S Y M P O S I U M :

M E D I C A L E D U C A T I O N I N I N D I A Indian J Pediatr 1993; 60 : 721-727

Guest Editor : V.K. Paul

Teaching of Pediatrics to the Medica l Graduates : A Reappraisal

Meharban Singh

Department of Pediatrics, All India Institute of Medical Sciences, New Delhi

National Relevance

C hildren constitute the foundation of a nation and healthy children evolve to become healthy adults to effectively participate in the national developmental programmes. Provision of education and promotion of health of the children to ensure fllem to achieve their optimal growth and development is most crucial for human resource development of a bociety. Children accotmt for over 40% of t~ur poptflation, and more over they are rather delicate and vulnerable and readily buffer from diseaseb and disabilities. Mortality among trader-5 children account for over 50% of all deaths in our country. It ~s obvious that a basic doctor who is expected to serve as a GDMO or a family physician is faced with a large number of children with health problem~ winch he is at present inadeqt.ately tr,iPled |o handle. Moreover, Pediatrics is nol ,m organ speciality, but a major discipline dealing with all health problems of cluldren. The practice of pediatrics is highly cost effective to the nation, because sawng a life

Reprint requests: Dr. Meharb,m Smgh, Professor and Head, Department of l'edlatrtcs, All India Institute of Medical Sciences, Ansan Nagar, New Delhi-ll0 020.

during infancy gives a long lease of productive life as opposed to saving a life in old age due to cancer or heart stroke. The national priority of controlling the burgeoning population cannot be achieved unless parents are assured that every child shall be provided with optimal health care to ensure intact survival. The importance of child health at the national level can be gauged by the fact that of 17 goals for health and family welfare listed in the National Health Policy document of 1983, 8 pertain to the health indices of children and newborn babies. 1 It is , theretore, mandatory that our first contact or basic doctor should have adequate knowledge, skills, expertise and right attitude to provide comprehensive, preventive, promotive, curative and rehabilitative services to children. It is a sad reality that examination is the greatest motivator of learning, and unless there is an independent mandatory qualifying examination, the students do not pay adequate attention to the subject. In most medical universities in India, Pediatrics is currently merged with medicine except in the state Medical Colleges of Orissa, Government Medical Colleges of Aurangabad, Nagpur, Sringar and ]abalpur. Recently, the Medical Council of India has approved that Pediatrics should

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be accorded the status of an independent discipline and recommended that there should be a separate examination in Pediatrics during, final professional M.B.B.S. examination. Th~s recom- mendation, however, awaits ratification by the Governing Body of the Medical Council of India, and its acceptance and adoption by the senates of Medical universities of various state Medical Colleges.

Attributes of a Physician

The right mix of qualities of head and heart, science and art and knowledge and skiffs is mandatory to effectively function as a physician. The physician should be an attentive listener, a careful observer, a sensitive cormnunicator, an astute clinician with a broad outlook to provide holistic c a r e to the patients and not mere c u r e

against diseases. He should be compassionate, caring, professionally competent and sensitive to the social and ethical issues. He must be adequately equipped to practice health promotive and preventive strategies both at the individual and community level. Tile current practice of selecting medical graduates entirely on, the basis of their intelligence and knowledge through entrance examinations is unsatisfactory. There is a need to take into consideration their background, attitudes and aptitudes while making the selection. Elitist candidates from convents are unlikely to serve the health needs of the community in the district hospitals, and community health centres. Unless we make the right choice of the prospective candidates at the entry point, we shall continue to produce technocrats rather than sensitive and skillful physicians who

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will not be able to live upto the expectations and adulations of the suffering humanity.

Pediatric Curriculum

We are training around 15,000 medical graduates every year in more than 130 medical colleges by using an outmoded British-inherited system of medical educa- tion. Unfortunately the current curriculum is content-laden, subject-oriented and ex- amination-driven. The curriculum is inap- propriate and is not need-based because it has been borrowed from the West. Due to rapid strides and advances in medicine and with acquisition of new knowledge, the curriculum has become top heavy be- cause of lack of attempts and even reluc- tance to remove the redundant and "dead wood" topics. 2

Sporadic attempts have been made to reorient the curriculum of the undergrad u- ate medical students taking into account the prevalent health needs of the popula- tion, and increasing emphasis on the acqui- sition of skills which are essential for effi- cient discharge of their duties and respon- sibilities. The reorientation of medical edu- cation (ROME) programme launched by Government of India in 1977 to provide training opportunities to the medical stu- dents at the district hospital, community health center and primary health center remained on paper and could not be launched due to logistic difficulties and lack of coordination between medical col- leges and health delivery systems. The world conference on medical educatioo declared at Edinburgh in 1988 that the medical education must be reoriented to globally support the mandates and goals of Alma Ata for providing basic health care

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to all by 2000 AD. 3 Provision of maternal and child health to the community at large constitutes over 80% of the component of basic health care and should thus receive maximal emphasis. Four premier medical institutes of the country (All India Institute of Medical Sciences, New Delhi; Institute of Medical Sciences, Banaras Hindu Uni- versity, Varanasi; J.I.P.M.E.R., Pondich- e;ry; and Christian Medical College, Vel- lore) in collaboration with the Department of Medical Education, University of IUi- ~ois, Chicago established a Consortium of Medical Institutions in 1987 to launch in- quiry driven strategies to introduce inno- vations in the field of medical education.* ,After initial difficulties and delay, the Con- sortium has drafted a revised curriculum for different disciplines being taught to the medical students and categorized them under 'must know', 'good to know' and 'need not know" categories, deliberated on the need for introduction of a course on humanities and ethics and development of modules for teaching of infectious dis- eases. The "nobility" of medical professior', is getting gradually eroded, and we must make serious efforts to ensure that upcom- ing young physicians are indoctrined and sensitized to the important issues of hu- manities, medical ethics, healing, compas- sion and interaction between body, mind and soul by introducing appropriate modi- fications in the curriculum, s

The students must be adequately prepared and equipped to have knowledge, skills and attitudes to tackle common health problems faced by children in our society. The focus should be on relevant national health issues, rather than rare or esoteric problems. The students must be exposed to the teaching material and modules created by the

Ministry of Health, Government of India in collaboration with intemational agencies (UNICEF, W.H.O.) to tackle the problems of acute gastroenteritis with special emphasis on ORT, acute respiratory infection, malnutri t ion and common infections (gastroenteritis, measles) and care of normal and low birth weight babies in the community. In view of the high contribution of neonatal mortality (over 60%) to the infant mortality rate, it is proposed that about 25% of didactic and bed-side clinical teaching in Pediatrics should be devoted to neonatology. Keeping these requirements in mind, two subcommittees constituted by the Medical Council of India have submitted detailed objectives and revised need-based curricula for teaching of pediatrics to the undergraduate medical students. 6,7 Indian Academy of Pediatrics has constituted a committee and assigned it the task of developing one core or model curriculum in pediatrics by amalgamating the two curricula which we hope to introduce in all the medical colleges of the country. A list of essential skills which all medical graduates must acquire has been finalised by the consortium of medical institutes. Internship phase must be effectively utilized for imparting practical training, acquisition of psychomotor and communication skills. It is recommended that clinical clerkship in Pediatrics should be allocated 8 weeks each during Part I and Part lI of Phase III clinical posting, so that a total of 16 weeks are allocated for the teaching of Pediatrics in accordance with the W.H.O. recommendations that 300 hours should be allocated to the discipline of Pediatrics for undergraduate teaching programine. The teaching of Pediatrics should be integrated with

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paraclinical and clinical disciplines of Pathology, Microbiology, Pharmacology, Obstetrics and Gynecology, and Community Medicine during Phase II and III.

Teaching and Learning Methods

The current practice of medical teaching is rather passive and teacher-centred with greater emphasis on didactic lectures. The teaching milieu of medical colleges is un- satisfactory, because after graduation many doctors are expected to work in a district or provincial hospital with inade- quate diagnostic facilities. Clinical clerk- ship constitutes the most important com- ponent of medical education and should be accorded highest sanctity and priority. The art of bed-side clinical teaching, which we inherited as a British legacy, is dwindling fast because of growing lack of interest for teaching among the faculty members be- cause of lack of promotional rewards to good and committed teachers. It is easier for the members of selection committee to count the number of research publications (of whatever worth they are) but difficult to assess and quantify the pedagogic sIdlls of the candidates under consideration for promotion or appointment. Due to this scenario there is a constant dilemma and growing lack of interest among the faculty members to neglect and relegate their teaching responsibilities. Most faculty members have driven themselves in the rat race of "Publish-or-Perish" with consider- able neglect of teaching and training of medical students.

Instead of passive teacher-based learn- ing we must usher the era of active stu- dent-based learning. The didactic teaching should be reduced to less than one-third of

total teaching time. Moreover, it is desir- able to outline the objectives, scope and contents of each lecture so that the teacher is provided with detailed guidelines to cover essential aspects of the topic. Talking about the futility of passive teacher-ori- ented learning and ill effects of examina- tion-associated anxiety on the minds of students, Okell stated that "if we taught and examined less, our students will learn more". 9 The students should be provided opportunities for problem-based learning where they are encouraged to exercise their analytical skills to analyze the infor- mation and crystallize their conclusions and therapeutic options. Instead of acquir- ing facts through rote memory, they should be exposed to experiential learning through case studies, tutorials, group dis.. cussions, seminars and simulation, and role play models. The bed side learning should be accorded the highest priority. In this context, Sir William Osler rightly stated that "to study the phenomenon of di.sease without books is to sails an un- charted sea, while to study books without patients is not to go to the sea at all ...... ". The standards of bed side teaching n~ust be enhanced by auditing teaching activity of the faculty members, and according it due importance and weightage during promotional interviews. There is a need for active cooperation between the health de- livery wing of the Ministry of Health and academic sections of Medical Colleges so that teaching to the medical students can be imparted in a melieu of community set- ting in which they are expected to work af- ter graduation. Teaching capabilities, though inherent to some extent, can be nurtured by appropriate faculty develop" ment activities. Every medical college should develop a medical education unit

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to enhance pedagogic skills of faculty members and develop appropriate audio- visual resource material for teaching by harnessing modem technology. 8 The com- puter-based learning has opened new vis- tas for the medical students for self-di- rected active learning with anxiety-free re- inforcing biofeedback mechanism.

It is a sad reality that most fresh medical graduates lack psychomotor and commu- nication skills, and right attitude to handle their patients with confidence. It is desir- able to introduce a system of log book dur- ing clinical clerkship and internship so that essential skills, case studies and practical information for handling of common child health problems of national importance is acquired by all of them before their certifi- cation.

Assessment and Evaluation

The nature and quality of assessment de- termines the quality of end product, i.e. basic doctor. The evaluation techniques must be linked with the educational objec- tives and core curriculum. 1~ The current system of evaluation lacks in day-to-day assessment and is often unreliable due to subjectivity in the viva-voce and practical examination. There is over-emphasis on re- call or rote memory while psychomotor and communication skills are not even evaluated due to lack of satisfactory tools.

There is need for a consistent and con- tinuous assessment during and following didactic and clinical clerkship in pediat- rics. Medical Council of India has recom- mended that 20% of the total marks in a subject should be earmarked for internal assessment and the candidate must secure at least 50% marks in the internal assess- ment in order to qualify for admission to

THE INDIAN JOURNAL OF PEDIATRICS 725

final summative assessment or examina- tion. At the All India Institute of Medical Sciences, equal weightage is accorded to the internal assessment and terminal ex- amination (50% each) which demands high degree of moral and professional responsi- bilities on the part of faculty members to ensure a fair and unbiased assessment.

The assessment must focus on relevant rather than rare health problems of chil- dren with special emphasis on diseases of children covered under the national health policy. It is important to increase focus and importance of internal day-to-day assess- ment with maintenance of a log book. The- ory paper should cover a large area of the subject by asking short answer structured questions and MCQs. The outmoded sub- jective system of clinical assessment by al- locating one long and one short case should be replaced by objectivized struc- tured clinical examination (OSCE), and holding structured viva-voce examination. Tools should be developed to assess atti- tudes and communication skills. Instead of assessment of recall, efforts should be made to assess the ability of the candidate to solve a clinical problem, interpret clini- cal and laboratory data and analyze avail- able information in the light of his core knowledge to reach to a plausible diagno- sis and plan rational management. At- tempts should be made to objectively as- sess his professional skills. There is a need to introduce a standardised national ex- amination for uniform assessment of all the medical graduates to maintain mini- mum standards of medical education and competency throughout the country. It would demand a uniform course curricu- lum for all undergraduate medical stu- dents which would indeed be a welcome' step. The current phase of internship in the

726 THE INDIAN JOURNAL OF PEDIATRICS 1993; Vol. 60. No. 6

career of medical graduate students is a mere waste of time, because it is used for preparing for the enterance to various postgraduate courses. Like other assess- ment tools, entrance examinations often ask esoteric questions pertaining to un- common disorders rather than common and relevant conditions. Modifications of our assessment procedure both in its objec- tivity and quality of contents is mandatory to change the attitude, and increase the emphasis of students towards issues which are of practical relevance. The fact that a large number of medical graduates are opting for post graduate and post doctoral studies, raises the fundamental issue re- garding the need and relevance of a basic doctor. There is a need for a national de- bate to discuss whether there should be two tracks of medical education, one cul- minating in the production of a basic doc- tor or a family physician, and the other progressing to produce specialists in vari- ous subspecialities depending upon the national needs of human resource develop- ment in various medical disciplines. Un- less corrective action is initiated now, In- dia would also be faced by too many spe- cialists and not enough general practitio- ners (GPs) or family physicians. The ad- mission criteria and core curricula for the undergraduate medical students belonging to these two tracks shall be different to serve their special needs and require- ments.

Continuing Pediatric Education of Family Physicians

Medical knowledge is expanding fast and unless one keeps abreast of these ad- vances, the patients may be denied the an- ticipated benefits. Human life is too pre-

cious and doctors must continue to update their knowledge and skills from cradle to grave. Family physicians must inculcate an ethos and develop a compulsive behaviour for a continuing self-directed learning which should be supported by profes- sional associations, academic bodies and training institutions. Medical Council of India, like other academic bodies abroad, should ensure that all family physicians and general practitioners are recertified every 5 years. Indian Academy of Pediat- rics has developed standard teaching mod- ules on common child health problems for the benefit of family physicians, and is in the process of producing audio cassettes and publications with questionnaires to develop a system of credit and recertifica- tions of GPs in collaboration with the Indian Medical Association.

REFERENCES

1. Ministry of Health and Family Welfare. National Health Policy, Government of India, 1983.

2. Abrahmson S. Diseases of curriculum, l Med Educ 1978; 53 : 952-957.

3. The Edinburgh Declaration. World Confer- ence on Medical Education of the World Federation-for Medical Education. Med Educ 1988; 22 : 481-482.

4. Verma K, D'Monte B, Adkoli BV et al. Inquiry-driven strategies for innovations in medical education in India. AIIMS, New Delhi 1990. Indian J Pediatr 1993; 60 : 739-749.

5. Singh M. Behavioural sciences and medi- cal ethics for undergraduate medical students. Indian J Med Educ "In Press'.

6. Chhaparwal BC, Walia BNS, Bhargava SK et al. Report of the sub-committee for cur- riculum in Pedatrics for undergraduate medical education. Indian Pediatr 1993; 30 : 408-425.

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7. Singh M, Paul VK. Recommendations of sub-committee constituted by Medical Council of India to prepare syllabus in Pediatrics for undergraduate medical students. Indian Pediatr 1993; 30 : 702-712.

8. Grand' Maison P, Des Marchans JE. Pre- paring faculty to teach in a problem-based

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10.

learning curriculum : The Sherbrooke experience. Canad Med Assoc J 1991; 144 : 557-562. Okell CC. Grains and scruples. Lancet 1938; i : 107-108. Weatherall DJ. Examining undergraduate examinations. Lancet 1991; 338 : 37-39.

FIT FOR LIFE

For people who do heavy physical work, an average day's labour provides sufficient exercise. But for people in sedentary jobs, regular leisure-time exercise offers many health benefits. To be fit you don't have to be able to finish a marathon race or develop a lot of muscles. Rather, you need to be of normal weight and to have enough flexibility, muscular strength and cardiovascular endurance to meet everyday demands.

There is no short cut to being fit. The duration and intensity of exercise should be built up slowly and regularly, over many months. The earlier you start, the better. And physical exercise should continue into old age; lifelong fitness requires lifelong regular exercise.

Abstracted from : World Health Magazine. Geneva, World Health Organization

January-February 1992, "Heart Health", World Health Forum 1993; Vol. 14 : 95.