Buried somewhere in government files for over three years is a document that could make classroom lectures in the nation's medical colleges give way to bedside lessons in villages. It's a document that contains dramatic proposals for a new system of medical education in the country. A group of doctors and health activists has now urged the health ministry to retrieve the document and act on it to change the way in which students become doctors in India.

In the existing system, students are mainly confined to a single medical college or institution for the entire four-and-a-half-year period of undergraduate education leading to the MBBS degree. In sharp contrast, the alternative system will require students to spend one-and-a-half years each at three different levels of healthcare ' first in rural health centres, then in district hospitals and finally in large city hospitals.

The Medical Council of India (MCI) has already approved the plan. But the 'alternative curriculum' is so radical that there are sharp divisions within India's medical community. Some doctors and policy-makers have said that the plan is 'impractical and unimplementable'. But others argue that its potential benefits make it worthwhile to launch it at least on an experimental basis.

Even the government has acknowledged that there is need to change the curriculum. At a special meeting last week between the health minister Anbumani Ramadoss and representatives of medical colleges, the minister indicated that the government is keen to improve the curriculum. 'We need to make it more practical-oriented, more rural-oriented and more social-oriented,' Ramadoss said.

Health activists and many doctors say that India has witnessed an unhealthy growth and commercialisation of medical education. India has around 225 medical colleges, 104 among them in the private sector, most of them clustered around cities or towns.

Old concerns

'The current system has given rise to the neglect of rural health care and to many medical graduates who are not really competent to practice medicine when they graduate,' says Dr K.M. Shyamprasad, chairman of the Christian Medical College in Ludhiana. 'The absence of infrastructure and patients in some private medical colleges leads to half-baked medical graduates,' Shyamprasad said.

Medical education officers attending the minister's meeting reiterated long-suspected concerns that many private medical colleges lack teaching staff and patients. One delegate, Dr Param Pal Singh Coonar, joint director of medical education in Punjab, said there are cases of dental graduates who've not extracted a single tooth during their education. Experts say that listening to lectures is a poor means of acquiring knowledge and even less effective in the development of medical skills.

'Our first objective was to convince the MCI to accept the curriculum and that has been achieved,' said Dr Gouri Pada Dutta, former professor of obstetrics and gynaecology at the Calcutta National Medical College and member of the state planning board in West Bengal. Dutta, who played a key role in devising the alternative curriculum, says it is intended to integrate medical education with community health.

Practice makes perfect: Calcutta Medical College students work in the lab (above). A light moment between classes on the college campus (below)

Going rural

Under the new proposals, the teaching and learning process would occur in patient settings. The students would learn clinical subjects through interaction with outpatients, and teaching in indoor wards at the bedside and in the emergency departments of hospitals. Each student would spend one-and-a-half-year each first in a rural community health centre, then a district hospital and, finally, in a large hospital.

There would be two groups of faculty ' a core group consisting of the regular faculty in medical colleges and a non-core group made up of the doctors in the rural community health centres and district hospitals. 'Doctors in such hospitals would find it stimulating to impart knowledge to young students,' said Dutta. The students will acquire first-hand knowledge of the socio-economic factors that influence community health.

The new system would expose students to problem-based and self-directed learning. While lectures and discussions with faculty would certainly continue, learning through real-life situations and through constant interaction with peers would be given greater emphasis than it is today.

Such an approach would also allow medical students to learn to work in rural conditions. 'Right now, many medical graduates have this notion that their knowledge cannot be practised in rural areas because of absence of facilities,' said Shyamprasad. 'The focus in conventional institutions is on sophisticated tests such as ultrasounds and CT scans. But the new approach would teach them how to successfully manage patients in resource-poor settings.'

Too many cooks

Proponents of the alternative curriculum say many developed countries, including the US, have encouraged community-based medical training in recent years. 'The existing curriculum here does not prepare students for community medicine or general practice,' said Dr Ravi Narayan, a health activist in Bangalore who is also global coordinator of the People's Health Movement. 'As a consequence, specialists examine even common illnesses. And patients are over-doctored, over-investigated, and over-treated.'

The alternative curriculum, Narayan said, is not really a novel concept. A few medical colleges ' such as the Christian Medical Colleges in Ludhiana and Vellore, the All India Institute of Medical Sciences in New Delhi, the St John's Medical College in Bangalore, and the Mahatma Gandhi Institute of Medical Sciences in Wardha ' have experimented with community-based training on small groups of students over the past few years.

But the proposal may encounter resistance from within the government. A senior officer of the directorate general of health services said that the system is unlikely to work given the existing infrastructure in rural areas. 'There are gross deficiencies in existing community health centres,' said a senior officer who did not wish to be named. 'There are staff constraints and lack of medicines. How could students be trained in such circumstances'

Experts rooting for the new curriculum, however, say it would produce medical graduates who would not in any way be inferior to those who graduate out of medical schools today. They say all it needs is a change in attitude among faculty, doctors and students. 'The only hurdles to the proposals are in the heads of planners and some professionals,' said Narayan.

URGENT! URGENT!

Classroom learning or bedside healing in villages' Do you think medical students should be made to undertake the latter before they become doctors' Write in to us by Saturday, April 16, 2005, and we will publish your views in the next edition of Careergraph. E-mail us at: career@abpmail.com, fax us at: (033) 2236 1208, 2225 3142 or snail mail asap to Careergraph, 6, Prafulla Sarkar Street, Calcutta-700 001.