology Dermatology Psychiatry which are also all broad specialities - and why not Physiology Anatomy - the list can go on.
1d. Okay again agreed that it may be good to have diverse persons entering a higher speciality - then I would argue - allot not more than 1 out of 5 or 6 seats to such non-Medicine MD PGs and keep it open to anyone with an MD //MS - and such persons who get a seat must work in the basic speciality (Medicine for DM courses and Surgery for MCh courses) for preferably 1 or 2 years (depending on their basic PG degree) - so their DM/MCh course would be 4 or 5 years instead of the regular 3 years. This would ensure that we have persons from all specialities coming in and also that they are well equipped for the speciality.
2. Entrance examination - (mode of selection)
Of course the current standard mode of selection for almost all courses is a written entrance examination (objective questions) - the interview has mostly been removed to avoid personal biases during this process. (however autonomous central institutions still take an interview to select those whom they want!!)
How to decide the syllabus for this exam - this has become a major bone of contention
2a. Logical thinking would demand that the exam should be in the basic speciality - here Medicine for DM and Surgery for MCh as they are the accepted basic prerequisites for these courses - or it should be in the particular speciality which the student seeks to get into - e.g. Neurology, Urology, etc.
It is strange that recently the NEET - SS (subspeciality) exam was held in the student's respective field - e.g. for if the PG was from Medicine he answered 200 MCQs in Medicine, if from Paediatrics he answered in Pediatrics, if from Pulmonology he answered 200 in Pulmonology.
This is grossly unfair and gives an unfair advantage to the other two because the syllabus of Medicine is so vast and Pulmonology is maybe least among them.
2c. In the past, the entrance exam was in the concerned DM/MCh subject or sometimes (and maybe more appropriate) half in the DM/MCh subject and half questions in basic degree (medicine / surgery)
2b. The current NEET model of exam in the student's respective basic PG degree subject will be most unhelpful and harmful - at least in the past when the exam was in the DM/MCh subject, at least the student used to read the theory books of those subjects - now he will just have basic knowledge of Pulmonology and come to Cardiology - (or one with Ortho knowledge will come into Surgical Oncology) - and it is a well known fact that patients are not water-tight cases - a Cardiac patient will have several other medical problems whose knowledge is essential even to a cardiologist.
2d. So what is the solution - again I would argue that the traditional format was correct - have 50% questions in the basic speciality - Medicine for DM entrance and Surgery for MCh entrance. The other 50% would be in the concerned speciality - like Cardiology or Neurosurgery etc.
2e. The other anomaly in the recent NEET- SS is that of having one entrance for all DMs and one entrance for all MChs. This is unheard of, till now. Super-specialities are subjects in which we expect students to have a lifelong commitment /dedication to and enter - not just take whatever the student gets (like the PG exam - which itself is not very appropriate) - so a student who wanted Cardiology but with less aptitude for endocrinology may opt for Endo if he doesnt get a Cardio seat - or the other way round.
What is wrong you may ask - again as i have said - these are the highest specialities and seats are few - we need persons who have a full commitment to the subject and have aptitude for it - we need someone who comes by choice not by chance.
2f. So the solution would be - do not have one exam for all DMs / MChs - but a separate exam for each
And the paper should be only in Medicine for DMs and Surgery for MCHs - not in other eligible subjects like Paeds, Ortho, Patho, etc.
3. Policy decisions / eligibility / entrance exams -
Finally who decides and how - on such policy issues - like eligibility, entrance exam etc. The MCI does it but it is all under a thick veil of secrecy - no one knows why suddenly a subject is given eligibility (biochem for DM endo or pulmonology for cardio or patho for hemato-oncology) why a subject is removed (ortho for neurosurgery, ENT for plastic) etc.
For example when the MCI gave eligibility to endocrinology for MD biochemistry, many in the MD PG entrance exam who did not get a clinical degree (more sought after) took MD biochemistry (preclinical and less sought after) hoping to do DM Endocrine later - but suddenly - one fine year - the MCI removed this eligibility - leaving scores of MD Biochem PGs shocked and helpless.
Unfortunately, as we all know the MCI is not a totally transparent / democratic body now - so how to get credibility on its decisions.
Hence all such decisions should be discussed in wider fora and opinions of all stakeholders taken before making major policy decisions which can affect / ruin the lives of medical students who already have struggled for more than a decade to reach this stage.
Ravi Venkatachelam
