Earlier this year, the National Medical Commission (NMC) advised medical colleges to alter the pattern of medical education by connecting undergraduate students to families in rural communities. The ‘family adoption programme’ links each medical student to three to five rural families. The student would need to visit these families once a month. With supportive supervision from a faculty member of the college, the student would get acquainted with the health problems of the family members, chart their course and assist in their management through facilitation of telehealth consultations and referrals to healthcare facilities if need be.
The objectives of this reform, which would supplement the standard medical curriculum, are to orient young medical students to commonly prevalent health problems and available health system resources in rural areas. The idea was that such medical students would serve better in rural areas after graduation than those receiving all or most of their education in urban settings. Several medical colleges have recently initiated this new programme for the commencing batches.
There has been just criticism that medical education in India has become disconnected from rural reality because it was mostly taught in hospitals imparting advanced medical care attached to medical colleges in highly urbanised locations.
This meant that students were not familiar with common conditions which called for care in primary care settings. They also saw diseases in a late phase of natural history. The ability to provide care in resource-constrained settings, such as many rural areas, was not a skill they could gain in the tertiary care environment.
Most importantly, the role definition of a doctor, in the perception of the medical student, was distorted and depersonalised by how training was sequenced in the conventional frame of medical education. There, the student first encounters a cold cadaver in the anatomy hall and is trained to dissect it or study it part by part to gather knowledge. Medical education thus takes a reductionist approach to the organs of the dead than a holistic appreciation of the health problems of the living.
When the student transitions to the clinical side in the hospital, the student is further encouraged to learn from ‘interesting clinical findings’ of patients: a heart murmur ‘on bed 24’ or an abdominal lump ‘on bed 11’, often not even referring to the patient who is the occupant of that bed. Much less identify and empathise with the human being who has the findings of clinical interest for the young learner whose focus is now on performing well in the exam rather than serving the patient. Even an idealistic student is in danger of emerging as a paternalistic physician in this process.
The Faculty of Medicine at the Suez Canal University is a WHO collaborating centre for medical education. It is internationally reputed for adopting ‘an integrated, student-centred, problem and community-based curriculum’ since its inception in 1978. There is integration between basic and clinical sciences, and the community becomes an educational medium. After entry into the programme, the students are trained to map the community’s prevalent health problems and assess their prioritised health needs, even as they course through the formal structured education in the institution.
Through regular community connect, they become informed facilitators. In the classroom and libraries, they seek and acquire the knowledge that can ameliorate the health problems they have noted in the community. Even in the hospital setting, this empathetic attitude helps them to identify with the person who is behind the label of a ‘case’.
When a student gets attached to a family (I prefer that to the paternalistic phrase that the student ‘adopts’ the family), there is an enhanced opportunity for greater medical learning and social understanding. The natural history of disease and recovery is tracked through time in the affected families during the long follow-up period.
Access to drugs and their affordability cease to be abstract issues, while drug resistance may be understood as a real challenge. The social determinants of health, including gender differences in access to healthcare, will be witnessed first-hand in some families. Financial barriers to healthcare, when evident, will make the medical student appreciate the need for universal health coverage.
The requirement of family attachment throughout undergraduate medical education will greatly enhance the quality of medical education by creating an emotional connection with the community and the patients therein. It reorients the young student’s mind from being a seeker of knowledge merely for personal and professional advancement to becoming an informed facilitator who acquires medical knowledge and skills to assist the community in promoting, preserving or regaining good health and wellbeing.
Now that this long overdue reform has been initiated, it must suffuse through the soul of medical education and not be treated merely as a token gesture to the often espoused but long-neglected concept of community connectedness.
Prof (Dr) K Srinath Reddy
Cardiologist, epidemiologist and President, Public Health Foundation of India (PHFI)