- Email: [email protected]
Rural MBBS degree in India
Comment
control. Recruiting such a person will show serious commitment to a bold new vision. This opportunity should not be missed.
3
*Salmaan Keshavjee, Francoise Girard, Mark Harrington, Paul E Farmer
5
Program in Infectious Disease and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA 02115, USA (SK, PEF); Division of Global Health Equity, Brigham and Women’s Hospital, Boston, MA, USA (SK, PEF); Partners In Health, Boston, MA, USA (SK, PEF); Open Society Foundations, New York, NY, USA (FG); and Treatment Action Group, New York, NY, USA (MH) [email protected]
4
6
7 8
9
We declare that we have no conflicts of interest. 1
2
WHO. Multidrug and extensively drug-resistant TB (M/XDR-TB): 2010 global report on surveillance and response. 2010. http://whqlibdoc.who. int/publications/2010/9789241599191_eng.pdf (accessed Oct 7, 2010). Stop TB Partnership. Basic framework for the partnership to stop TB. 2010. http://www.stoptb.org/assets/documents/about/STBBasicFramework.pdf (accessed Oct 1, 2010).
10
Wells CD, Cegielski JP, Nelson LJ, et al. HIV infection and multidrug-resistant tuberculosis: the perfect storm. J Infect Dis 2007; 196 (suppl 1): S86–107. Keshavjee S, Seung K. Stemming the tide of multidrug-resistant tuberculosis: major barriers to addressing the growing epidemic. November, 2008. http://ghsm.hms.harvard.edu/uploads/pdf/iom_mdrtb_ whitepaper_2009_01_14.pdf (accessed Oct 7, 2010). Szreter S. Rethinking McKeown: the relationship between public health and social change. Am J Public Health 2002; 92: 722–25. Keshavjee S, Gelmanova IY, Pasechnikov AD, et al. Treating multidrugresistant tuberculosis in Tomsk, Russia: developing programs that address the linkage between poverty and disease. Ann N Y Acad Sci 2008; 1136: 1–11. Keshavjee S, Farmer PE. Time to put boots on the ground: making universal access to MDR-TB treatment a reality. Int J Tuberc Lung Dis 2010; 14: 1222–25. Lindert K, Linder A, Hobbs J, de la Brière B. The nuts and bolts of Brazil’s Bolsa Família Program: implementing conditional cash transfers in a decentralized context. May, 2007. http://siteresources.worldbank.org/ INTLACREGTOPLABSOCPRO/Resources/BRBolsaFamiliaDiscussionPaper. pdf (accessed Oct 1, 2010). Broekmans J, Caines K, Paluzzi JE. Investing in strategies to reverse the global incidence of TB. 2005. http://www.unmillenniumproject.org/ documents/TB-frontmatter.pdf (accessed Oct 1, 2010). UN. The Millennium Development Goals Report 2010. 2010. http://www. un.org/millenniumgoals/pdf/MDG%20Report%202010%20En%20r15%20 -low%20res%2020100615%20-.pdf (accessed Oct 1, 2010).
Rural MBBS degree in India Published Online July 29, 2010 DOI:10.1016/S01406736(10)61006-9
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.1 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.1,2 A sharp debate has ensued in the Indian media with the vocal medical fraternity generally
Mikkel Ostergaard/Panos
The printed journal includes an image merely for illustration
1284
opposed to the new degree on the grounds that the shorter duration will result in inadequately trained professionals.2,3 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 www.thelancet.com Vol 376 October 16, 2010
Comment
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.4 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.5,6 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.7 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
www.thelancet.com Vol 376 October 16, 2010
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.8 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.9 *Sanjay Kinra, Yoav Ben-Shlomo Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK (SK); and Department of Social Medicine, University of Bristol, Bristol, UK (YB-S) [email protected] We declare that we have no conflicts of interest. 1
2
3
4 5 6 7
8 9
Anon. MBBS goes rural, doctors to villages. Deccan Chronicle Oct 12, 2009. http://www.deccanchronicle.com/bengaluru/mbbs-goes-rural-doctorsvillages-019 (accessed July 23, 2010). Mascarenhas A. MCI’s proposal to start rural MBBS invites sharp criticism. Indian Express Jan 19, 2010. http://www.indianexpress.com/news/mcisproposal-to-start-rural-mbbs-course-in/569099 (accessed July 23, 2010). Anon. Rural MBBS discriminatory, says NHRC. Jan 30,2010. http://www. indiaedunews.net/Medical/Rural_MBBS_course_discriminatory,_says_ NHRC_10448 (accessed July 23, 2010). Remmen R, Derese A, Scherpbier A, et al. Can medical schools rely on clerkship to train students in basic clinical skills? Med Educ 1999; 33: 600–05. Evidence-based Medicine Working Group. Evidence-based medicine: a new approach to teaching the practice of medicine. JAMA 1992; 268: 2420–25. Emanuel EJ. Changing premed requirements and the medical curriculum. JAMA 2006; 296: 1128–31. Blumenthal D, Gokhale M, Campbell EG, Weissman JS. Preparedness for clinical practice: reports of graduating residents at academic health centers. JAMA 2001; 286: 1027–34. Rosenblatt RA, Schneeweiss R, Hart LG, Casey S, Andrilla CH, Chen FM. Family medicine training in rural areas. JAMA 2002; 288: 1063–64. Batalden P, Davidoff F. Teaching quality improvement: the devil is in the details. JAMA 2007; 298: 1059–61.
1285
control. Recruiting such a person will show serious commitment to a bold new vision. This opportunity should not be missed.
3
*Salmaan Keshavjee, Francoise Girard, Mark Harrington, Paul E Farmer
5
Program in Infectious Disease and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA 02115, USA (SK, PEF); Division of Global Health Equity, Brigham and Women’s Hospital, Boston, MA, USA (SK, PEF); Partners In Health, Boston, MA, USA (SK, PEF); Open Society Foundations, New York, NY, USA (FG); and Treatment Action Group, New York, NY, USA (MH) [email protected]
4
6
7 8
9
We declare that we have no conflicts of interest. 1
2
WHO. Multidrug and extensively drug-resistant TB (M/XDR-TB): 2010 global report on surveillance and response. 2010. http://whqlibdoc.who. int/publications/2010/9789241599191_eng.pdf (accessed Oct 7, 2010). Stop TB Partnership. Basic framework for the partnership to stop TB. 2010. http://www.stoptb.org/assets/documents/about/STBBasicFramework.pdf (accessed Oct 1, 2010).
10
Wells CD, Cegielski JP, Nelson LJ, et al. HIV infection and multidrug-resistant tuberculosis: the perfect storm. J Infect Dis 2007; 196 (suppl 1): S86–107. Keshavjee S, Seung K. Stemming the tide of multidrug-resistant tuberculosis: major barriers to addressing the growing epidemic. November, 2008. http://ghsm.hms.harvard.edu/uploads/pdf/iom_mdrtb_ whitepaper_2009_01_14.pdf (accessed Oct 7, 2010). Szreter S. Rethinking McKeown: the relationship between public health and social change. Am J Public Health 2002; 92: 722–25. Keshavjee S, Gelmanova IY, Pasechnikov AD, et al. Treating multidrugresistant tuberculosis in Tomsk, Russia: developing programs that address the linkage between poverty and disease. Ann N Y Acad Sci 2008; 1136: 1–11. Keshavjee S, Farmer PE. Time to put boots on the ground: making universal access to MDR-TB treatment a reality. Int J Tuberc Lung Dis 2010; 14: 1222–25. Lindert K, Linder A, Hobbs J, de la Brière B. The nuts and bolts of Brazil’s Bolsa Família Program: implementing conditional cash transfers in a decentralized context. May, 2007. http://siteresources.worldbank.org/ INTLACREGTOPLABSOCPRO/Resources/BRBolsaFamiliaDiscussionPaper. pdf (accessed Oct 1, 2010). Broekmans J, Caines K, Paluzzi JE. Investing in strategies to reverse the global incidence of TB. 2005. http://www.unmillenniumproject.org/ documents/TB-frontmatter.pdf (accessed Oct 1, 2010). UN. The Millennium Development Goals Report 2010. 2010. http://www. un.org/millenniumgoals/pdf/MDG%20Report%202010%20En%20r15%20 -low%20res%2020100615%20-.pdf (accessed Oct 1, 2010).
Rural MBBS degree in India Published Online July 29, 2010 DOI:10.1016/S01406736(10)61006-9
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.1 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.1,2 A sharp debate has ensued in the Indian media with the vocal medical fraternity generally
Mikkel Ostergaard/Panos
The printed journal includes an image merely for illustration
1284
opposed to the new degree on the grounds that the shorter duration will result in inadequately trained professionals.2,3 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 www.thelancet.com Vol 376 October 16, 2010
Comment
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.4 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.5,6 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.7 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
www.thelancet.com Vol 376 October 16, 2010
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.8 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.9 *Sanjay Kinra, Yoav Ben-Shlomo Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK (SK); and Department of Social Medicine, University of Bristol, Bristol, UK (YB-S) [email protected] We declare that we have no conflicts of interest. 1
2
3
4 5 6 7
8 9
Anon. MBBS goes rural, doctors to villages. Deccan Chronicle Oct 12, 2009. http://www.deccanchronicle.com/bengaluru/mbbs-goes-rural-doctorsvillages-019 (accessed July 23, 2010). Mascarenhas A. MCI’s proposal to start rural MBBS invites sharp criticism. Indian Express Jan 19, 2010. http://www.indianexpress.com/news/mcisproposal-to-start-rural-mbbs-course-in/569099 (accessed July 23, 2010). Anon. Rural MBBS discriminatory, says NHRC. Jan 30,2010. http://www. indiaedunews.net/Medical/Rural_MBBS_course_discriminatory,_says_ NHRC_10448 (accessed July 23, 2010). Remmen R, Derese A, Scherpbier A, et al. Can medical schools rely on clerkship to train students in basic clinical skills? Med Educ 1999; 33: 600–05. Evidence-based Medicine Working Group. Evidence-based medicine: a new approach to teaching the practice of medicine. JAMA 1992; 268: 2420–25. Emanuel EJ. Changing premed requirements and the medical curriculum. JAMA 2006; 296: 1128–31. Blumenthal D, Gokhale M, Campbell EG, Weissman JS. Preparedness for clinical practice: reports of graduating residents at academic health centers. JAMA 2001; 286: 1027–34. Rosenblatt RA, Schneeweiss R, Hart LG, Casey S, Andrilla CH, Chen FM. Family medicine training in rural areas. JAMA 2002; 288: 1063–64. Batalden P, Davidoff F. Teaching quality improvement: the devil is in the details. JAMA 2007; 298: 1059–61.
1285