Postgraduate medical education in South Asia
BMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7443.779 (Published 01 April 2004) Cite this as: BMJ 2004;328:779All rapid responses
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I fully agree that the fact that large numbers of South Asian
doctors and specialists serve world wide is an oblique assurance of the
quality of the product of medical education in the region. What we were
highlighting in our editorial were areas requiring attention in the
training process that yielded that product. Postgraduate courses in most
of the region are not guided by modern educational theory.
I am sorry if you perceived a lack of optimism in our editorial – it
was not meant. Fifty years – post independence, is a short time in the
life of a nation or a region and much has been achieved in the sphere of
medical education in the region during this time. There was a rapid
increase in the number of medical schools. For instance in India alone
from 17 in 1947 to 221 at present. Countries in the region except Bhutan
and Maldives produce sufficient doctors for state service. Furthermore
there is some pride in the fact that India, Pakistan, Nepal, Sri Lanka and
Bangladesh have the capability of providing specialist training in all
medical specialties. However it is now time to move on and fine tune the
training that the region provides and bring it up to global standards .
This includes as you had rightly mentioned, the setting of proper
standards for infrastructure facilities in centres that are used for
postgraduate education. So both infrastructure and training process
requires attention.
Regarding external review, I agree with you that the content of
postgraduate training programmes in the region should be planned by
content specialists in the region. This is so especially in clinical
disciplines and we were not suggesting otherwise. In contrast laboratory
based disciplines and ones such as forensic medicine can gain much from
subject specialists in the West.
For any educational process to improve, it has to be subject to
periodic external review. This can be by a person(s) within or without the
region. External examiners can provide very useful feedback on the
educational process and the objectivity and choice of assessments and
standards in comparison with postgraduates in the west. This process of
benchmarking and constant comparison of standards is important to the
progress of postgraduate education.
Competing interests:
None declared
Competing interests: No competing interests
It was so encouraging to have a response to our editorial on
postgraduate education in South Asia from a medical student in the region.
Yes, indeed there are better, innovative and more interesting and
effective ways for teaching and learning medicine, than what you describe
so graphically. Modern methods of teaching medicine concentrate on self
learning and life long learning and is skills based. Problem solving,
behavioural aspects and communication receive emphasis. As far as possible
teaching should be interactive. There are many medical schools in the
region which have incorporated such modern teaching methods to their
programmes.
As medical students, you are the most important stake holders of
medical education. Through your student associations and unions you can
form important pressure groups which demand and lobby for change. You had
referred to the gap between the west and the east. If you examine the
history of the region, you will realise this gap did not always exist.
Even now, there may be many aspects of life which are more satisfying in
the east than the west. Every region and nation has its ups and downs. We
have to cope, never despair, but always try to improve. If I may
translate something that the Lord Buddha said “The shadow for your head is
your own hand”.
Competing interests:
None declared
Competing interests: No competing interests
The Southeast Asian region is still in the 'ice age' in every aspect
of
life. It'll be the last one to get the opportunity to appreciate the
innovative technologies that the West had decades ago. While people in the
West are competing to widen the horizon of human achievements, people here
are competing for the fundamental needs. Isn't this a heart breaking
truth?
Despite revolutionary development in the field of medicine in the
past
100 years and despite so many programmes like 'Health for All by
2000','Education for All' trying to articulate the differences between the
West and the East , there still exists a Significant Gap.
Our part of region is virtually being dragged by the West. I may
sound
derogatory, but it's inevitably true.
And it is no exception in health sector. this region has been helpful
for
the West by being itself the ground for clinical trials of new drugs.
There is no doubt,people in this part of the world are suffering from
diseases due to poor sanitation, eye soaring hygienic condition diarrhoeal
diseases & respiratory tract infection are the major killers among the
children of Nepal.Each year diarrhoea kills more than 40,000 children
under 5years of age. Protein energy malnutrition is another major problem.
More than 50% of children below the 5 years of age are moderately to
severely malnourished. everyday a child goes blind due to vit A
deficiency. TB & leprosy still exist in endemic form. 44% of the
population in the hilly region(especially in the Far-Western region of
Nepal) suffer from iodine deficiency disorders.8 out of 10 women suffer
from anemia.
Since I'm a medical student, I think it'll be wise to talk on the
Education system of SE Asian region.The focus is on the education because
it generates the health manpower which serves as an important resource for
the health programme. The education system of Nepal is very old-fashioned
like reading the traditional voluminous Epics. Students are compelled to
feed the subject matters garrulously. They have their ancestrally passed
down method- 'The Rataou Method".It's not going to be helpful in the long
run because their brains go vacant a day after the exam.
I'm sure we can develop newer method that help us to learn things in
a
playful way which will be interesting to us and have clearer impression on
our memories. To uplift the health status of SE Asia, we should primarily
emphasize on the education system because it functions as the factory to
produce manpower.
And the quality of manpower ultimately makes the difference!
Competing interests:
None declared
Competing interests: No competing interests
I disagree with the authors' view that India is studded with
centrally supported postgraduate centres of excellence. Infact, there are
not more than 10 such centres at present. It is no doubt that these
institutions are comparable to the best in the world in standards of
patient care and medical education. But, the standard in the rest of the
postgraduate centres is appaling. There are many so called 'tertiary care
hospitals' which do not even have a blood gas analyser! One has to
remember that the doctors trained in the premier insttitutes in India
invariably go abroad and the poor Indian is left with doctors trained in
under equipped institutions. Unfortunately,Medical Council of India which
is a regulatory body for medical schools is not free from corruption. New
medical schools are being opened every year in India where one can
virturally buy a medical degree. And one can become a consultant
physician.....Who cares about the Blood Gas!
Competing interests:
None declared
Competing interests: No competing interests
Some of the suggestions by Mendis et al(1) to improve postgraduate
medical education are controversial and not necessarily practical. On the
implied suggestion that the training and postgraduate examinations should
be subjected to external review by examiners from developed countries, I
differ from them. Firstly, the practicality and the expenses will drive
up the cost of the exam posing difficulty for many trainees. Secondly, I
do not believe that the curriculum and training of the developed countries
provide sufficient knowledge and training about the diseases prevalent in
third world to enable them to deal with those diseases. If that is the
case, are they the appropriate people to advise and suggest about third
world training? This is not a criticism of that curriculum as there is no
need for it to give sufficient emphasis on those diseases. The curriculum
and style of postgraduate examinations in developed countries continue to
change not only in pursuit of excellence but also due to the necessity of
reducing the burden of examinations. The latter is important in atleast
certain countries as the takeup and dropout rates are unfavourable.
Quality control and excellence in medical training are not only dependant
upon the quality of education but also on the infrastructure. Thought
there is plenty of scope for improvement in training there in South Asia,
the major fault lies in the poor infrastructure of the hospitals and the
consequent inadequate practical experience which clouds the good
theoretical knowledge imparted by South Asian curriculum. Currently,
emphasis on sound theoretical knowledge and vast clinical exposure cover
up the main disadvantage.
Further, I do not share their lack of optimism in South Asian medical
education as South Asian graduates continue to remain a useful commodity
worldwide.
References:
1. Mendis L, Adkoli BV, Adhikari RK, Huq MM and Qureshi AF. Postgraduate
medical education in South Asia. BMJ 2004; 328:779.
Competing interests:
None declared
Competing interests: No competing interests
To the Editor:
I would like to commend Mendis et al for providing an excellent
overview of postgraduate education in South East Asia. Having undergone
training in India, I would like to add a few observations.
There are huge differences in the curriculum, teaching, clinical
experience and examinations between institutions in the same city, let
alone different regions of the country. There are centrally funded
institutes providing excellent training, but the majority of the
institutes are lagging behind.
Most trainees are confined to one single hospital and to one single
specialty during the whole of their postgraduate training. This narrows
their experience.
The clinical experience gained is excellent, if only because of the
patient numbers. There are no working time directives as yet in South Asia
!!
Competing interests:
None declared
Competing interests: No competing interests
sir,
Apart from the shortcomings highlighted by the learned authors, few
very important facts are missing.
1. Entry to undergraduate/postgraduate/postdoctoral training
programmes have 'Quota' system, which gives preference to 'cast' rather
than merit. In some states, there are only 10% of the seats are left as
'Open'.On top of it, most of the so called entrance exams are conducted by
corrupt individuals further adding the insult to the system.
2. In most of the private colleges, candidates pass the exam by
paying the bribe to the examiners.
3. Standards are lowered if the candidate is appearing the exam for
second or third time, making the matters worse.
4. There is no concept of continuing medical education. Once you
become a doctor, you will practice what you learnt in medical school till
you retire!
Solution is simple. What we have in south asia was started by British
people 100 yrs ago. Borrow their current system.
Competing interests:
None declared
Competing interests: No competing interests
Most of the undergraduate and postgraduate training in India
concentrate on imposing theoretical knowledge and test the candidate’s
ability to accurately identify even subtle clinical findings. These may be
relevant about fifty years ago when facilities for investigations and
access to databases were non-existent. For example, still a lot of
emphasis is given to accurately identify mitral stenosis in a patient with
multivalvular heart disease rather than management of congestive cardiac
failure.
I think one of the main reasons for having such a slow progression is due
to lack of involvement of doctors who have trained in western countries in
committees that decide the medical curriculum. Postgraduate medical
qualifications from U.K and U.S.A are not recognised by the Indian Medical
Council and therefore doctors with qualifications such as MRCP and FRCS
cannot work in teaching hospitals unless they have higher qualifications
from Indian universities. Moreover any doctor who wants to work in a
government hospital (and therefore stands a higher chance of getting in to
governing bodies such as Indian Medical Council) should also pass the
public service commission examination. Because of all these hurdles almost
all the doctors in India with western qualifications work in private
hospitals, which play no role in the design of medical curriculum or
examinations. This is in stark contrast with countries such as Srilanka
where it is compulsory for the trainees to have a period of training
abroad.
Therefore the Indian medical council should encourage Indian doctors from
western countries to come and work in the government teaching hospitals by
recognising their post graduate qualifications and also remove the hurdles
to get in to administration. By virtue of their broad training, these
doctors will then be able to help the system to move forward.
Competing interests:
None declared
Competing interests: No competing interests
Editors,
I completely agree with the views published in this article. Postgraduate
education in India has been following the apprenticeship mode of
training. The method of evaluation is usually the long cases which are
mostly neurology cases(in internal medicine).In this pattern of evaluation
the common diseases, which are encountered by the average Indian
postgraduate, are nowhere in the picture. Amalgamation of low cost health
care as well as evidence based medicine into the current postgraduate
education is essential. Things have been changing in the past decade but
the changes are being brought about at a snails pace. The local government
will have to work with the medical organizations and medical institutions
to revamp the current postgraduate training programme
Competing interests:
None declared
Competing interests: No competing interests
Mirroring practice
I spent a few days in the Urology Department of Colombo General
Hospital, in August 2003. The experience was highly educational and
satisfying. I was welcomed to join the daily routine of the surgical
team, from attending clinics, to ward rounds and theatre sessions.
I observed the immense workload of heaving outpatient clinics, where
time is predominantly spent taking a history, rather than over
investigating patients. In the operating theatre, I observed the
differences in procedures performed in the UK and Sri Lanka. For example,
in Sri Lanka, the irrigation fluid used in a TURP(transurethral resection
of prostate) is water as it is more economical while in the UK glycine is
used.
Just as trainees at the specialist registrar level in Sri Lanka have
to complete a year in UK, Australia, New Zealand or Singapore (1), I feel
that UK trainees can learn a great deal from a period of time abroad.
REFERENCES :
(1) Postgraduate medical education in South Asia. Lalitha Mendis, B V
Adkoli, R K Adhikari, M Muzaherul Huq, Asma Fozia Qureshi BMJ 2004;
328:779
Competing interests:
None declared
Competing interests: No competing interests