- Email: [email protected]
Post-MBBS exit test for doctors in India
Correspondence
and Ministry of Health and Social Welfare, Banjul, The Gambia (MC) 1
2
Cole-Ceesay R, Cherian M, Sonko A, et al. Strengthening the emergency healthcare system for mothers and children in The Gambia. Reprod Health 2010; 7: 21. Hafeez A, Zafar S, Qureshi F, Mirza I, Bile K, Southall D. Emergency maternal and child health training courses and advocacy to achieve Millennium Development Goals in a poorly resourced country; challenges and opportunities. J Pak Med Assoc 2009; 59: 243–46.
again. We should take note of whether the Democratic Party truly maintains public participation in policy making. We declare that we have no conflicts of interest.
*Mariko Takeuchi, Masaharu Tsubokura [email protected] University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan 1
Japan’s health policy
Corbis
In his Offline piece on Japan’s health system (Sept 11, p 858),1 Richard Horton criticises the fact that large vested interests dominate and that the voice of the academic community is almost silent in Japan. The Ministry of Health, Labour and Welfare (MHLW) was indeed formerly the only think tank involved in Japan’s health policy, but the political power shift in 2009 enabled the public to participate in policy making. Before the regime change, MHLW held absolute authority over policy decisions and some problems inevitably could be pointed out. First, MHLW bureaucrats exclusively selected members of policy board meetings.2 Such a procedure tapped into a limited range of opinions, leading to biased policy making. Second, scientists and doctors could not express their opinion against MHLW’s policy. They feared offending the bureaucrats since they had the power to shuffle personnel. However, the regime change enabled patients, doctors, and scientists to convey their opinions to the government. Medical students appealed for an increase in the number of doctors on television and the newspapers, and I was provided with an opportunity to discuss the matter with several politicians. These actions contributed to an increase in medical school quotas after a 24-year stagnation. This publicled reform seems similar to that of the UK during the Blair administration. We hope that this trend will continue; however, the government and bureaucrats could collude 1900
2
Horton R. Offline: Japan: a mirror for our future. Lancet 2010; 376: 858. Tomoko O. Who is paying the price of health care? Japan Times 2010; March 14. http:// search.japantimes.co.jp/cgi-bin/ fs20060314a3.html (accessed Nov 15, 2010).
Richard Horton1 discusses Japan’s endemic political crisis and the threats to its health-care system. However, he does not mention the ongoing drastic revision of health-care policy after regime change from the Liberal Democratic Party of Japan (LDP) to the Democratic Party of Japan (DPJ) in 2009. These changes in Japan are similar to the New Labour health reforms in the UK2 in many respects: increases in medical expenditure and doctors’ supply directed by political leadership. Over the period 1961–2009 of the Japanese universal health insurance coverage, the LDP governed the Japanese health-care system. Under the initiative of the bureaucracy and its regulation, the LDP had reined in the total medical fee, which triggered medical facilities’ closures. The collapse of regional health care has been caused by this flawed policy and by physician shortages.3 After the change of government in 2009, the DPJ took the political initiative and placed 100 political appointees in the ministries. For the first time in 10 years, the DPJ increased the total medical fee to 0·19%, adding 570 billion yen.4 Moreover, greater remuneration was allocated to firststage inpatient treatment in the departments of emergency medicine, obstetrics, paediatrics, and surgery, as well as to hospitals for complex operations. These strategies turned the trend of doctors’ resignations and
helped to prevent the further collapse of medical services. The education ministry now plans to establish new medical schools to cover a deepening shortage of doctors.5 Japan should learn from the British lessons on health reform2—DPJ’s ability to make radical changes of health policy is tested. We declare that we have no conflicts of interest.
*Koichiro Yuji, Tomoko Matsumura, Yuko Kodama, Naoko Murashige, Masahiro Kami [email protected] Department of Internal Medicine, Research Hospital, Institute of Medical Science, University of Tokyo, Tokyo 108-8639, Japan (KY); and Division of Social Communication System for Advanced Clinical Research, Institute of Medical Science, University of Tokyo, Tokyo, Japan (TM, YK, NM, MK) 1 2
3
4
5
Horton R. Offline: Japan: a mirror for our future. Lancet 2010; 376: 858. Brown H. Tony Blair’s legacy for the UK’s National Health Service. Lancet 2007; 369: 1679–1682. Hiratate H. Patients adrift: the elderly and Japan’s life-threatening health reforms. Japan Focus March 11, 2008. http://japanfocus.org/Hiratate-Hideaki/2693 (accessed Sept 21, 2010). Anon. Greater remuneration should be allocated for hospital doctors. Japan Times Feb 19, 2010. http://www.japantimes.co.jp/ weekly/ed/ed20100227a1.htm (accessed Sept 21, 2010). Anon. More medical schools eyed to combat lack of doctors. Japan Times June 22, 2010. http://search.japantimes.co.jp/cgi-bin/ nn20100622a6.html (accessed Sept 21, 2010).
Post-MBBS exit test for doctors in India I am writing in response to a Times of India article dated Sept 17, 2010, which describes a common post-MBBS examination—“an exit test before docs can practice”.1 Apparently the newly constituted board of governors at the Medical Council of India (MCI) has accepted the fact that not all fresh medical graduates are ready for serving in society, meaning that they agree about the deterioration of medical education in our country. The story of the tainted president of the MCI, Ketan Desai, who is still in custody, has already been covered in The Lancet.2 www.thelancet.com Vol 376 December 4, 2010
Correspondence
There is no doubt that Desai’s long bull-run is one of the main factors behind the deterioration of medical education in India. With the mushrooming of private medical colleges and the various policies of the government, the standard of medical education has been compromised. Of course there are many exceptionally good teaching and non-teaching institutes which are encouraging medical tourism in the country, but they are not a true reflection of the prevailing conditions in our country.3 Even this fast-growing medical tourism is at stake after the report of a new superbug from India.4 I am sure this post-MBBS test will never come into force and even if by chance it does, it will further add to the misery of the already deteriorating medical education in India. If you look into the current trend of students opting for medical fields, it is evident that most are average or belowaverage students. This exit test will add to this adverse situation. Even the reservation policy of the government will be a big hurdle. What will happen to those who will not be able to clear the test? They have after all put in more than 5 years of time, labour, and more importantly money. How will the Indian Government, which has failed to control the rampant quackery that prevails in rural as well as urban areas, be able to prevent these qualified quacks from practising medicine? The members of the newly formed board of governors at the MCI should look deeply into the reasons that have led to the deterioration in standards of medical education in general rather than coming up with an absurd idea which is hard to implement. At the same time the government should give serious thought to attracting brilliant brains to this profession and to stopping the exodus of doctors from this country, particularly to the UK and USA. The health of the common man should be the priority rather than medical tourism. I declare that I have no conflicts of interest.
www.thelancet.com Vol 376 December 4, 2010
Sudhir Kumar Thakur
for the MBBS and probably more than just kidney transplantation and angiography has to be excluded to condense the course. Reducing the study of basic sciences will make BRMS graduates no different from quacks, who have practical knowledge but lack scientific rigor.
[email protected] Santosh Medical College, Shipra Sun City, Indirapuram, Ghaziabad, UP 201014, India 1
2 3 4
Times News Network. Post-MBBS: an exit test before docs can practise. Times of India 2010; Sept 18: 10. Chatterjee P. Trouble at the Medical Council of India. Lancet 2010; 375: 1679. Thakur SK. Responsible writing. Ind J Surg 2010; 72: 278. Kumarasamy KK, Toleman MA, Walsh TR, et al. Emergence of a new antibiotic resistance mechanism in India, Pakistan, and the UK: a molecular, biological, and epidemiological study. Lancet Infect Dis 2010; 10: 597–602.
I declare that I have no conflicts of interest.
Debajyoti Datta [email protected] NRS Medical College and Hospital, Kolkata, West Bengal 700014, India 1
Rural MBBS degree in India: ignoring the real problem?
2
3
In their Comment (Oct 16, p 1284), Sanjay Kinra and Yoav Ben-Shlomo praise the introduction of the Bachelor of Rural Medicine and Surgery (BRMS) degree in India. However, this stop-gap approach masks the real problem of lack of infrastructure in the health delivery system. Recently, junior doctors in Kolkata protested against the lack of infrastructure in top government hospitals.2 When the premier hospitals are in this state, the rural scenario can easily be understood, although it gets little media attention. Medical services are not an island that would function without overall rural development. Moreover, the possibility of a dichotomy will always persist. Those who are capable of qualifying for the MBBS will do so, leaving those who are not to study the BRMS. The BRMS course is to be taught in rural settings by retired professors,3 but it is naive to assume that professors of medical colleges in urban areas will relocate to rural areas if even junior doctors are unwilling to do so. With only a 6-month internship, BRMS graduates would be responsible for managing a primary health centre, whereas subordinate nurses would have studied for 5 years.4 Overall, the duration of study is 1 year less than 1
4
Kinra S, Ben-Shlomo Y. Rural MBBS degree in India. Lancet 2010; 376: 1284–85. Anon. SSKM junior doctors call strike after assault, ire at lack of security. The Telegraph Sept 26, 2010. http://www.telegraphindia. com/1100926/jsp/bengal/story_12983286. jsp (accessed Oct 20, 2010). Mascarenhas A. MCI’s proposal to start rural MBBS invites sharp criticism. Indian Express Jan 19, 2010. http://www.indianexpress.com/ news/mcis-proposal-to-start-rural-mbbscourse-in/569099 (accessed Oct 20, 2010). Prakash D, Samaram G. IMA opposes govt proposal of “Bachelor of Rural Medicine & Surgery (BRMS)—3 ½ yrs course”. http:// imampstate.com/circulars/IMA_ Memorandum.pdf (accessed Oct 20, 2010).
Simian viruses and emerging diseases in human beings Recent advances in our understanding of the simian origins of HIV have brought us very close to a comprehensive set of explanatory models and evidence to account for the facts and timing of the emergence of the AIDS epidemic. In response, some of the leading figures doing research and scholarship on this important issue held an international symposium in Paris, France, on June 9–10, 2010. Sponsored by the Paris-Diderot University’s Faculty of Medicine and Department of History and Philosophy of Science, the Symposium featured more than 20 scientists and scholars from Europe, Africa, and the USA, with various disciplinary backgrounds in virology, evolutionary and computational biology, epidemiology, history, and anthropology. The meeting
For the symposium website see http://www.simianvirusesand emergingdiseasesinhumans.org/
1901
and Ministry of Health and Social Welfare, Banjul, The Gambia (MC) 1
2
Cole-Ceesay R, Cherian M, Sonko A, et al. Strengthening the emergency healthcare system for mothers and children in The Gambia. Reprod Health 2010; 7: 21. Hafeez A, Zafar S, Qureshi F, Mirza I, Bile K, Southall D. Emergency maternal and child health training courses and advocacy to achieve Millennium Development Goals in a poorly resourced country; challenges and opportunities. J Pak Med Assoc 2009; 59: 243–46.
again. We should take note of whether the Democratic Party truly maintains public participation in policy making. We declare that we have no conflicts of interest.
*Mariko Takeuchi, Masaharu Tsubokura [email protected] University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan 1
Japan’s health policy
Corbis
In his Offline piece on Japan’s health system (Sept 11, p 858),1 Richard Horton criticises the fact that large vested interests dominate and that the voice of the academic community is almost silent in Japan. The Ministry of Health, Labour and Welfare (MHLW) was indeed formerly the only think tank involved in Japan’s health policy, but the political power shift in 2009 enabled the public to participate in policy making. Before the regime change, MHLW held absolute authority over policy decisions and some problems inevitably could be pointed out. First, MHLW bureaucrats exclusively selected members of policy board meetings.2 Such a procedure tapped into a limited range of opinions, leading to biased policy making. Second, scientists and doctors could not express their opinion against MHLW’s policy. They feared offending the bureaucrats since they had the power to shuffle personnel. However, the regime change enabled patients, doctors, and scientists to convey their opinions to the government. Medical students appealed for an increase in the number of doctors on television and the newspapers, and I was provided with an opportunity to discuss the matter with several politicians. These actions contributed to an increase in medical school quotas after a 24-year stagnation. This publicled reform seems similar to that of the UK during the Blair administration. We hope that this trend will continue; however, the government and bureaucrats could collude 1900
2
Horton R. Offline: Japan: a mirror for our future. Lancet 2010; 376: 858. Tomoko O. Who is paying the price of health care? Japan Times 2010; March 14. http:// search.japantimes.co.jp/cgi-bin/ fs20060314a3.html (accessed Nov 15, 2010).
Richard Horton1 discusses Japan’s endemic political crisis and the threats to its health-care system. However, he does not mention the ongoing drastic revision of health-care policy after regime change from the Liberal Democratic Party of Japan (LDP) to the Democratic Party of Japan (DPJ) in 2009. These changes in Japan are similar to the New Labour health reforms in the UK2 in many respects: increases in medical expenditure and doctors’ supply directed by political leadership. Over the period 1961–2009 of the Japanese universal health insurance coverage, the LDP governed the Japanese health-care system. Under the initiative of the bureaucracy and its regulation, the LDP had reined in the total medical fee, which triggered medical facilities’ closures. The collapse of regional health care has been caused by this flawed policy and by physician shortages.3 After the change of government in 2009, the DPJ took the political initiative and placed 100 political appointees in the ministries. For the first time in 10 years, the DPJ increased the total medical fee to 0·19%, adding 570 billion yen.4 Moreover, greater remuneration was allocated to firststage inpatient treatment in the departments of emergency medicine, obstetrics, paediatrics, and surgery, as well as to hospitals for complex operations. These strategies turned the trend of doctors’ resignations and
helped to prevent the further collapse of medical services. The education ministry now plans to establish new medical schools to cover a deepening shortage of doctors.5 Japan should learn from the British lessons on health reform2—DPJ’s ability to make radical changes of health policy is tested. We declare that we have no conflicts of interest.
*Koichiro Yuji, Tomoko Matsumura, Yuko Kodama, Naoko Murashige, Masahiro Kami [email protected] Department of Internal Medicine, Research Hospital, Institute of Medical Science, University of Tokyo, Tokyo 108-8639, Japan (KY); and Division of Social Communication System for Advanced Clinical Research, Institute of Medical Science, University of Tokyo, Tokyo, Japan (TM, YK, NM, MK) 1 2
3
4
5
Horton R. Offline: Japan: a mirror for our future. Lancet 2010; 376: 858. Brown H. Tony Blair’s legacy for the UK’s National Health Service. Lancet 2007; 369: 1679–1682. Hiratate H. Patients adrift: the elderly and Japan’s life-threatening health reforms. Japan Focus March 11, 2008. http://japanfocus.org/Hiratate-Hideaki/2693 (accessed Sept 21, 2010). Anon. Greater remuneration should be allocated for hospital doctors. Japan Times Feb 19, 2010. http://www.japantimes.co.jp/ weekly/ed/ed20100227a1.htm (accessed Sept 21, 2010). Anon. More medical schools eyed to combat lack of doctors. Japan Times June 22, 2010. http://search.japantimes.co.jp/cgi-bin/ nn20100622a6.html (accessed Sept 21, 2010).
Post-MBBS exit test for doctors in India I am writing in response to a Times of India article dated Sept 17, 2010, which describes a common post-MBBS examination—“an exit test before docs can practice”.1 Apparently the newly constituted board of governors at the Medical Council of India (MCI) has accepted the fact that not all fresh medical graduates are ready for serving in society, meaning that they agree about the deterioration of medical education in our country. The story of the tainted president of the MCI, Ketan Desai, who is still in custody, has already been covered in The Lancet.2 www.thelancet.com Vol 376 December 4, 2010
Correspondence
There is no doubt that Desai’s long bull-run is one of the main factors behind the deterioration of medical education in India. With the mushrooming of private medical colleges and the various policies of the government, the standard of medical education has been compromised. Of course there are many exceptionally good teaching and non-teaching institutes which are encouraging medical tourism in the country, but they are not a true reflection of the prevailing conditions in our country.3 Even this fast-growing medical tourism is at stake after the report of a new superbug from India.4 I am sure this post-MBBS test will never come into force and even if by chance it does, it will further add to the misery of the already deteriorating medical education in India. If you look into the current trend of students opting for medical fields, it is evident that most are average or belowaverage students. This exit test will add to this adverse situation. Even the reservation policy of the government will be a big hurdle. What will happen to those who will not be able to clear the test? They have after all put in more than 5 years of time, labour, and more importantly money. How will the Indian Government, which has failed to control the rampant quackery that prevails in rural as well as urban areas, be able to prevent these qualified quacks from practising medicine? The members of the newly formed board of governors at the MCI should look deeply into the reasons that have led to the deterioration in standards of medical education in general rather than coming up with an absurd idea which is hard to implement. At the same time the government should give serious thought to attracting brilliant brains to this profession and to stopping the exodus of doctors from this country, particularly to the UK and USA. The health of the common man should be the priority rather than medical tourism. I declare that I have no conflicts of interest.
www.thelancet.com Vol 376 December 4, 2010
Sudhir Kumar Thakur
for the MBBS and probably more than just kidney transplantation and angiography has to be excluded to condense the course. Reducing the study of basic sciences will make BRMS graduates no different from quacks, who have practical knowledge but lack scientific rigor.
[email protected] Santosh Medical College, Shipra Sun City, Indirapuram, Ghaziabad, UP 201014, India 1
2 3 4
Times News Network. Post-MBBS: an exit test before docs can practise. Times of India 2010; Sept 18: 10. Chatterjee P. Trouble at the Medical Council of India. Lancet 2010; 375: 1679. Thakur SK. Responsible writing. Ind J Surg 2010; 72: 278. Kumarasamy KK, Toleman MA, Walsh TR, et al. Emergence of a new antibiotic resistance mechanism in India, Pakistan, and the UK: a molecular, biological, and epidemiological study. Lancet Infect Dis 2010; 10: 597–602.
I declare that I have no conflicts of interest.
Debajyoti Datta [email protected] NRS Medical College and Hospital, Kolkata, West Bengal 700014, India 1
Rural MBBS degree in India: ignoring the real problem?
2
3
In their Comment (Oct 16, p 1284), Sanjay Kinra and Yoav Ben-Shlomo praise the introduction of the Bachelor of Rural Medicine and Surgery (BRMS) degree in India. However, this stop-gap approach masks the real problem of lack of infrastructure in the health delivery system. Recently, junior doctors in Kolkata protested against the lack of infrastructure in top government hospitals.2 When the premier hospitals are in this state, the rural scenario can easily be understood, although it gets little media attention. Medical services are not an island that would function without overall rural development. Moreover, the possibility of a dichotomy will always persist. Those who are capable of qualifying for the MBBS will do so, leaving those who are not to study the BRMS. The BRMS course is to be taught in rural settings by retired professors,3 but it is naive to assume that professors of medical colleges in urban areas will relocate to rural areas if even junior doctors are unwilling to do so. With only a 6-month internship, BRMS graduates would be responsible for managing a primary health centre, whereas subordinate nurses would have studied for 5 years.4 Overall, the duration of study is 1 year less than 1
4
Kinra S, Ben-Shlomo Y. Rural MBBS degree in India. Lancet 2010; 376: 1284–85. Anon. SSKM junior doctors call strike after assault, ire at lack of security. The Telegraph Sept 26, 2010. http://www.telegraphindia. com/1100926/jsp/bengal/story_12983286. jsp (accessed Oct 20, 2010). Mascarenhas A. MCI’s proposal to start rural MBBS invites sharp criticism. Indian Express Jan 19, 2010. http://www.indianexpress.com/ news/mcis-proposal-to-start-rural-mbbscourse-in/569099 (accessed Oct 20, 2010). Prakash D, Samaram G. IMA opposes govt proposal of “Bachelor of Rural Medicine & Surgery (BRMS)—3 ½ yrs course”. http:// imampstate.com/circulars/IMA_ Memorandum.pdf (accessed Oct 20, 2010).
Simian viruses and emerging diseases in human beings Recent advances in our understanding of the simian origins of HIV have brought us very close to a comprehensive set of explanatory models and evidence to account for the facts and timing of the emergence of the AIDS epidemic. In response, some of the leading figures doing research and scholarship on this important issue held an international symposium in Paris, France, on June 9–10, 2010. Sponsored by the Paris-Diderot University’s Faculty of Medicine and Department of History and Philosophy of Science, the Symposium featured more than 20 scientists and scholars from Europe, Africa, and the USA, with various disciplinary backgrounds in virology, evolutionary and computational biology, epidemiology, history, and anthropology. The meeting
For the symposium website see http://www.simianvirusesand emergingdiseasesinhumans.org/
1901