A comment on “Perspective on medical education in India”

Dear Editor

“At present diagnosis as well as medicine in general is in a good deal of turmoil, with many problems pressing for solution.”^[1]

A scathing review of the erstwhile physician in 1938, where the author goes on to state –

“A prolific cause of errors in diagnosis is ignorance on the part of the practitioner.”^[1]

Hence, this century-old concern – dwindling standards of medical education – addressed in the article, “Perspective on medical education in India” piqued my interest.^[2] The author should be praised for casting much needed light on the perceived decline of medical education in India. The author herself, being a Professor of Pediatrics, has a rich experience of clinical teaching and her observation – “Easy accessibility to a plethora of investigations and a vast therapeutic armamentarium makes the physicians feel that a clinical diagnosis is superfluous” – affirms a particularly alarming trend in medicine: the dearth of bedside teaching of physical diagnosis.

Over 70 years ago, Henry Christian wrote,

“The usual work program of the resident staffs of our hospitals is defective…it does not provide adequate training to develop interns and residents into well trained clinicians…undesirable emphasis placed on investigation as the most important factor in the training.”^[3]

This constant barrage of constructive criticism has, probably, led to the exemplary standards that medicine has achieved today. Henry Christian, a student of the great William Osler, comes from a period of exclusive clinical diagnoses. His students, whose training he condemns, grew up to be stalwarts at a time when investigations took the focus away from clinical medicine. The author fittingly calls that “an era of master teachers.” And then came the new generation of “millennial teachers” who have had to make the transition from being students of the “laboratory investigations” era to being teachers in the “modern imaging era.” Probably, we will grow up to a future “telemedicine era” and learn to teach basics of teleconsultation.

It is true that the ward rounds of today entail service-oriented tasks without sufficient educational time. This leads to a lack of patient contact and dedicated teaching time that arises from various competing priorities which Paul Bergl summarizes excellently –

“The complexity and acuity of inpatient care, resident work hour restrictions, and the focuses on quality, timely documentation and discharge seemingly have made bedside teaching an afterthought.”^[4]

It requires years of practice and repeated exposure to physical findings to consistently recognize abnormalities. The senior professor’s demonstration of examination merits a prominent and permanent place on rounds. Being the most experienced member of the team, his or her evaluation has an impact on clinical decision making and serves to educate trainees. Thus, we must realign our priorities and bring teaching of the examination back to the bedside.

I agree with the author that the solution lies in the competency-based medical education with student-centered training, formative work-based assessment, and student feedback. In the words of the author herself, we need teachers with “vast vision of the past and a great imagination to see the future.”