India has come out with a “Rural MBBS” program in which the course duration has been shortened from the conventional six years and a half (including house surgeoncy) to four years.
These doctors will have training with no frills. Their training will not include exotic surgery or too detailed basic sciences, but will be problem oriented training in ordinary ailments. They will have to sign an agreement by which they will have to practice in a rural area for a minimum of ten years.
There has been considerable debate about this new program and the medical fraternity has been generally against it. In a recent article in The Lancet entitled “Rural MBBS degree in India”, the authors Sanjay Kinra and Yoav Ben-Schlomo point out how poor the medical service in rural India is, and raise a couple of issues.
One simple question is:
- Do we know it for a fact that the current six and a half years is the optimal period of training for a doctor?
- On the other hand, are the rural and smaller hospitals competent to train these doctors?
Comment: Rural MBBS Degree in India
Sanjay Kinra, Yoav Ben-Shlomo – The Lancet, Saturday, October 16, 2010, Volume: 376, Issue: 9749, Pages: 1284 to 1285
To address the shortfall of doctors in rural India, the Medical Council of India is starting an innovative Bachelor of Medicine and of Surgery (MBBS) rural degree.
Although details of this course are still emerging, reports suggest that it will be shorter in duration (4 years) than the standard MBBS in India (5·5 years, which includes a 1-year mandatory internship), and the qualifying doctors will be allowed to practise only in rural areas for the first 10 years, after which time they might be eligible to work in urban areas.
A sharp debate has ensued in the Indian media with the vocal medical fraternity generally opposed to the new degree on the grounds that the shorter duration will result in inadequately trained professionals. However, inherent to this debate is the assumption that the current duration of the MBBS in India is right, and more generally, that we know how long it takes to produce a competent medical doctor.
To investigate this question, we overviewed (using electronic sources) medical curricula for 55 countries. The duration of medical education is relatively consistent across the world with medical training taking about 6 years, ranging from 5 to 8 years, before a licence to practise is obtained. Medical training is typically split into 5 years of schooling, of which the first 3 years are preclinical and the fourth and fifth are clinical, followed by a 1-year apprenticeship on the job. However, there is considerable variation in the intensity of teaching, with shorter courses either being more intense, or requiring the students to be graduates. Interestingly, graduation did not necessarily have to be in a related field. We also informally surveyed graduates from several countries, which generated some ad-hoc common themes—eg, “there was a lot of wasted time, but it allowed me to grow up” and “most of the clinical skills are gained after qualification”. A crucial question, in view of the cost of medical training, is whether we currently teach too much basic science, and whether a more focused problem-based learning course supplemented with laboratory-based training in clinical skills is adequate to produce competent doctors in a shorter time. Yet others have argued for inclusion of underserved skills, such as good communication and an evidence-based approach to practice, which would increase the duration of courses. Course content and delivery will affect the course’s duration.
The shorter duration of the rural MBBS in India will be achieved by excluding certain specialist topics (eg, kidney transplantations or angiography) that are deemed to be irrelevant for rural practitioners who will provide primary medical care, but not undertake surgical treatment or manage complex cases. It seems plausible to deliver the required education and training in this time, especially because rural doctors will be expected to focus on a particular setting. The course will be delivered entirely in rural health centres and hospitals, which ironically might result in the rural doctors having a higher level of competency in clinical skills, which are generally agreed to be important for doctors, compared with their urban counterparts. What remains to be seen, however, is whether it will be possible to consistently and reliably deliver high-quality education in small rural centres.
The other criticisms levelled at the rural MBBS, such as increased likelihood of mistakes or infringement of human rights due to treatment by inadequately trained doctors, bear little credibility. Currently, the shortage of doctors in rural India stems from the unwillingness of most doctors, who were born and trained in urban areas, to move to rural areas. The rural MBBS scheme aims to train people from rural areas in those rural areas, in the belief that they will stay, which offers some hope of providing medical care to large parts of rural India that currently lack it. Whether or not they succeed, the Indian Government should be praised for trying to find an innovative solution to a deeply entrenched problem, which is not unique to India. In the end, the quality of care will depend not only on the duration of medical training, but also on its quality and, perhaps even more importantly, the “after-sales” service. Medical education is largely experiential learning, and robust systems for continuous medical education and audit are vital to allow these rural doctors to maintain and update their clinical knowledge and skills on an ongoing basis.
* – Full text with references can be viewed on TheLancet.com (free registration required)