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Ahead of print publication
Current scenario and future perspectives of postgraduate medical education in India


 Director Medical Services, Apollo Hospitals, Ahmedabad, Gujarat, India

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Date of Submission22-Sep-2021
Date of Acceptance25-Sep-2021
Date of Web Publication10-Nov-2021
 

  Abstract 


Currently, India is lagging behind in the medical doctors-to-population ratio, and the problem is even critical for postgraduate (PG)-qualified specialist doctors. However, there are rapidly advancing measures that are being taken toward improving health care for the whole population. The Government has the mandate to increase the number of seats for PG medical education and the teaching faculty to address the shortage of specialized medical doctors. The future of the PG medical education curriculum would include enhancements such as broader use of technology and inclusion of courses such as medical ethics and health economics. In addition, incorporating virtual learning, flipped classroom models, simulation studies, and interprofessional education in PG medical education would help to improve the quality and efficiency of medical education. Integration, innovations, and implementation are crucial keys to the reforms and should help PG medical education to achieve new heights in India in the near future.

Keywords: COVID-19, doctors, hospitals, medical college, medical education, postgraduate, undergraduate


How to cite this URL:
Sheth A. Current scenario and future perspectives of postgraduate medical education in India. Apollo Med [Epub ahead of print] [cited 2021 Nov 30]. Available from: https://www.apollomedicine.org/preprintarticle.asp?id=330277





  Introduction Top


India is one of the fastest-growing economies in the world, with a population of more than 1.3 billion, which has over 1.2 million registered medical practitioners.[1] With the growth of the economy, the demand for health care has increased over various medical specialties, thereby creating an intensified demand for doctors with specialized medical skills (postgraduate [PG]). The World Health Organization (WHO) recommends a ratio of medical doctors to the population of 1:1000. As of 2020, this ratio for India overall is about 1:1456,[2] although few states have achieved the WHO recommended ratio.[3] Even though India is nearing the recommended target by WHO, the distribution of doctors within the specialties needs attention. Given the number of available medical education seats, it is estimated that only about half or a lower number of undergraduate (MBBS) students can pursue PG education.[4] The ratio of specialty medical doctors to the general population is even lower.

This review is aimed at assessing the current status of PG medical education in India, its challenges, and provides possible solutions to overcome these.


  Materials and Methods Top


For this review, a comprehensive review of the literature was one on the search engines of PubMed, Scopus, and Google Scholar, using the keywords “PG education” AND “medical,” AND “India.” The details of PG education in India were also extracted out from the websites of the National Medical Council (https://www.nmc.org.in/about-nmc/), and the Diplomate of National Board (https://natboard. edu. in/aboutus. php). Appropriate publications were used for this study.


  Results and Discussion Top


The results of this review and the relevant discussion on it are described below in various subheadings.

Medical education in India

Medical education in India was historically regulated by the Medical Council of India from the preindependence time till it was replaced by the National Medical Commission (NMC) in 2020.[5] The NMC aims to improve access to quality and affordable medical education, ensure the availability of adequate and high-quality medical professionals in all parts of the country, promote equitable and universal health care that encourages community health perspectives, and make services of medical professionals accessible to all the citizens. It also aims to encourage medical professionals to adopt the latest medical research in their work and to contribute to research. The NMC assesses medical institutions periodically, maintains a medical register for India, and enforces high ethical standards in all aspects of medical services.[6] The Undergraduate Medical Education Board, the PG Medical Education Board, the Medical Assessment and Rating Board, and the Ethics and Medical Registration Board are autonomous bodies under the NMC that play a role in achieving the aims of NMC.[7] PG medical education is offered by public and private sector medical colleges/hospitals in India with the degree courses MD/MS and DM/MCh that are regulated by NMC.

Measures to increase the postgraduate medical seats

As a measure to increase the number of doctors, the number of seats available for medical education has increased in the past few years. This has been achieved through the increased involvement of private medical colleges/hospitals and standalone private sector hospitals to provide the necessary infrastructure as well as the availability of DNB, FNB courses, etc. DNB/FNB courses which are conducted by the National Board of Examinations (NBE) are equivalent to MD/MS courses available for PG medical education.[8] The NBE contributes to almost 25% of the total available PG medical seats through its DNB/FNB courses.[9] The NBE plays a key role in integrating big private/corporate sector hospitals with eminent doctors, state-of-art technology, and infrastructure with PG medical education. It also integrates the government sector to PG medical education in regions where there is a lack of NMC courses through the involvement of district hospitals. To help address the need for improvement in primary and secondary health care, the NBE introduced PG diploma courses in eight broad PG specialties as part of their key reform 2019–2020. The NBE is also a key central PG examination board in India that conducts PG entrance, Foreign Medical Graduate Examination, PG super-specialties entrance, PG diploma entrance tests, and DNB/Fellowship exit examination.[8]

Current postgraduate medical education in India

The current PG medical education course regulated by NMC in broad specialties spans over 2 years (diploma courses) to 3 years (degree courses). The competency-based curriculum is autonomous and self-directed and includes a formative and summative assessment essential for successful completion. The learning experience during PG is focused on community-based activities to address the community's needs. The major components of the PG courses include theoretical knowledge, practical and clinical skills, thesis skills, attitudes, including communication skills, and training in research methodology. The educational methods involve attending lectures, seminars, journal clubs, clinical meetings, grand rounds, encouraging group discussions, involvement in research studies in the concerned specialty, and exposure to the applied aspects of the subject relevant to clinical specialties. To achieve this, the ratio of recognized PG faculty to a student is 1:1 each for degree and diploma courses in each unit per year. Cumulative knowledge and skills assessment for the courses is done through examinations taken at the end of the 2nd year for diploma courses and 3rd year for degree courses.[10]

Challenges in the current postgraduate medical education

There are a few challenges in the current PG medical education in India. The rapid growth of medical colleges has resulted in increased need of faculty and consequent lack of faculty at some medical colleges. There is also a lack of a robust program for faculty training. The geographical distribution of the medical colleges is skewed, wherein almost two-third of the new colleges are in the southern states, serving approximately one-third of the population of the country. The current curriculum lacks emphasis on topics such as medical ethics, health economics, and behavioral sciences. Most medical colleges undertake research more due to administrative reasons rather than a recognizable need and passion for medical advancement. Since the research endeavor for the PG medical student acts only as a permit to appear in the exit examination, the focus for them lies in just getting the research project completed rather than focusing on the core research, its values, impact, and outcomes.

Future perspectives and recommendations for postgraduate medical education in India

Incorporation of new strategies

With the increase in the number of medical seats in India, it becomes imperative to consider the geographic distribution of colleges/hospitals and the population density and needs to achieve health equity for the community. The inter-specialty distribution should also be considered to achieve a beneficial ratio of MBBS-to-PG medical education. Clinical and nonclinical seats should have a proportion of 70:30 to address the clinical and other health-care needs of the community effectively. Nonclinical specialties such as anatomy and biochemistry do not involve direct patient interaction. Having a higher ratio of clinical specialties such as medicine, surgery, and radiology would serve the purpose of providing direct care to society. The increase in the number of students calls for increased demand for faculty. Encouraging more faculty positions in newly established colleges and providing better incentives to the faculty can help address the increased demand. Simultaneously, the quality of medical education should not be overlooked. Clinical education and skills should be reinforced through the evidence-based practice of medicine, thereby revealing the significance of research and supporting research opportunities. Research projects/thesis conducted during the PG course sharpen the student's writing skills, increase awareness of the field of interest, and fuel the ambition to learn in-depth. A thesis has its value when the research work is published in scientific journals and adds to the global pool of knowledge.[11] The course curriculum should have a greater emphasis on training in medical ethics, health economics, and behavioral sciences. Such courses prepare the students for real-life experiences and help them become better doctors, nurture healthy doctor–patient relationships, and improve the quality of care given.

Effective use of technology

With advancement, easy access, and increased usage of technology, integrating technology into the traditional learning methods would be beneficial to the current medical education system. The COVID-19 pandemic has shown that technology can be applied to many sectors of health care such as remote health care and virtual/online learning. Remote health care, which includes telehealth and telemedicine, is an approach wherein medical services from consultation to diagnosis and follow-up are offered to patients by doctors from remote locations through technology using telephones, video conferencing, etc. Electronic health records (EHRs) are an integral part of remote health care. They are patient health records that are stored on secure servers and can be accessed from any location. The EHR system is built to provide centralized storage and secure access for all patient records by doctors, patients, and other health-care personnel. This system is in its initial developmental stage in India, but over time, the use of EHR would grow. Remote health care is a rapidly expanding area, and it would be essential that future students be well versed with EHR, the changing technology, and its usage.

Virtual learning

The COVID-19 pandemic has led to the wider use of virtual learning across all academic sectors, including medicine. Virtual learning, which was not used as much previously, has been accepted and adopted by most students during the pandemic. Although it requires resources, such as the Internet, computers/smartphones, and knowledge of basic computer skills, it increases the flexibility of study schedules through easy access to recorded didactic lectures. This benefits PG medical students as they can learn and relearn at their own pace, convenience, and work/study location. These lectures become increasingly powerful when used with flipped classroom model, an effective strategy for medical education, widely used in western countries. Flipped classroom model is a learning strategy where students complete preassigned readings and train on case/problem solving when the class is in session through discussions, thereby improving student engagement. It has been observed that flipped classroom education models for medical students have led to higher examination scores, improved practical skills, and improved course satisfaction. Virtual learning also includes the use of interactive technologies such as polling features which can thus improve student engagement. Gamification strategies or interactive gaming education solutions have been increasingly incorporated into traditional curricula to promote use among medical students. Virtual platforms permit novel and creative methods for medical education and warrant continued use.[12]

Simulation-based studies

Simulation-based studies have been increasingly used in western countries and are revolutionizing medical training. Simulation-based studies can help with the early acquisition of complex clinical skills, increase the importance of patient safety, and reduce patient dissatisfaction about being “practiced on.”[12] There are several types of simulation techniques that are available for medical training. Mannequin-based simulators use complex computer-driven electronic and pneumatic mannequins that look like realistic patients. Such mannequins can breathe, respond to medicines, talk, and have vital sign outputs into the clinical monitoring equipment. Partial or complex task trainers provide realistically yet focused practice for the student and are designed for a specific procedure, such as central line placement, bronchoscopy, or airway management. Screen-based computer simulators contain programs that run on personal computers or the Internet that allow learners to work through cases using clinical knowledge and critical decision-making skills. Standardized patients or “actors,” especially trained to present their medical histories, simulate physical symptoms and portray emotions as specified by each case. Virtual reality (VR) is a simulated, immersive environment, created by a combination of computer-based images and interface devices. A VR environment may include visual stimuli, sound, motion, and smell.[13] Simulation-based studies come with additional costs for the institution but would provide improved perception and greater skills for future medical professionals.

Interprofessional education

Interprofessional education (IPE) is another practiced educational strategy, often combines PG medical students with members of other health-care disciplines, including, but not limited to, medical students and faculty from other specialties, nurses and nursing students, pharmacists, social workers, clinical laboratory personnel, and hospital administrators. A team is formed, and the IPE session includes presenting case scenarios and encouraging interprofessional discussions and problem solving. Members/students from each profession view the case and try to identify and solve issues based on their specialty but as a team with other professions. IPE increases mutual respect and trust among the professions, improves the understanding of professional roles and responsibilities, and provides a platform for effective communication. IPE has been shown to increase job satisfaction and have a positive impact on patient outcomes (e.g., decreased patient length of hospital stay, and a reduced number of medical errors).[14] IPE helps PG medical students develop more confidence, reduce medical errors, and improve health outcomes. IPE sessions can be carried out through classroom learning and team-based approaches to patient care through simulations or internet-based learning. The duration of IPE varies greatly and depends on the institution's requirements. A study mentioned the median duration of about 60 h/course.[15] IPE can be conducted as a single session or multiple sessions over a time period.

Artificial intelligence

Medical education in the future will be strongly influenced by artificial intelligence through skillful medicine-machine interaction that will enable physicians to reduce the knowledge-practice gap.[16]


  Conclusion Top


India is rapidly advancing toward its goal to improve health care for the whole population. Increasing the number of seats for PG medical education as well as faculty would help to address the shortage of specialized medical doctors. The future of the PG medical education curriculum would include enhancements such as broader use of technology and inclusion of courses such as medical ethics and health economics. In addition, incorporating virtual learning, flipped classroom models, simulation studies, and IPE in PG medical education would help improve the quality and efficiency of medical education. Three “I”s – Integration, Innovations, and Implementation – are crucial to the reforms. Integration of private and public health-care systems for effective use of medical education resources, innovations to bring out the best in medical education and to create a strong organizational culture, and a timely implementation of reforms will achieve new heights for the future PG medical education in India.

Acknowledgments

I would like to extend my sincere thanks to Dr. Raju Vaishya (Apollo Hospitals, Delhi, India), Dr. Vishruti Pandya (University of Alabama at Birmingham, USA), and Dr. Rakesh Sharma (NBE in Medical Sciences, India), for their expertise and contribution to the manuscript.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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2.
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Correspondence Address:
Abhijat Sheth,
Apollo Hospitals, Ahmedabad, Gujarat
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/am.am_106_21





 

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