Tuesday, March 22, 2011

Study on Medical education among Internee doctors in 2002-03 still relevent

I did study among internee doctors in 2002-03 among four state of India and five medical colleges its really intersting to read the findings.
Dr. Niraj Pandit

Attitude of Internee Doctors to Medical Education in India.

The objective of Medical Education is to create efficient and compassionate healers to serve indigenous society’s aspirations and priorities. In present days, the country have achieved ten fold increase in number of medical colleges and the out put of doctors mainly specialist and super-specialists.
Objective: to know the attitude of an internee doctors towards medical education and to know the attitude of internee doctors to health care system.
Design: The present study was conducted in five medical colleges over 4 state of India, name Gujarat, Rajasthan, Madhya Pradesh and Maharastra. It was a cross sectional study. The study participants, internee doctors were selected randomly from respective medical colleges during year 2002 – 03. Minimum 30 internees selected from respective college.
Analysis: proportion is used for analysis.
Results: 59% of participants said their knowledge in different subjects is adequate. Only 6% of internees liked the lecture as mode of teaching. But 21% said they are happy and will be interested to attend lecture if audio-visual aid incorporated. 36% of study participants liked learning by doing method for acquiring skill. On asking about the interesting – boring subject among medical course, 29%, 22% and 15% replied Medicine, Surgery and Community Medicine respectively were the interesting subjects; 19% and 14% said Community Medicine and Bio-chemistry respectively are boring subjects. The study revealed that 95% of study population wanted to do post-graduation. But 43% of all would be happy if they get chance to work in rural area.
Conclusion: There is need to elaborate such study, which help to plan medical education.
Key words: Medical education, interesting, boring, attitude

Attitude of Internee Doctors to Medical Education in India.
Education needs no definition. Medical education occupies a crucial position as it involves a close and deep study of life itself and its vital process. The objective of Medical education is to create efficient and compassionate healers to serve indigenous society’s aspiration and priorities.1 In 1988 world conference on Medical education in Edinburgh Scotland resolved to make training of physician more relevant to the needs of the majority in their own societies.2 In present scenario, we have achieved ten fold increase in the number of medical colleges and the output of doctors, resulting in large number of specialists and equally impressive number of super-specialists. This has been largely unplanned and without any thought for finding rewarding areas for them. That leads to frustration and either force do private practice or leave country. The promotion of medical college in smaller towns (cities) has not made much of an impact on the distribution of medical manpower. Nearly 70% of India’s 4,50,000 doctors are concentrated in urban areas.3

MCI determines the standards and qualification of Medical School in India. It also sanctions curricula.4,7 Medical education is in English and text books often provide examples unrelated to India. Pedagogy consists mainly of lectures and rote learning predominates. Education is not patient oriented or community oriented, mainly hospital oriented or disease related.

The National need of medical manpower has been time to time determined by Government of India. Several reports of commissions ranging from the Bhore commission to Mudaliar commission have defined health need of nation. In this line the latest document is national Health policy 2002.5 In NHP 2002, has raised question on the quality of medical education that is highly uneven and in several instances even sub-standard. Teaching is more theoretical, making it difficult for fresh graduate to effectively meet even the primary health care needs of population. To rectify these, there is need to modify existing curriculum. A need based skill-oriented syllabus, with more significant component of practical training would make useful to fresh doctors. There is shortage of specialist in public health and family medicine, to overcome these shortages the NHP 2002 envisages the progressive implementation of mandatory norms to raise the proportion of postgraduate seats in these disciplines in medical education (up to 25% of seats). Looking to this scenario in medical education the present study was conducted in five different medical colleges over four states of India. The objectives of study are, to know the attitude of an internee doctors towards medical education and to know the attitude of internee doctors to health care system.

It is a cross-sectional study. The study was conducted in five medical colleges over 4 state, name Gujarat, Rajasthan, Madhya Pradesh and Maharashtra. The study was conducted during year 2002-2003. The study participants were selected randomly who are doing internship during that year. Minimum 30 study participants were selected from each medical college. Thus total 155 were the study population. Only those internee doctors who are doing their internship were included in study population. The pilot pre-tested proforma was used to collect data. After taking informed consent, the internees were interviewed. The proformas were sent to respective medical college by post. The department of Community medicine of all five medical colleges has helped to collect data. Thus collected data has been analyzed.

Result and Discussion:
The result performance of students during their study time revealed that average 80-86% of students passed in first attempt; very few are chronic repeaters (2- 2.5%) in all years (Table – I).
Table – I Attempt to pass MBBS during course:
Attempts Ist MBBS (%) IInd MBBS (%) IIIrd MBBS (%)
Ist Attempt 124 (80) 134 (86.5) 124 (80)
2nd Attempts 27 (17.5) 17 (11) 26 (16.8)
>=3 attempts 4 (2.5) 4 (2.5) 3 (2)
Total (%) 155 (100) 155 (100) 155 (100)

77.4% (120) of students said that their choice of medical field is satisfactory and 22.6% (35) were not happy with their present field, at the end of course.

On asking their knowledge in different subjects, about 59% (90) of internees have feeling that their knowledge in various subjects is adequate. On asking which is the most interesting subject, 29% (45) replied medicine and 22% (34) surgery; 15% (24) community medicine and 10% (16) obstetrics and gynecology (Table – II), Where as community Medicine 19% (30) and bio-chemistry 14% (22) were considered boring subjects. Didactic mode of teaching may be the reason behind that.
Table – II Details of Interesting and Boring subjects:
Subjects Boring (%) Interesting (%)
Community Medicine 30 24
Anatomy 11 1
Bio-chemistry 22 45
Physiology 2 0
Pharmacology 3 2
Microbiology 6 0
Pathology 3 0
FM 3 9
Medicine 1 45
Surgery 5 34
Obs/Gyn 6 16
ENT 5 2
Ophthalmology 3 2
Orthopedics 1 2
Dental 1 0
Anesthesiology 1 2
Skin 1 2
Pediatrics 4 3
All subjects of MBBS 3 1
All non-clinical 1 0
None 18 0

Table – III Best method of teaching medical subjects:
Methods for teaching Frequency (%)
Lecture 9 (5.8)
Audio-visual 33 (21.3)
Practical 35 (22.3)
Demonstration 12 (7.7)
Learning by doing 56 (36.1)
Problem solving method 8 (5.2)
Other (like community oriented study) 2 (1.2)

Only 6% (9) of internees would like the lecture as mode of teaching media (Table – III). In MCI regulation 1997 also said that lectures alone are generally not adequate as a method of training and are a poor means of transferring/ acquiring information and even less effective at skill development and in generating the appropriate attitude.8 But it was observed that interest is increased if the audio-visual aids incorporated in lecture (21%). 36% (56) would like to learn by the learning by doing method. MCI suggested in that regulation that every efforts should be made to encourage the use of active methods. Even though very less number of students like the lecture as method of teaching, 72% of all students were regular in classes during their study. This is due to MCI guideline that 75% of attendance must to appear in final exams8.

The important observation is that 95% of all students want to do post graduation. This observation is not infavour of country’s national policy. In the era of social injustice,6 the need of Nation is the basic doctor who can cater services to rural and tribal population. It revealed that there is need to rethink about present medical education, which is still urban oriented and specialist and super-specialist oriented. But one good observation was that almost 43% of internee would like to work in rural area. This revealed that students have a will to work in rural area but something is lacking that ask more research work in this field.

Regarding Monitoring & supervision of internship programme, 49% of internee did not want such supervision but 38% said there should be internship monitoring programme. As the MCI regulation 1997 has recommended internship assessment for internees. On that basis medical education cell of all colleges should prepare skill based training programme.
Conclusion :
Indeed, the study was not well planned, but the findings of study are mind-blowing. They are
1. There is need to plan such indepth systematic multi center study to understand real need of change.
2. There is a need to review medical education regularly by each medical education cell of colleges.
3. The majority of students want to do postgraduation; this finding is eye opening, it raises the question weather we are producing basic doctors or specialist? The need of hour is basic doctors.
4. There is need to change our traditional didactic method of teaching. Many innovative teaching methods like demonstration, first hand experience, Problem Solving for Better Health, Problem Based Learning, Animation etc.
5. There is need to strengthen the skill based internship programme and proper supervision of same.

1. Z Amin, Medical Education in Asia: Is it time for optimism; Annals Academy of Medicine, Commentary March 2004, 33 (2)
2. Jaswal S. Health and human development, Indian J Matern Child Health. 1995 Apr-Jun;6(2):31-2.
3. Mudur G. Mandatory rural practice proposed in India, BMJ. 1995 Nov 4;311(7014):1186-7
4. Krishnan P. Medical education, Health Millions. 1992 Feb-Apr;18(1-2):42-4.
5. National Health Policy 2002, http://unpan1.un.org/intradoc/groups/public/documents/APCITY/UNPAN009630.pdf
6. K. Park Text book of Preventive and Social Medicine, 17th edition 2002; chapter-21 page 650
7. Medical council of India regulation on Graduate medical education 1997, published in part III section –4 of Gazette of India dated 17th may 1997, 1701 - 1726

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