Each global pandemic is a fresh reminder of the fact that countries cannot fight such events in isolation and there has to be coordination at least among the medical fraternity across the world to save lives and get the situation under control. A truly international medical education system is a concept that can help connect the world seamlessly during such emergencies. Though there aren’t many takers yet for the recently initiated World Health Organisation program to implement accreditation for accreditors of medical schools worldwide, Grenada-based St. George’s University (SGU) has been an exception. SGU, which runs the world’s largest English speaking medical school that attracts students from 140 countries, follows a system that is universally accredited and accepted. This University, which also maintains a wide network of partner schools in different countries in addition to its sprawling Caribbean Island campus, provides students opportunities to get trained in many countries. Recognising the global challenge of physician shortages, it also offers a range of scholarships for Commonwealth students, who can undertake clinical training in the US, UK and Canada. Dr G Richard Olds, President of St. George’s University and a world authority on med-schooling, is a proponent of an international medical education system. He believes that such a system is highly beneficial not only for implementing a global standard in medical practice, but also for enabling students to understand patient populations in different geographies. A strong critic of the traditional English (British) medical education system that is still followed in India, Dr Olds says that Indian medical education system has challenges on several fronts, in this month’s Straight Talk with Editor.
India’s medical education system, though one of the largest in the world in terms of the number of institutions and students, isn’t yet considered competitive globally. The country continues to face a severe shortage of doctors and suffers from poor quality healthcare. What do you think are the real reasons for this situation?
There are many challenges in the Indian medical education system, some of which I also found almost similar to those in countries such as the US and the UK too. The primary issue with the medical education systems in these countries is the same — an inadequate number of medical schools in proportion to the population and a shortage of faculties. This leads to not only inadequate seats for deserving students, but also a severe shortage of doctors to cater to the actual demand. Other critical issues pertaining to India include the unequal demographic distribution of medical schools and a further reduced number of residency seats and opportunity for clinical training. The fewer number of medical schools as compared to the demand drives many Indian students, who aspire to take a medical degree as a career option, to foreign schools every year. A severe shortage of residency courses forces a large number of medical graduates to migrate from India for clinical training and specialisation. The very limited number of PG seats also pushes a large percentage of these graduates to remain general practitioners (GPs) with their undergraduate degree, which is not considered as a qualification to practice medicine in the US or the UK. India allows them to practice with just that degree.
Another big challenge, in addition to losing doctors to developed countries, is the dearth of doctors, even GPs, to serve in rural areas. The key reason behind this is unequal demographic distribution of medical colleges in the country and, to a certain extent, a standardised test score to get into medical colleges. Since a large majority of medical schools in India are in bigger cities, the graduates who complete their education in these cities often hesitate to go back to the rural areas to practice. At the same time, a one-for-all admission test makes the entry of less competitive rural students into medical schools difficult.
India also loses a good portion of its medical graduates to foreign countries due to the better work environment there and financial considerations. Graduates who seek residency courses in advanced countries due to shortage of seats in India also tend to find better opportunities in those countries for professional reasons as well as far better remuneration. Residency training in advanced countries like the US or UK also enables them to secure medical licenses for many other countries. As a result of these inherent issues in the traditional medical education system in India, the country continues to suffer from a severe shortage of doctors on the one hand and struggles with lower quality of healthcare due to very few specialists and well trained doctors on the other.
As a veteran medical educationalist with broad exposure to different systems across the world, what are your suggestions for India to overcome these challenges?
Obviously, the quick solution is to create more schools. But in order to overcome the challenges of shortage of doctors for rural service, you need to also ensure the distribution of those additional schools across the country, and with emphasis on increased residency courses and capacities. Long-duration residency courses in hospital schools are very important as a deeper clinical practice is the most critical element in medical education and practice.
I also understand that the availability and retention of expert medical faculty is another big issue in Indian medical education. This needs to be addressed by providing a better work environment and financial compensation. From my Indian experience, I must also say that let the doctors be free from non-medical work, such as administrative and bureaucratic responsibilities, as these often put an unnecessary burden on them and help only to make their work less enjoyable.
You emphasised the importance of long duration residency programmes like the ones offered in the western world. But, do you think such longer duration courses are feasible in India?
There is so much that is happening in the field of medicine. In other words, there is so much we can do today as compared to what we could do forty or fifty years ago to save lives, with the advancement in medicine. But, most of these new things are quite sophisticated and fairly complicated. For instance, understanding molecular medicine and many of the latest things in medical technology, and taking the case of this pandemic — understanding the disease, the nuances of the virus, disease severity and the mechanisms of transmission etc — all that makes it so obvious that the doctors need to be trained much more.
In fact, the US has fully eliminated the system of GPs, who used to practice medicine after their medical school and a year’s internship, several years ago. The US went for a three-year residency in internal medicine after medical school decades ago; the UK went for a more aggressive training programme of four years plus, after graduation. So, I strongly feel that clinical training is very important and there should be more intensive residency programmes everywhere.
You (SGU) have a partner school in India and that makes you quite familiar with the system and the learning material in Indian medical schools. How do you compare the curriculum taught in India with those of other countries?
India followed the English education system in its medical schools. This was formed according to the needs of that time and basically focused more on pre-existing knowledge and learning materials. But the practice of modern medicine in the latest era gives much more importance to hands-on learning and clinical training. While the UK has almost fully changed that system over the years, India is still stuck in the same. One of the main drawbacks of this system is the relatively little clinical experience students get compared to US trained physicians. The reason is that the English system used to push for information-based education in most of the five-year programmes, with very little focus on clinical experience. This is also the reason why Indian and English students were put into internships after medical school to gain exposure to clinical activity. On the contrary, the US medical education gives its entire focus in the last 2 to 3 years of medical school to clinical experience. In addition, American schools have also recently introduced clinical medicine activity in the first year of the five-year programme itself.
These programmes are not exactly focused on a pre-knowledge-based approach, but on the real hospital work culture, such as how to work in a team of medical technicians, nurses and peers and how to interact with the patients and people and to learn the art of medicine, in addition to clinical training on a wider range of topics before getting into specialty programmes. Even in England, med-schools have started exposing their students to out-patient settings much earlier than what used to be ten years ago. I would even suggest that doctors should be trained with other healthcare professionals like nurses and technicians to help boost their ability to work as a team.
Indian doctors are generally considered brilliant globally. Will you rate the Indian students in med schools too at the same intellectual level?
I rate them very highly. The students from India do extremely well not only in medicine but in all other fields as well. I must say, Indian doctors are really smart and hard working and they make terrific physicians. That is not the problem. The challenge often lies in ensuring the right education and training for them in their own country. The only criticism that I may have about Indian physicians when they first come to the United States is the cultural gap, as they aren’t really exposed to a population that is much more diverse than in India. So they need to learn to work within a diverse patient population. In a lateral standpoint, I would say Indian doctors would do extremely well given the opportunity and from a cultural standpoint, they need to adjust in a country that is made up of people from all over the world and gain the experience to become a truly international physician.
What are your views about entry tests like NEET in India and MCAT in the US to get into medical schools? Do you support the concept of an internationally accepted qualifying system for doctors?
Depending solely on such a test score for medical admission has its intrinsic problems and limitations. First, it ends up disproportionately selecting students from the rich and privileged class who can afford to get trained to pass such examinations. At the same time, many brilliant and passionate students miss the opportunity if they are not qualified in this scoring method. Secondly, a test score is not the only aspect that makes a good doctor. There are more important qualities as well that need to be considered as a base for the medical profession.
Towards the goal of an international standard of medical education, I think there should be a system of quality physician training which has worldwide acceptance. In a way, we are reaching there with medical licensing that is recognised mostly around the world. For eg., doctors trained in the UK can practice anywhere in commonwealth countries and in the United States. Also, we have Board Certification in the US with which one can practice in several countries, including India. More importantly, the concept that is initiated at World Health Organisation recently for the accreditation of accreditors of medical schools around the world can really help achieve this goal, though it may take longer as many medical schools around the world may find it difficult to rise to that high level.
What makes SGU a preferred destination for aspiring doctors from around the world?
Well, there are many factors that make a medical school the best in the global context. SGU is currently the largest English speaking medical school in the world and I strongly believe that it is the best, though I may sound a bit biased. Certainly, our statistics proves that it makes the best med-school through metrics. Of course, we are expensive, but what makes us different is an interesting philosophy in education that helps make the admission process and the course design truly customised for the students by understanding their background and their way forward. We follow a rigorous admission process, wherein we interview each student to know not only their academic score but other aspects like their commitment to the education, their passion and perspectives for this profession and other skill sets as well. If we like a student as a potential physician, we take them through a pathway that can really optimise his or her success. For example, SGU offers various types of course designs, such as a five-year, six-year or even a seven-year programme, depending on the student’s ability to adjust with the teaching and the training. At the same time, since we take students from across the world, we can train them as per the requirement of their respective countries using our wide network of partner schools and teaching hospitals which also comply with the world’s top accreditation. This way, our med-school students also have the opportunity to learn medicine in some of the other best and most well-known hospitals in the world. That explains why we attract students from around the world, with a steep rise in the number of applications every year, and why we have the least attrition rate, the lowest in the world of medical schools.