Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
The cart before the horse....
- sonal singh (2 April 2004)
-
Winds of change in south Asia
- Samir S Patil (2 April 2004)
-
India must recognise postgraduate training programmes from western countries
- Ganeshkumari Ramesh (2 April 2004)
-
few more facts
- Ramakant sharma (3 April 2004)
-
Glaring inequalities
- Sridhar Surapaneni (3 April 2004)
-
Infrastructure and not the training is at fault
- Ramachandran Sivakumar (3 April 2004)
-
Postgraduate medical education in India: 100 years behind.
- koteshwara muralidhara (4 April 2004)
-
Isn't there a better way of imparting knowledge?
- Suman Rai (6 April 2004)
-
Re: Isn't there a better way of imparting knowledge?
- Lalitha Mendis (8 April 2004)
-
Re: Infrastructure and not the training is at fault
- Lalitha Mendis (8 April 2004)
-
Mirroring practice
- Tharani Nitkunan (20 April 2004)
|
|
|||
|
sonal singh, Resident-Physician Unity health System,Rochester,NY14626
Send response to journal:
|
Sir-The efforts of the authors to provide an insight into the medical education system in South Asia are commendable, but any attempt of improving postgraduate medical education without addressing the real challenges facing undergraduate medical education in South Asia is putting the cart before the horse. (1) In India and all across South Asia undergraduate medical education is facing a crisis of its own. Although The Medical Council of India, a regulatory body, recognizes medical colleges in India, there is no set standard on methods of admission, course content, duration of study or periods of internship. (2) Most colleges have an outdated curriculum from the post-colonial era. The medium of education is English, which tends to favour the urban elite. Libraries lack books and journals, and medical colleges do not foster an atmosphere conducive for critical thinking and research. Outdated books cite examples unrelated to the problems of the region. There is hardly any emphasis on the community health and understanding of indigenous problems. The emphasis is on rote learning, and evidence based medicine and problem based learning are still unheard of in this part of the world. Most of the faculty are private practitioners with little enthusiasm for teaching and lack proper incentives. There is a dearth of suitable role models and mentors. Physicians graduating from medical colleges lack necessary training and skills to face the challenges of real –life practice. Several of them, including me, go overseas due to lack of opportunities in their homeland Medical colleges are starved of funds and are caught up in bureaucratic red-tapeism. There has been a recent upsurge of private medical colleges all over India. (3) The mushrooming of private medical schools that charge exorbitant sums without adequate infrastructure and facilities has contributed to the overall dismal picture. (4) Although we have made rapid strides in Information technology in other spheres, it has failed to have a significant impact in the field of health care and medical education. Medicine seems to have fallen out of favor as a challenging career for young people with a scientific bent of mind as they choose more rewarding careers. Unless we are able to lure these youngsters back into medicine the dream of improving medical education in this part of the world will remain just that- a dream. 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 (2) Medical education. Krishnan P Health Millions. 1992 Feb-Apr; 18(1-2): 42-4. (3) Private medical education takes off in India. RK Bansal Lancet. 2003 May 17; 361(9370): 1748-9.PMID: 12767776. (4) Report highlights shortcomings in private medical schools in India.BMJ 2004; 328:70 (10 January) Competing interests: None declared |
|||
|
|
|||
|
Samir S Patil, Registrar Internal Medicine Wockhardt Hospitals,Mulund, Mumbai,India.400078.
Send response to journal:
|
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 |
|||
|
|
|||
|
Ganeshkumari Ramesh, Clinical observer in child and adolescent psychiatry North Staffordshire Combined Health Care NHS Trust,Stoke on Trent ,ST2 8LD
Send response to journal:
|
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 |
|||
|
|
|||
|
Ramakant sharma, halton general hospital runcorn wa7 2da
Send response to journal:
|
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 |
|||
|
|
|||
|
Sridhar Surapaneni, Specialist Registrar, Anaesthesia Royal Preston Hospital, Preston PR2 9HT
Send response to journal:
|
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 |
|||
|
|
|||
|
Ramachandran Sivakumar, Specialist Registrar Lister Hospital, Stevenage, UK, SG1 4 AB
Send response to journal:
|
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 |
|||
|
|
|||
|
koteshwara muralidhara, Senior House Officer Central Middlesex Hospital, London
Send response to journal:
|
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 |
|||
|
|
|||
|
Suman Rai, Student IOM,00977
Send response to journal:
|
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 |
|||
|
|
|||
|
Lalitha Mendis, Director Postgraduate Institute of Medicine of Sri Lanka, 160, Norris Canal Road, Colombo 7 , Sri Lanka.
Send response to journal:
|
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 |
|||
|
|
|||
|
Lalitha Mendis, Director, Postgraduate Institute of Medicine of Sri Lanka, 160, Norris Canal Road, Colombo 7, Sri La
Send response to journal:
|
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 |
|||
|
|
|||
|
Tharani Nitkunan, Clinical Research Fellow Institute of Urology
Send response to journal:
|
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 |
|||