Relevance of the Flexner Report to contemporary medical education in South Asia

Financial barriers and inequity in medical education in India: challenges to training a diverse and representative healthcare workforce

India has been historically challenged by an insufficient and heterogeneously clustered distribution of healthcare infrastructure. While resource-limited healthcare settings, such as major parts of India, require multidisciplinary approaches for improvement, one key approach is the recruitment and training of a healthcare workforce representative of its population. This requires overcoming barriers to equity and representation in Indian medical education that are multi-faceted, historical, and rooted in inequality. However, literature is lacking regarding the financial or economic barriers, and their implications on equity and representation in the Indian allopathic physician workforce, which this review sought to describe. Keyword-based searches were carried out in PubMed, Google Scholar, and Scopus in order to identify relevant literature published till November 2023. This state-of-the-art narrative review describes the existing multi-pronged economic barriers, recent and forthcoming changes deepening these barriers, and how these may limit opportunities for having a diverse workforce. Three sets of major economic barriers exist to becoming a specialized medical practitioner in India - resources required to get selected into an Indian medical school, resources required to pursue medical school, and resources required to get a residency position. The resources in this endeavor have historically included substantial efforts, finances, and privilege, but rising barriers in the medical education system have worsened the state of inequity. Preparation costs for medical school and residency entrance tests have risen steadily, which may be further exacerbated by recent major policy changes regarding licensing and residency selection. Additionally, considerable increases in direct and indirect costs of medical education have recently occurred. Urgent action in these areas may help the Indian population get access to a diverse and representative healthcare workforce and also help alleviate the shortage of primary care physicians in the country. Discussed are the reasons for rural healthcare disparities in India and potential solutions related to medical education.

A Primer on General Surgery Applicants Who Have Graduated From Indian Medical Schools

Background: Graduates of Indian medical schools account for the greatest proportion of non-US born international medical graduates applying to general surgery residency programs.Purpose: Provide information to facilitate fair and holistic review of applicants from Indian medical schools.Research Design: Comprehensive review of the Indian medical education system, including history, regulatory agencies, medical school admission, curriculum, cultural differences, immigration issues, and outcomes after residency.Results: The Indian medical education system is one of the world's oldest. The number of medical schools and graduates continues to increase. Medical school admission criteria are variable. Recent regulatory changes have improved the quality of applicants entering the US. Emphasis on academic performance over volunteerism as well as communication styles differ from US graduates. The success of graduates during and after residency is well documented.Conclusions: Understanding the differences in the US and Indian medical education systems will provide a basis for the fair evaluation of applicants.

Current challenges for doctors in India: Deprofessionalisation, reprofessionalisation or fragmentation?

Western-trained doctors in India struggled to establish themselves as a medical 'profession' in the 1920s and 1930s and these struggles continued into the post-colonial period. The direction of travel is, however, no longer clear. Increasing evidence of a crisis in doctors' collective ability to provide a form of self-regulation since 2000 is highlighted. India's Supreme Court suspended the operations of their country's medical councils in the face of a proliferation of poorly regulated private medical colleges. Practitioners of alternative systems of medicine and unqualified medical practice continue, while new 'short-course' doctors take over tasks previously restricted to fully fledged MBBS doctors. The diversification of the social origins of medical students, with rising numbers of doctors from a wider range of social backgrounds, threatens their aspirations to high status. There is little diminution of the earnings of elite doctors, yet their conditions of work are increasingly constrained by financial targets. Young doctors face uncertain futures. This article analyses the increasingly diverse occupational positions of doctors in India using a Bourdieusian lens and asks whether an alternative, stable form of institutional arrangements is emerging, as some have claimed, or if fragmentation is a more apt description.

Cultural adaptation, the 3-month efficacy of visual art training on observational and diagnostic skills among nursing students, and satisfaction among students and staff- a mixed method study

Background

Visual art training is a student-led approach using Western art pieces as the main teaching resources. It has been developed and applied in nursing and medical education in the United States. This study aimed to adapt visual art training to Chinese cultural context, then to compare the efficacy of the culturally-tailored visual art training versus traditional education on observational and diagnostic skills at 3-month follow-up among Chinese nursing students in master program.

Methods

This study included Phase 1 (cultural adaptation) and Phase 2 (3-month efficacy evaluation). It was conducted from June to September, 2019. In Phase 1, cultural barriers were identified and cultural adaptation strategy were made based on two focus group interviews. Phase 2 was a randomized controlled trial in a local museum. A total of 106 first-year nursing students in master program were randomized to the intervention group or the control group. Both groups received traditional education. In addition, intervention group received a visual art training (including a field-guided museum visit with observation and debriefing of Chinese oil paintings and clinical images, four teaching hours). Data were collected for both groups at baseline and 3-month follow-up on the observational and diagnostic skills measured by clinical image tests. Learning satisfaction with the visual art training was investigated among 53 intervention students and teaching satisfaction was done in 10 staff members by self-administered questionnaires.

Results

In phase 1, we adapted a culturally-tailored visual art training for nursing students in China. Observational skills of the intervention group increased significantly compared with the control group 3 months after the training (p < .001). A trend towards the improvement of diagnostic skills was indicated with increment of 2.92 points of the intervention group vs. 0.39 of the control group (p > .05). In general, all participants and staff were satisfied with the visual art training, especially the selected Chinese oil paintings and the student-led teaching process, but 34% (n = 18) were not satisfied with the long distance from the museum.

Conclusions

A culturally-tailored visual art training with great acceptability and feasibility was implemented in China. It had a sustained positive effect on improving the observational skills of Chinese nursing students. This study can be used for a reference to introduce visual art training to nursing students or nurses from other cultures.

Trial registration

Retrospectively registered in Chinese Clinical Trial Registry (ChiCTR2000037956) on 4th September, 2020.

The socio-economic transition and health professions education in Mongolia: a qualitative study

Background

Former socialist countries have undergone a socio-economic transition in recent decades. New challenges for the healthcare system have arisen in the transition economy, leading to demands for better management and development of the health professions. However, few studies have explored the effects of this transition on health professions education. Thus, we investigated the effects of the socio-economic transition on the health professions education system in Mongolia, a transition economy country, and to identify changes in requirements.

Methods

We used a multi-level perspective to explore the effects of the transition, including the input, process, and output levels of the health professions education system. The input level refers to planning and management, the process level refers to the actual delivery of educational services, and the output level refers to issues related to the health professionals, produced by the system. This study utilized a qualitative research design, including document review and interviews with local representatives. Content analysis and the constant comparative method were used for data analysis.

Results

We explored tensions in the three levels of the health professions education system. First, medical schools attained academic authority for planning and management without proper regulation and financial support. The government sets tuition fees, which are the only financial resource of medical schools; thus, medical schools attempt to enroll more students in order to adapt to the market environment. Second, the quality of educational services varies across institutions due to the absence of a core curriculum and differences in the learning environment. After the transition, the number of private medical schools rapidly increased without quality control, while hospitals started their own specialized training programs. Third, health professionals are struggling to maintain their professional values and development in the market environment. Fixed salaries lead to a lack of motivation, and quality evaluation measures more likely reflect government control than quality improvement.

Conclusions

Mongolia continues to face the consequences of the socio-economic transition. Medical schools’ lack of financial authority, the varying quality of educational services, and poor professional development are the major adverse effects. Finding external financial support, developing a core curriculum, and reforming a payment system are recommended.

Is enhancing the professionalism of healthcare providers critical to tackling antimicrobial resistance in low- and middle-income countries?

BACKGROUND

Healthcare providers' (HCPs) professionalism refers to their commitment and ability to respond to the health needs of the communities they serve and to act in the best interest of patients. Despite attention to increasing the number of HCPs in low- and middle-income countries (LMIC), the quality of professional education delivered to HCPs and their resulting professionalism has been neglected. The Global Action Plan on Antimicrobial Resistance (AMR) seeks to reduce inappropriate use of antibiotics by urging patients to access antibiotics only through qualified HCPs, on the premise that qualified HCPs will act as more responsible and competent gatekeepers of access to antibiotics than unqualified HCPs.

METHODS

We investigate whether weaknesses in HCP professionalism result in boundaries between qualified HCPs and unqualified providers being blurred, and how these weaknesses impact inappropriate provision of antibiotics by HCPs in two LMIC with increasing AMR-Pakistan and Cambodia. We conducted 85 in-depth interviews with HCPs, policymakers, and pharmaceutical industry representatives. Our thematic analysis was based on a conceptual framework of four components of professionalism and focused on identifying recurring findings in both countries.

RESULTS

Despite many cultural and sociodemographic differences between Cambodia and Pakistan, there was a consistent finding that the behaviour of many qualified HCPs did not reflect their professional education. Our analysis identified five areas in which strengthening HCP education could enhance professionalism and reduce the inappropriate use of antibiotics: updating curricula to better cover the need for appropriate use of antibiotics; imparting stronger communication skills to manage patient demand for medications; inculcating essential professional ethics; building skills required for effective collaboration between doctors, pharmacists, and lay HCPs; and ensuring access to (unbiased) continuing medical education.

CONCLUSIONS

In light of the weaknesses in HCP professionalism identified, we conclude that global guidelines urging patients to only seek care at qualified HCPs should consider whether HCP professional education is equipping them to act in the best interest of the patient and society. Our findings suggest that improvements to HCP professional education are needed urgently and that these should focus not only on the curriculum content and learning methods, but also on the social purpose of graduates.

Retaining Doctors in Rural Bangladesh: A Policy Analysis

Background: Retaining doctors in rural areas is a challenge in Bangladesh. In this study, we analyzed three rural retention policies: career development programs, compulsory services, and schools outside major cities – in terms of context, contents, actors, and processes.

Methods: Series of group discussions between policy-makers and researchers prompted the selection of policy areas, which were analyzed using the policy triangle framework. We conducted document and literature reviews (1971-2013), key informant interviews (KIIs) with relevant policy elites (n=11), and stakeholder analysis/position-mapping.

Results: In policy-1, we found, applicants with relevant expertise were not leveraged in recruitment, promotions were often late and contingent on post-graduation. Career tracks were porous and unplanned: people without necessary expertise or experience were deployed to high positions by lateral migration from unrelated career tracks or ministries, as opposed to vertical promotion. Promotions were often politically motivated. In policy-2, females were not ensured to stay with their spouse in rural areas, health bureaucrats working at district and sub-district levels relaxed their monitoring for personal gain or political pressure. Impractical rural posts were allegedly created to graft money from applicants in exchange for recruitment assurance. Compulsory service was often waived for political affiliates. In policy-3, we found an absence of clear policy documents obligating establishment of medical colleges in rural areas. These were established based on political consideration (public sector) or profit motives (private sector).

Conclusion: Four cross-cutting themes were identified: lack of proper systems or policies, vested interest or corruption, undue political influence, and imbalanced power and position of some stakeholders. Based on findings, we recommend, in policy-1, applicants with relevant expertise to be recruited; recruitment should be quick, customized, and transparent; career tracks (General Health Service, Medical Teaching, Health Administration) must be clearly defined, distinct, and respected. In policy-2, facilities must be ensured prior to postings, female doctors should be prioritized to stay with the spouse, field bureaucrats should receive non-practising allowance in exchange of strict monitoring, and no political interference in compulsory service is assured. In policy-3, specific policy guidelines should be developed to establish rural medical colleges. Political commitment is a key to rural retention of doctors.

Effectiveness of integrated teaching module in pharmacology among medical undergraduates

Context:

Over the years with advancement of science and technology, each subject has become highly specialized. Teaching of medical students has still remained separate in various departments with no scope of integration in majority of medical institutes in India. Study was planned to have an experience of integration in institute and sensitize faculty for integrated teaching–learning (TL) method.

Aims:

To prepare and test effectiveness of integrated teaching module for 2^nd year MBBS student in pharmacology and to sensitize and motivate faculties toward advantages of implementing integrated module.

Settings and Design:

Education intervention project implemented 2^nd year MBBS students of Government Medical College and New Civil Hospital, Surat.

Subjects and Methods:

Students of second MBBS were divided into two groups. One group was exposed to integrated teaching sessions and another to traditional method. Both the groups were assessed by pre- and post-test questionnaire, feedback and focus group discussions were conducted to know their experience about process.

Results:

A total of 165 students of the 2^nd year MBBS were exposed to the integrated teaching module for two topics in two groups. One group was taught by traditional teaching, and another group was exposed to the integrated TL session. Both the groups have shown a significant improvement in posttest scores but increase in mean score was more in integrated group. During analysis of feedback forms, it was noted that students preferred integrated TL methods since they help in better understanding. Faculty feedback shows consensus over the adaptation of integrated TL methods.

Conclusions:

Integrated TL sessions were well-appreciated by students and faculties. To improve the critical reasoning skills and self-directed learning of students, integrated TL is highly recommended for must know areas of curriculum.

Role Models and Teachers: medical students perception of teaching-learning methods in clinical settings, a qualitative study from Sri Lanka

BACKGROUND

Medical education research in general, and those focusing on clinical settings in particular, have been a low priority in South Asia. This explorative study from 3 medical schools in Sri Lanka, a South Asian country, describes undergraduate medical students' experiences during their final year clinical training with the aim of understanding the teaching-learning experiences.

METHODS

Using qualitative methods we conducted an exploratory study. Twenty eight graduates from 3 medical schools participated in individual interviews. Interview recordings were transcribed verbatim and analyzed using qualitative content analysis method.

RESULTS

Emergent themes reveled 2 types of teaching-learning experiences, role modeling, and purposive teaching. In role modelling, students were expected to observe teachers while they conduct their clinical work, however, this method failed to create positive learning experiences. The clinical teachers who predominantly used this method appeared to be 'figurative' role models and were not perceived as modelling professional behaviors. In contrast, purposeful teaching allowed dedicated time for teacher-student interactions and teachers who created these learning experiences were more likely to be seen as 'true' role models. Students' responses and reciprocations to these interactions were influenced by their perception of teachers' behaviors, attitudes, and the type of teaching-learning situations created for them.

CONCLUSIONS

Making a distinction between role modeling and purposeful teaching is important for students in clinical training settings. Clinical teachers' awareness of their own manifest professional characterizes, attitudes, and behaviors, could help create better teaching-learning experiences. Moreover, broader systemic reforms are needed to address the prevailing culture of teaching by humiliation and subordination.

Trends in national licensing examinations in medicine

CONTEXT

As a contribution to this special issue commemorating the journal's 50th volume, this paper seeks to explore directions for national licensing examinations (NLEs) in medicine. Increases in the numbers of new medical schools and the mobility of doctors across national borders mean that NLEs are becoming even more important to ensuring physician competence.

OBJECTIVES

The purpose of this paper is to explore the use of NLEs in the future in the context of global changes in medical education and health care delivery.

METHODS

Because the literature related to NLEs is so large, we have not attempted a comprehensive review, but have focused instead on a small number of topics on which we think we have something useful to say. The paper is organised around five predicted trends for NLEs.

DISCUSSION

The first section discusses reasons why we think the use of NLEs will increase in the coming years. The second section discusses the ongoing problem of content specificity and its implications for the design of NLEs. The third section examines the evolution of large-scale, standardised cognitive assessments in NLEs and suggests some future directions. Reflecting the fact that NLEs are, increasingly, attempting to assess more than just knowledge, the fourth section addresses the future of large-scale clinical skills assessments in NLEs, predicting both increases in their use and some shifts in the nature of the stations used. The fifth section discusses workplace-based assessments, predicting increases in their use for formative assessment and identifying some limitations in their direct application in NLEs. The concluding section discusses the cost of NLEs and indulges in some further speculations about their evolution.

Postgraduate Emergency Medicine Training in India: An Educational Partnership with the Private Sector

BACKGROUND

Emergency medicine (EM) is a recently recognized specialty in India, still in its infancy. Local training programs are developing, but remain very limited. Private, for-profit hospitals are an important provider of graduate medical education (GME) in India, and are partnering with United States (US) universities in EM to expand training opportunities.

OBJECTIVE

Our aim was to describe current private-sector programs affiliated with a US university providing postgraduate EM training in India, the evolution and structure of these programs, and successes and challenges of program implementation.

DISCUSSION

Programs have been established in seven cities in India in partnership with a US academic institution. Full-time trainees have required didactics, clinical rotations, research, and annual examinations. Faculty members affiliated with the US institution visit each program monthly. Regular evaluations have informed program modifications, and a local faculty development program has been implemented. Currently, 240 trainees are enrolled in the EM postgraduate program, and 141 physicians have graduated. A pilot survey conducted in 2012 revealed that 93% of graduates are currently practicing EM, 82% of those in India; 71% are involved in teaching, and 32% in research. Further investigation into programmatic impacts is necessary. Challenges include issues of formal program recognition both in India and abroad.

CONCLUSIONS

This unique partnership is playing a major early role in EM GME in India. Future steps include official program recognition, expanded numbers of training sites, and a gradual transition of training and education to local faculty. Similar partnership programs may be effective in other settings outside of India.

Mapping the rapid expansion of India's medical education sector: planning for the future

BACKGROUND

India has witnessed rapid growth in its number of medical schools over the last few decades, particularly in recent years. One dominant feature of this growth has been expansion in the private medical education sector. At this point it is relevant to trace historically and geographically the changing role of public and private sectors in Indian medical education system.

METHODS

The information on medical schools and sociodemographic indicators at provincial, district and sub-district (taluks) level were retrieved from available online databases. A digital map of medical schools was plotted on a geo-referenced map of India. The growth of medical schools in public and private sectors was tracked over last seven decades using line diagrams and thematic maps. The growth of medical schools in context of geographic distribution and access across the poorer and relatively richer provinces as well as the country's districts and taluks was explored using geographic information system. Finally candidate geographic areas, identified for intervention from equity perspective were plotted on the map of India.

RESULTS

The study presents findings of 355 medical schools in India that enrolled 44250 students in 2012. Private sector owned 195 (54.9%) schools and enrolled 24205 (54.7%) students in the same year. The 18 poorly performing provinces (population 620 million, 51.3%) had only 94 (26.5%) medical schools. The presence of the private sector was significantly lower in poorly performing provinces where it owned 38 (40.4%) medical schools as compared to 157 (60.2%) schools in better performing provinces. The distances to medical schools from taluks in poorly performing provinces were longer [median 65.1 kilometres (km)] than from taluks in better performing provinces (median 41.2 km). Taluks farthest from a medical school were, situated in economically poorer districts with poor health indicators, a lower standard of living index and low levels of urbanization.

CONCLUSIONS

The distribution of medical schools in India is skewed in the favour of areas (provinces, districts and taluks) with better indicators of health, urbanization, standards of living and economic prosperity. This particular distribution was most evident in the case of private sector schools set up in recent decades.

Indian medical students in public and private sector medical schools: are motivations and career aspirations different? - studies from Madhya Pradesh, India

BACKGROUND

In recent years, there has been a massive growth in the private medical education sector in South Asia. India's large private medical education sector reflects the market driven growth in private medical education. Admission criteria to public medical schools are based on qualifying examination scores, while admission into private institutions is often dependent on relative academic merit, but also very much on the ability of the student to afford the education. This paper from Madhya Pradesh province in India aims to study and compare between first year medical students in public and private sector medical schools (i) motives for choosing a medical education (ii) career aspirations on completion of a medical degree (iii) willingness to work in a rural area in the short and long terms.

METHODS

Cross sectional survey of 792 first year medical students in 5 public and 4 private medical schools in the province.

RESULTS

There were no significant differences in the background characteristics of students in public and private medical schools. Reasons for entering medical education included personal ambition (23%), parental desire (23%), prestigious/secure profession (25%) or a service motive (20%). Most students wished to pursue a specialization (91%) and work in urban areas (64%) of the country. A small proportion (7%) wished to work abroad. There were no differences in motives or career aspirations between students of public or private schools. 40% were willing to work in a rural area for 2 years after graduating; public school students were more willing to do so.

CONCLUSION

There was little difference in background characteristics, motives for entering medicine or career aspirations between medical students in from public and private sector institutions.

Faculty development projects for international health professions educators: Vehicles for institutional change?

BACKGROUND

Projects are an important tool in faculty development, and project emphasis may offer insights into perceived education priorities. Impact of projects has been focused on individuals, not institutions or health.

AIM

Education innovation projects of Fellows in an international faculty development program were examined to better understand perceived needs in health professions education and institutional impact of projects.

METHOD

Four hundred and thirty-five projects were analyzed to identify focus areas. Fellows were asked to identify changes in their schools and communities resulting from their projects.

RESULTS

New education methods and curriculum change were common project focus areas. Regional differences were evident with a higher percentage of education methods projects by Fellows residing in India (52%), compared with South Africa (25%) and Brazil (24%). Fifty-six percent of projects were incorporated into the curriculum and/or incorporated as institutional policy. One-third to two-thirds of respondents noted improved teaching quality, collaboration, education research interest, assessment, student performance, and curriculum alignment with community health needs.

CONCLUSION

National differences in project focus may offer insight into local conditions and needs. High rates of diffusion of projects and impact on faculty, students, and curriculum suggest that faculty development projects may be a strategy for institutional change in resource limited environments.

Selection criteria and pre-clinical academic performance in a private medical college in Nepal: a case study

BACKGROUND

All medical schools in Nepal use academic merit as the criterion for selecting students. Medical educationists in Nepal seek to make the selection process more transparent and fair to applicants from different socio-economic backgrounds, while striving to raise the educational standards.

AIM

To evaluate the efficacy of selection methods in relation to academic success.

METHOD

Formative and Summative scores of three groups that had used different selection criteria were obtained and subjected to statistical analysis.

RESULTS

The group selected through an interview (INT) showed significantly better performance on the formative exam in Year 1. Scores of the first come first served group (FCF) on Summative exam in Year 1 were significantly lower than those of INT or the group selected from the entrance exam merit list (KUM), with also the lowest pass rate. No significant differences were present amongst the formative or summative scores of the groups in Year 2, albeit INT which showed the highest pass rate.

CONCLUSION

The academic performance of students at the end of two years of basic sciences does not appear to correlate with pre-admission academic merit. The usefulness of an interview is reflected in a higher pass rate. It might be worthwhile to include an interview in the selection process with a concomitant change in the methods of student assessment.

AMEE 2010 symposium: medical student education in the twenty-first century - a new Flexnerian era?

As we mark the 100th anniversary of the Flexner report which revolutionized the process of medical education, there is again concern that we face a critical need for change in the process of medical education in order to meet the needs of learners, teachers, and patients. In this symposium, panelists shared perspectives on medical education reform from throughout the world, including The Future of Medical Education in Canada, the role of regulators in contributing to reform, the evolution of accreditation standards, the current state of medical education in Southeast Asia, and the perspectives of a medical student on medical education reform. In the "Audience discussion" section, themes emerged surrounding medical education as a social good, the need for governmental support of medical education, the cost of medical education and the rise of for-profit medical schools, and embracing a broader view of health professional education. There remain remarkable parallels in calls for reform in medical education at the turn of the twentieth and twenty-first centuries but education which is patient-centered and actively involves the voices of our patients and our students is likely to be a hallmark.