What is missing in medical education.

The missing ‘E’s of medical education
K. Srinath Reddy

Medical education needs to be reconfigured to increase the emphasis on epidemiology, economics, ethics, empathy and engagement with the health system.
The Flexner Report, published in the United States in 1910, had a major impact on the reconfiguration of medical education in North America and, subsequently, in Britain and Europe. It called for a stronger scientific foundation in medical education, with emphasis on laboratory-linked learning. By prescribing standards for medical schools, it not only changed the way medicine was taught but also limited the number of schools accredited to create a community of modern medical professionals, wherein entry was sharply restricted and strictly regulated. An elite group of doctors started to grow around the world, wearing the mantle of the scientific method and waving the flag of technology-led medical care.

The Flexner model needs re-examination a century later, when the multiple determinants of health are better recognised and the many dimensions of health care better understood. Reductionist medical education provides the scientific rigour of evidence gathered from focussed research. However, it limits the understanding of a complex interplay of multiple systems that operate within the human body, as well as in its physical and social environments, to define the balance between health and disease. There is now a growing recognition of the need to infuse a greater degree of inter-disciplinary learning into medical education, for broadening the spectrum of knowledge and expanding the ambit of practice.

Modern medical education in India has been modelled on the British pattern, which followed the Flexner framework. It evolved to accommodate the Indian context in some areas of content and some aspects of pedagogy. However, there are several deficiencies which adversely affect the knowledge, attitudes and practice of the young professionals who graduate from the majority of medical colleges in India. These gaps in training ultimately affect the quality of health care and need urgent redress if medical education is to serve its larger societal purpose. While a few institutions have created educational environments and crafted learning methods to partially overcome these deficiencies, the problems abound, unrecognised and unattended, in most medical colleges. Principally, the gaps can be identified as the missing ‘E’s of medical education: epidemiology, economics, ethics, empathy and engagement.

Epidemiology: While epidemiology has traditionally been defined as the study of the dimensions, distribution and determinants of disease, within and across populations, it also forms the basis of disease prevention and health promotion. Equally important, it helps to estimate the probabilities of events occurring at the level of a population or an individual. These events may relate to the occurrence of a disease or the beneficial outcome of a treatment. Epidemiology also teaches us about the probabilities of a ‘false positive’ or a ‘false negative’ diagnostic test result when the test is employed in persons with varying clinical profiles. Estimation of expected outcome probabilities, based on a Bayesian understanding of prior probability, helps to better define the benefit-risk ratios of different treatment approaches.

Simply put, medical students should be able to distinguish that an abnormal exercise ECG result (‘positive’ treadmill test) is associated with very different probabilities of being indicative of coronary heart disease in a 56-year-old male smoker and a 38-year-old woman with anaemia and not indiscriminately refer both of them for a coronary angiogram. They should also be able to critically appraise the methodological strengths and weaknesses of published research, to aid them in clinical decision-making during their future practice.
Risk assessment is a critical element of decision-making in health, whether it involves population level policies or individual level clinical care. Yet, the average medical student is not familiar with the interpretation of different risk indicators like relative risk, absolute risk and population attributable risk, despite their widely varied implications and applications. Epidemiological orientation will prepare a doctor to be a better clinician, researcher and policymaker.

Epidemiology has now evolved into application areas such as clinical epidemiology, social epidemiology, genetic epidemiology, nutritional epidemiology and pharmaco-epidemiology, apart from classical domains such as infectious disease epidemiology and chronic disease epidemiology. Medical education in India is virtually bereft of exposure to epidemiology, apart from a few perfunctory and non-contextual explanations in the curriculum of Preventive and Social Medicine. Rarely does a teacher in Clinical Medicine or Gynaecology apply the epidemiological method in explaining the population context of a health problem or in explicitly evolving a decision tree for choosing a particular method of treatment in an individual patient.

Economics: While the cost of health care is an important element both from a societal viewpoint and an individual patient’s viewpoint, considerations of the comparative cost-effectiveness of different diagnostic tests or treatment methods do not feature in medical education. The incremental cost-benefit of sequential diagnostic testing, rather than a simultaneous array of multiple diagnostic tests, is seldom discussed in the classroom or clinical settings where medical students are taught.

Despite effective generic drugs being available, costly brand name drugs are prescribed by the young doctors whose choice is more influenced by what drug industry representatives tell them than by the consideration of a patient’s purchasing capacity. Even where the government spends, the concept of an ‘opportunity cost’, wherein money spent on unnecessary tests or treatments is seen as money diverted from other potentially lifesaving health interventions, is never ingrained into the mind of a medical student.

Ethics: While the subject of medical ethics is taught as a minor part of Forensic Medicine, it is not highlighted sufficiently throughout the medical curriculum, especially in the settings where clinical subjects are taught. Concepts related to confidentiality and informed consent are neglected or notionally dealt with. Patient rights do not figure in any clinical discourse, in a conventional medical college. Unfortunately, role modelling by senior doctors is deficient in this vital area of medical education.

Empathy: Lack of empathy is a fundamental flaw of modern medical education. It relates to the role definition of a doctor during the years of medical schooling and determines whether a medical professional views his or her role, vis-À-vis a patient, as an impersonal provider of services, a paternalistic benefactor or a learned facilitator. Unfortunately, the structure of conventional medical education distorts the process by which this role is defined in the mind of the student. The first contact in a medical college is with a cadaver. The student is taught to acquire knowledge from the dead, in an impersonal manner, for self-advancement. On entering the clinical wards, he or she is directed by well meaning teachers and senior students to examine patients with statements like “see that case — he has a nice heart murmur” or “go to bed no. 24 — there is an interesting case of abdominal mass.” The driving force becomes ‘how can I learn from this patient,’ and the question of ‘how can we help this patient’ becomes secondary.

This depersonalisation carries into the future careers of doctors who pride in their learning and see the patient as an incidental beneficiary of their skills. In a ‘provider-consumer’ model of health care, the patient becomes a mere customer. At best, the relationship is transactional. At its worst, the relationship is exploitative and degenerates into crass commercialisation.

In contrast, picture a pattern of medical education which commences with the medical novitiates being guided in conducting a survey of the health conditions in their neighbourhood communities (urban and rural). The students would identify the major health problems of the community and return to the medical college, motivated by the desire to gain knowledge which will help them to assist that community in overcoming those challenges. Attaching a medical student to a family, to be followed up over the 5 years of medical education, would provide a context and continuing exposure to the natural history of diseases, health care costs and performance of health systems, as exemplified by the living experience of that family. Through such connectivity, the students would define their role as ‘informed facilitators’ who must acquire and apply knowledge to improve the health status of the community, rather than merely to enhance their professional status, social standing and financial earnings.

Engagement: As students train in tertiary care hospitals located in urban environments, they have little understanding of the larger health system which delivers health care to the population. They do not get to visit a district hospital which is a critical junction point in the health system or learn how national health programmes are routed through the district health network. The rural posting is too limited to provide familiarity with primary health care needs and constraints. Several factors which determine who reaches the medical college hospital present a restricted profile of health disorders. When such a medical student is asked to go to a village, immediately after graduation, he or she is in a totally unfamiliar setting widely separated from the training institution’s sophisticated facilities.

If a substantial part of medical training is imparted in the district hospital and the sub-district health system, young doctors will be far better positioned to serve the health care needs of the population. Such an engagement with the health system, during the period of formative training, is essential to design, develop and deliver a doctor attuned to India’s needs and equipped to respond to them.

(K. Srinath Reddy is president of the Public Health Foundation of India.)