As the 157th report on quality of medical education in India was released by the Rajya Sabha Parliamentary standing committee (henceforth RS Report) recently, the much-needed revisions in MBBS curriculum have come after a 21-year hiatus since the Regulations of Graduate Medical Education in 1997.This report is, therefore, crucial to understand the extent to which medical colleges have been able to incorporate Competency Based Medical Education (CBME) (Medical Council of India, 2019) with a patient-centric, gender-sensitive, environment-appropriate and outcome-oriented focus.The RS Report indicates that medical education in India has made significant progress and is in keeping with international standards of medical education. It suggests that the real impediments to medical education are: inadequate number of medical colleges, shortage of medical educators, infrastructural limitations and limited bio medical research opportunities.While the report has a series of recommendations, the core objective of reviewing the quality of medical education is remiss, despite the core objective of the RS Report being: to scrutinise the quality of medical education, review medical curriculum and assess expertise of the existing medical faculty.Implementation of new curriculum A majority of the 60-page report focuses on infrastructural concerns with some information on faculty issues in medical colleges and ends with broad comments on quality control of medical education in India.While a sizeable section of the report comments on CBME, it does not critically review the implementation of the new curriculum. The committee visited medical colleges in Mumbai, Goa and New Delhi and interacted with the faculty. Yet the report fails to provide insights into the actual implementation of the new curriculum on the ground. Neither did the committee make a note of the challenges faced in teaching CBME nor did it record any good practices from these colleges.Experience of medical educators The report suggests rigorous and comprehensive implementation of AETCOM modules (Attitude, Ethics and Communication) The objective of this module is to strengthen communication skills and develop a sensitive and humanitarian perspective amongst medical students. However, the RS Report does not throw any light on the experiences of medical educators teaching AETCOM or provide any examples of good practices related to implementation of AETCOM.Nevertheless, the committee recommends including these elements in NEET. However, without substantive evidence on change in perspectives, attitudes and skills of students, this recommendation may not hold ground.Creation of teaching modules and resources for medical educatorsIt is disconcerting that the report makes no mention of a significant effort by Maharashtra University of Health Sciences (MUHS) to integrate social determinants of health in undergraduate medical education, with a particular focus on gender.This endeavour of MUHS in collaboration with the Department of Medical Education and Research (DMER) and Centre for Enquiry into Health and Allied Themes (CEHAT), a non-governmental organisation in Maharashtra sought to create awareness on differences in gender and sex and its relation to health seeking behaviours, recognising gender as a social determinant of health, understanding gender-based violence and its impact on health apart from comprehending the concept of bio-ethics.An important output of the endeavour has been the creation of teaching modules and resources for medical educators to engage MBBS students. These modules compliment CBME curriculum and are being used by the state medical colleges after being endorsed by the Academic Council of Medical Education, Maharashtra as supplementary teaching material. This initiative began in 2015 in Maharashtra and has now been replicated in medical colleges of Karnataka, Telangana, Bihar to name a few.This endeavour addresses key concerns such as poor attitudes towards patients, stigmatising and blaming as well as stereotyping behaviours that have been observed in a recent study conducted by CEHAT (Bavadekar et al., in press). The study sought to understand the extent of gender sensitivity in clinical practices towards women and queer people.The findings of this study suggested that doctors operationalised consent procedures mechanically, pressured women to make contraceptive choice immediately after delivery, created conditional access for MTP services and blamed women for not using contraception.Also read: Medical Misogyny: We Need to Talk About Obstetric ViolenceThe gender biases about women in general and rape and domestic violence survivors in particular, are rife amongst doctors. Doctors were oblivious to gender diversity such as LGBTQIA+ (Lesbian, Gay, Bisexual, Transpeople, Intersex, Asexual and others) as well as their health needs. As suggested by the RS Report, cultivating right attitude, ethics and communication are pivotal to becoming a sensitive doctor. In this context, the best practices from above mentioned colleges can be a useful resource to those implementing AETCOM.Shortage of medical practitioners The RS Report suggests that there is an urgent need to increase the number of seats for undergraduate and postgraduate medical education and for this purpose encourages private investment as well as setting up of private medical colleges.Given a context where medical students graduating from private medical colleges pay huge fees which then compels them to work in the private health sector to be able to repay the debts incurred, they are unlikely to be available for public health service.Despite having 13 lakh registered medical practitioners across India (MCI, 2015) and almost 1 lakh medical graduates in 2022, the shortage of doctors at primary health care remains huge. The RS Report has noted malpractice in the form of, failing medical students (to make them pay again to reappear for exams) because private medical colleges are driven by profit motive.On boarding the private sector In an unregulated system, private healthcare providers continue to profiteer by compromising on quality healthcare as well as accessibility of health services. It is an established fact that those accessing private health care have experienced out of pocket expenditure and thereby financial debts.An important piece of evidence of the state failure is seen in the lack of regulation of charitable hospitals, which receive several benefits from government in terms of land and electricity at subsidised rates, concessions on import duty for medical and other equipments.In return, these hospitals are expected to make 20% of their beds available for economically marginalised people and also offer free treatment or treatment at a concessional rate. A review of the charitable hospitals in Mumbai (Kurian, 2013) showed that 20% of beds were never made available for the poor.The data reported by these hospitals to the charity commissioner was also inconsistent and unreliable. However, the government failed to demand accountability from them. Given the poor state of regulation of private health services, incentivising the same entity to set up medical colleges is unpardonable.Instead of recommending that public investment to upgrade the infrastructure and training of personnel of government medical colleges be increased, it is the private sector that is being on boarded.Health research The RS Report makes an important observation about the lack of research in medical institutes and poor allocation of financial budget to conduct rigorous research. The report does not uncover the reasons for concentration of most research being done by a handful of premium medical educational institutes.Nevertheless, the report seeks to encourage collaboration with private research firms without clarifying whether these would include for-profit research institutes of pharma companies or the challenges in maintaining research ethics and integrity of teaching institutes.Although this is an important observation, it maintains a narrow focus, predominantly centering on a biomedical approach by highlighting research related to ‘disease burden’. But, health is not just about bio-medical research.In order to foster reforms in public health, research evidence on community health, quality of healthcare and issues concerning accessibility and affordability are equally important. Research is also foundational for implementation of evidence-based clinical practices.For instance, in the case of tuberculosis, through years of dedicated research, often driven by the advocacy of feminists and public health experts — ‘gender’ is now recognised as a critical determinant impacting the disease’s course, leading to the formulation of a gender policy for TB in India.AYUSH not reviewedThe exclusion of AYUSH (Ayurveda, Yoga and Naturopathy, Unani, Siddha, and Homeopathy) disciplines from review by the Rajya Sabha committee signifies a reductionist approach to healthcare.The National Health Policy of 2017 articulates the government’s proposition to integrate AYUSH services into primary healthcare. Since 2017-18, Ayurvedic practitioners have been granted permission to practice allopathic medicine after undergoing a six-month training programme. Presently, there are approximately 7,55, 780 AYUSH doctors practicing in India (National Health Profile, 2022).As AYUSH gains prominence in the broader healthcare landscape, a holistic and inclusive curriculum review becomes imperative to ensure that their education aligns with healthcare standards.Moreover, it underscores the educational parallelism between AYUSH and allopathic medicine, with students undertaking a comprehensive five-and-a-half-year course covering subjects such as surgery, ophthalmology, and gynaecology.The notable absence of AYUSH disciplines from the RS Report is a critical oversight. Addressing these concerns through a comprehensive curriculum review for AYUSH disciplines is essential to harness their full potential in providing integrated and effective healthcare services. Ignoring this critical aspect may undermine the overall goal of an inclusive and plural healthcare systemTo conclude, the RS Report falls short on many accounts since it fails to provide insights into efforts already made to ensure quality medical education as well as those that need to be made. Hence it would not be out of place to state that the Rajya Sabha’s esteemed committee has lost an opportunity to familiarise itself with ground realities and to that extent the recommendations of this report will contribute little or nothing to address the ills that continue to plague the medical education system in India.The authors are thankful to Dr. Padmini Swaminathan and Dr. Jagadeesh Reddy for their review comments. Sangeeta Rege is the director of the Center for Inquiry into Health and Allied Themes (CEHAT) and Amruta Bawdekar is a research officer in CEHAT.
