Medical education must become more inclusive

"Why have you weaponised the attendance in lectures against us?", "Why are you blackmailing us with the internal assessment marks?" I have heard young medical students implore with agony during one on one discussions about their experiences in college. In medical colleges most universities impose a mandatory attendance in more than 75% of lectures and 80% of clinical classes and a mandatory passing marks in internal assessments to make them eligible to appear in the final examination to pass that year and move on to the next one. While the intention behind this is to ensure that structured learning happens, such a mandate is oppressive to many students, even to those who are very serious about their studies. 

Last year a group of first year medical students got together to write a letter to the Health Secretary of the Government of Tamil Nadu. Scanned copy of this letter went viral in all medical teaching social media groups and platforms. The students had appealed to the Health Secretary to intervene and 'save them' from the onslaught of boring PowerPoint presentations and uninteresting lectures which they found to be a 'waste of their time'. Instead they requested more clinical exposure, bedside learning and practical sessions. The letter created a lot of hype in social media. There were debates among faculty groups calling it "uprising of the minions". Some senior faculty labelled it degradation of medical education, which was already going to the dogs. I was a medical teacher for close to a decade and have seen all this happen first hand. Here is a reflection on my experiences. 

In 2019, the National Medical Council, the apex body that governs the curriculum of medical education, revised the medical curriculum and introduced the Competency Based Medical Education (CBME). For many of us who were in medical teaching at that time, this was a time of excitement and anticipation. We were all waiting eagerly for the new method of teaching which brought with it a lot of promise. The old curriculum suffered from serious problems. They were highly teacher centric. The teaching program was conceived and implemented in a manner that was convenient to the teacher. It was planned in such a way that the teacher did not have to take much efforts to engage in a class. For example, they would prepare for a lecture on acute myocardial infarction this week, prepare a PowerPoint presentation for it and rehash the same thing year after year for batches of students. Occasionally, some new development would take place and would go into the presentation as a new slide. The PowerPoint presentation gave the convenience of not even having to remember what needs to be said. One could just read out from the slides. Throw in some clinical images here and there, an ECG here and an Echocardiogram image there, the lecture is all set. I have been in charge of making teaching schedules in the department where I worked. I have heard some of my colleagues say, "Give me the same topic as last time. I already have the PowerPoint ready" Clinical classes also became teacher centric. A fixed number of 'exam cases' would be all that a teacher had to teach. If a teacher prepares for a clinical case, they can keep repeating the same thing again and again batch after batch. The teaching would never be specific to the patient who was examined and presented. It would be generic to the disease condition that was discussed. The only reason why this worked was because, medical education is a life long learning process and therefore a doctor would see the common diseases and problems during their practice and learn on the job. Then CBME came and we were excited about it. 

CBME promised to make medical education more student centric. Two interesting teaching methods came up - small group teaching and self directed learning. While it is easy to give an unprepared spiel about any topic in a large lecture, it is far more challenging to engage a small group of 15-20 students on focused topics. Moreover, it is tough to hold a small group of students together in a session of self directed learning. These sessions would demand that the teacher prepare intensively before the class. But most medical colleges face faculty shortages and increasing number of students. Many colleges have 150-250 students per batch and just about 5-10 faculty in a department. Given the diverse array of activities including clinical work, operation theatre work, laboratory work in addition to teaching, that would leave just 2-3 faculty free for teaching. This made handling such small group sessions and self directed learning impossible. Small group teachings which were originally conceptualised as intense small group engagement of students on certain topics, became small group didactic lectures. Instead of a lecture hall of 250 students, 5 batches of 50 students started being called as 'small groups'. They are small compared to the magnitude of the whole class, but not at all small when it comes to the matter of active participation and engagement. In the name of CBME, the same old didactic teaching is being continued in a new format. Novel fancy names are being given to activities, new forms of record keeping and log books are introduced. But the teaching seems to remain the same. 

With this hugely boring and disengaging medical pedagogy, inspiring students to attend classes has become a huge challenge. "We would rather spend our afternoons in peace either doing something we enjoy, or even resting" they feel. Many started singing up for online tutorials for post-graduate competitive exam preparation. The advantage of these sessions was that they could take it at any time of the day when they were fresh and engaged and it could happen in the comfort of their homes, in their rooms. The interested students started hanging out in the library or the hospital wards with their seniors, post-graduate students and junior faculty whom they could relate to and learn in their own pace. But this was anti-establishment and so attendance percentages became mandatory. Coercing students to attend lectures and demonstrations that are meaningless and boring does more harm to them than good. Even the most enthusiastic and interested students that I have interacted with, dream of a world where there is no attendance requirement in boring lecture classes. 

The students are further threatened and intimidated by a barrage of internal assessment exams. In the third year there used to be 4 subjects, community medicine, forensic medicine, ENT and Ophthalmology. The students used to have an internal assessment exam once a month in each of these subjects. Sometimes, they would be spaced out through the month at the rate of one subject a week. So the students would keep writing internal assessment exams throughout the year. They would be constantly under the pressure to study for exams. In some colleges, internal assessment marks are sent to the parents of the students through email. What more humiliation can a young man or woman, just entering an independent learning life in medical college, have more than being answerable for their 'low scores' in oppressive internal assessment exams. There would be a threat that if the students do not pass all the internal assessment exams, they would not be allowed to take the final qualifying examination. 

Not only this, medical education has a one-size-fits-all approach. It does not consider the fact that different learners have different learning potentials and different learning styles. While some may enjoy an engaging lecture session, some may prefer to sit in a small group and learn on their own. While some may prefer making seminars and symposium presentations, others may be shy and prefer listening to video lectures. The student does not have a choice on the method of learning that they prefer. It may not be practical to cater to the needs and demands of each of the 250 students in a batch. But there must be enough avenues and opportunities for students to explore learning in their preferred methods. I know of a young, reticent third year student who went into an emotional breakdown because she was forced to participate in a role play session in front of a class of 150 students. 

In such an oppressive learning environment, how do we expect our young doctors to learn and thrive? Any teacher who has taken interest in their students' lives and had one honest conversation with them would understand how the medical education system sucks the enthusiasm and life out of young students. We need to drastically rethink our medical education system. If we are able to implement CBME in its true spirit, that itself would be a great move forward. The NMC mandates medical education technology workshops for all medical teachers. I have attended two such workshops and facilitated sessions in several others. I don't think they make any impact on medical education. They make medical teaching-learning more and more regimented and empty the process of its vitality and joy.  There is a need to sit with young medical students, those who are currently in the system and those who have passed out and learn from them, what went right and what went wrong. Instructional design must be diversified. Participative adult learning methods must become the norm. This would mean increasing the number of medical teachers, engaging with part time teachers, adjunct teachers and emeritus teachers to focus intensively on diverse learning techniques. Attendance mandate must be relaxed. Attendance percentage has become a tool of oppression and does not meet its intended purpose. If classes are engaging and interesting, attendance will automatically go up. The focus must be on modifying instructional design. The innumerable internal assessment exams must be stopped. Formative assessment in small groups and continuous feedback must be implemented with a motive to improve learning. Today medical education excludes those who do not fit in with its demands. Medical education must become inclusive. It should embrace people of different aptitudes and different interests. Just like how there is a space for different types of doctors in the world, there must be space for different types of medical students to thrive and become those doctors.