Wednesday, July 26, 2017

decimation of biomedical scientists in India

An open letter to the office bearers of the Medical Council of India.

Open because MCI does not respond to direct letters written to it. Open also for the world to know what is going on with the India's biomedical scientists.

Why doesn't MCI respond to us?

When individuals write to the MCI, their letters are discussed in the Executive Committee meeting. None of the letters or memoranda from the National MSc Medical Teachers' Association (NMMTA), the association of members representing the teachers working in medical colleges across 26 states and are ever taken up. NMMTA office bearers even had met both the President and the Secretary at MCI office. We constitute around 13% of the teaching faculties in the medical colleges. Inexplicably, all our letters and memoranda have been consistently ignored as if we don't exist. It pains to see that our concerns are continuously ignored and trivialized.

The President had assured to look into our grievances and place our memorandum in the committee, which probably never happened. Our repeated pleas to take it up too failed to produce any results. When this was asked via the RTI act, the reply from MCI callously was "Efforts are being made to locate the relevant files relating to your representation". We were also assured by both the President and the Secretary that the decision to promote medical M.Sc degree teachers to the post of Assistant Professor without the requirement of a Ph.D would appear in the Gazette. That promise too was not kept.  It bothers us to see such discrimination at MCI. Why are our issues being trivialized and ignored? 

The rise and the fall of medical M.Sc degree in MCI

There was a time when medical M.Sc courses were offered to doctors and therefore was included in the first schedule of the IMC Act 1956. Perhaps on the recommendation of the Mudaliyar Committee, the courses were thrown open to the non-doctors to fulfill the shortage in pre- and para-clinical subjects. These non-medical teachers went on to become professors and heads of the departments. They set syllabus, taught, trained and guided both MBBS and MD students in their subjects during the course of their employment.

Until the late 1980s MCI used to recognize medical M.Sc courses and gave permission to medical colleges to conduct these courses. Since then, MCI has washed its hands off these courses. Even when asked via the RTI act, MCI has not furnished any documentary evidence of its withdrawal from the first schedule of IMC Act 1956. Has this degree lost value and importance just because it is no longer taken up by doctors? Is the value of a degree based on who pursues it? Why should the education be degraded just because "lesser children" pursue it?

Prior to 1998, non-medical teachers could head the department even without Ph.D. Subsequently, Ph.D was made mandatory for the post of Assistant Professor and above, Ph.D was made mandatory for examinership, later HOD posts too were denied and now MCI is discouraging medical colleges from hiring non-medical persons. Lately, perhaps non-medical teachers are being denied to guide MD students for their dissertation. What have we done to deserve such a downfall? Has medical M.Sc degree fallen out of favor just because MD degree in the same subjects is available in plenty?

Truth about medical M.Sc courses

Ever since MCI disowned these courses, it has suffered variations in the curriculum and syllabus across the universities. The duration of these courses in the subjects of Anatomy, Physiology, Biochemistry, Pharmacology, and Microbiology have varied from 2-3½ years although UGC maintains it to be a 2-year course. In contrast to the general M.Sc courses, the medical M.Sc courses in the medical colleges are run for 3 years. The first year is dedicated to Anatomy, Physiology, Biochemistry, just like the first year MBBS syllabus. It is this aspect that makes the M.Sc degree "medical" as one gets to know about the human body. In the remaining two years, the students focus on their specialty. These courses are run in the same department, by the same teachers using the same resources as for MD courses. The students go through laboratory practicals, dissertation, seminars and journal presentation just as their peers undertaking MD courses do. Depending on the institution, medical M.Sc students also get posted to the central laboratories and even do night shifts. Our graduate degrees are different but the postgraduate degrees are qualitatively similar. Why are we constantly at the receiving end? We agree that we haven't had the kind of 'clinical exposure' that doctors have, but we are not here to see patients. We don't pretend to be doctors or treat patients, why call us quacks? Our repeated pleas with both the Ministry of Health & Family Welfare and Human Resource Development to get the medical M.Sc courses transferred back to the MCI for regulation and recognition have fallen on deaf ears. Once back in the MCI, these medical courses could be regulated.

How did we get in here?

Most of us are from humble backgrounds, who could not get past the reservation system or pay enormously to study medicine. We were also taken for a ride with the lures of jobs in medical colleges, research institutions, and laboratories by the medical colleges that conduct these medical M.Sc courses. It is only after the completion of the degree that people came to realize the harsh realities that they have neither the dignity nor the opportunity in the healthcare setup. After spending precious time of the youth and lakhs of their parents' hard-earned money, they are bluntly told that they are not eligible to practice what they learned. What can be more painful than that?

Why did the MCI paint medical M.Sc courses poorly?

Time and again, MCI has claimed that it has nothing to do with the conduct of medical M.Sc courses, yet it takes the liberty to opine on it. In one case filed in the Jaipur bench of Rajasthan High Court, the counsel appearing on the behalf of MCI presented three table of differences between B.Sc and MBBS, MD and M.Sc, and super-speciality and Ph.D. Obviously, this table was prepared from the feedback from MCI. It is very unfortunate that this table was created with the sole intention of showing M.Sc courses in poor light and projecting medical courses as superior. In doing so, several incorrect information was projected as facts, which neither the opposing counsel nor the judge failed to notice, clarify or question. This irresponsible representation has caused immense damage to us, as they continue to be circulated.

First of all, comparing MBBS with B.Sc is inappropriate as the two courses are totally different and are not comparable in any way. It is like comparing tomatoes with rabbits. These two graduate degrees are totally different and have nothing in common. Similarly, comparing super-speciality and Ph.D is also inappropriate as the two are entirely different. Super-speciality courses are true courses with defined curriculum and syllabus whereas Ph.D is a research undertaken on a small area of interest, whose outcome is to prove or disprove a hypothesis. Once again, these two not comparable in any respect.

The only comparable courses are MD and medical M.Sc. These two are identical in course and curriculum except that the medical M.Sc course also includes one year of Anatomy, Physiology, and Biochemistry. The MCI's counsel provided incorrect information that in medical M.Sc courses, the students are not trained in clinical and diagnostic methodologies and that techniques or in the interpretation of clinical diagnostic techniques practically in relation to patients are not conducted. These are plain lies. Clinical laboratory diagnosis is an integral part of the medical M.Sc curriculum in Microbiology and Biochemistry, which lays emphasis on the interpretation of the test result with respect to patient's condition. The ultimate responsibility of interpreting a test lies with the physician dealing with the patient, not with the biochemist or microbiologist sitting in the laboratory. A thesis is not mandatory in the medical M.Sc course of some universities, but not in most universities, as claimed by the MCI's counsel. Barring few exceptions, most colleges conduct medical M.Sc as a three-year course, unlike what MCI's counsel has claimed. These inaccurate and inappropriate tables of differences are being widely circulated to further denigrate and belittle medical M.Sc degree. MCI is primarily guilty of this misinformation. The process of showing someone down to project oneself high is in a poor taste.

Unabated public shaming of non-medical persons

We and our degree are routinely shamed and belittled in private and public fora. Why are we being constantly ridiculed and denigrated like this? Why take us into the system and then thoroughly show us down at every stage and opportunity? Like every human, we too deserve the dignity of labor. Nowhere in the world has a postgraduate degree been decimated and humiliated like this.

Not just the medical M.Sc degree but also Ph.D is ridiculed by our medical colleagues. They conveniently forget that both medical and non-medical degrees are the product of the same institution. Both the medical M.Sc and Ph.D are conducted by the same department and teachers who also conduct MD courses. In most cases, the Ph.D guides in the medical colleges are MD holders, who have never undertaken Ph.D themselves. If the quality of the degree is supposedly bad, then it also reflects on the medical colleges, the department, and the medical teachers, not entirely on the degree holders. It is rather paradoxical that while the doctors are the one who set the syllabus, conduct the course, train the students, guide the dissertation, evaluate the students and award the degrees, they also engage in belittling it. We are at loss to understand how the Ph.D, which is the outcome of research on a small area of interest, empowers non-medical teachers with additional skills to conduct routine UG academic works such as setting question papers or valuating papers. But, PhD is still insisted. Obviously, this is done with the sole intention to keep us out or make it more difficult for us to participate in the prestigious, premium and lucrative exercise of conducting UG examinations. It is often argued that evaluation of medical students are "clinically oriented", therefore non-medical teachers must not be allowed to participate in it. The worth of a medical student can not be decided solely by the examinations in the pre-and para-clinical subjects. Such trivial excuses are made with an ulterior motive to deny our participation.

Our medical colleagues routinely engage in influencing college administrations, universities, MCI and health ministry seeking to deny us jobs in medical or dental colleges, routine academic roles in the examination process or guiding PG students. Why are we being disallowed to undertake the roles we are trained in? Why don't we get the value that our education offers? Why don't we get to perform the roles according to our designations? Why such disdain and prejudice towards us?

While the MD holders are entitled to enjoy every fruit that is there to offer in the system, non-medical teachers have a huge list of ineligibilities thrust upon them. Every other postgraduate degree has a value attached to it, but not ours. We are deemed to be unfit for almost every role in the healthcare; be it teaching or diagnostics. We can't set question papers, we can't evaluate answer scripts, we can't conduct viva-voce, we can't guide MD students and now we can't sign laboratory test reports. Is our postgraduate education so worthless that we are totally incapable of doing anything?

The malpractices and corruption involved in the conduct of both the UG and PG levels of medical education are no secrets. We don't intend to criticize them because we consider ourselves to be a part of the same medical education system and don't want to discredit it. Why isn't the same courtesy extended to us?

Are non-medical teachers a total misfit?

We are not doctors and don't carry that pretention either. We don't seek to examine patients or treat them. We have only three roles, which our education has empowered and skilled us: to teach, conduct research and work in the diagnostic laboratory. Yet, attempts are regularly made to deny us all of these. Why are our rights being snatched away from us?

Often we are accused by our medical colleagues that since we don't have "clinical exposure" and "bedside experience". Another argument floated is that the education is "more clinical these days" and that the knowledge of non-medicos is "bookish", we can't offer a better education to the medical students. There is no denying that as non-doctors, we lack these exposures but to allege that we can't offer good education is outlandish. Non-medical teachers teach in pre-and para-clinical subjects, which are the basic medical sciences and non-clinical subjects. These students will get to learn all the clinical aspects of the diseases and disorders once again in detail when they study clinical subjects. Integrated teaching with other departments ensures that they get wholesome knowledge. Besides, all the clinical information is available in the textbooks and the teacher too can learn from them. Learning is a never ending process and the teacher learns too. In a medical college, a non-medical teacher is also continuously exposed to other academic activities such as PG seminars, journal clubs, CMEs, workshops etc.

Non-medical teachers can be appointed only to the extent of 30%, the remaining 70% are doctors. Why should the blame of "poor education" of medical students land upon 30% non-medical teachers while 70% medical teachers absolve themselves of all responsibilities? Why can't they compensate for what a non-medical teacher lacks? Why can't they provide the "clinical knowledge" to the students, which a non-medical teacher couldn't? Making non-medical teachers the scapegoats to hide their own inefficiency is a poor strategy.

None of the Indian medical colleges feature in world's top ten medical institutions. In almost all of the top ten global institutions, non-medical teachers in the pre- and para-clinical subjects constitutes 50-60% of the teaching faculty. Isn't it wonderful that despite having such a large number of teachers without "clinical knowledge" and "bedside exposure", their institution ranks top? Why is it so convenient to always blame the non-medical teachers for the poor quality of education that our medical colleges provide?

Are non-medical teachers unproductive?

In a medical college, MD/MS degree is considered supreme. Mere possession of this degree is deemed perfect to be a teacher and all the academic responsibilities that come along with it. Since there is no insistence on quality in teaching and no evaluation of teachers' performance, the medical teachers have taken their place for granted. All their shortcomings are ignored. Since non-medical teachers with medical M.Sc degree are perceived as "outsiders" and are alleged to have gained "lateral entry", they are thoroughly scrutinized at every level. While the medical doctors get away with any or all insufficiencies, non-medicals have to prove themselves on a regular basis. In order to survive this bias, non-medical teachers always strive to give their best. In fact, some of the finest and dedicated teachers are non-doctors, a fact that the MCI President admitted during our interaction. Degrees don't make a person smart or stupid, it is one's dedication and effort that defines a person. There are useful and useless people with either degree, we have to identify people by their virtues, not by the names of the degrees. Mere possession of a celebrated degree doesn't make one great. If we are to develop our medical education like in the west, we will have to quit this academic apartheid and involve the best of minds from as many streams.

How did the MCI utilize our services?

MCI labels us as "non medical scientists". How did the MCI make use of these "scientists" in the last few decades? Did MCI ever have a policy of engaging scientists to strengthen and improve the basic medical sciences? What is the point of recruiting scientists and engage them only in teaching? Research has never been a strong point of our medical education system. MCI has forced research on medical faculty by threatening to deny promotions and the results are out there to see. If MCI is serious about promoting research then it must utilize the services of these scientists in setting up and running research units in medical colleges. But, all that MCI has done is to suppress these scientists.

How are non-medical teachers coping with the medical system?

The experience of non-medical persons in medical college is varied; this depends on the attitude of the management, medical colleagues as well as own conduct and worth. The working conditions of many non-medical persons in medical colleges are pathetic and inhuman. The types of discrimination and humiliations that they have to bear at the hands of the medical peers on a regular basis is appalling. Some of them been harassed and humiliated constantly to such an extent that they have lost all self-esteem and live in self-pity. They have been kept suppressed so much that they fear even standing up against their mistreatment.  What did they do to deserve such a mistreatment? Why inflict so much psychological trauma? 

Many of them are appointed to the non-teaching posts of tutors or demonstrators with paltry salary. Despite putting in years of service, neither they get salary hikes nor promotions. Many of them are used only as a cheap labour and not included in the teachers' declaration forms submitted to the MCI. Government medical colleges have in-service schemes enabling employees to undertake higher education but these are nonexistent in private colleges. With research being a sham in most private colleges and funding unavailable, many non-medical persons are unable to undertake Ph.D. Due to abysmally low salaries, they can't afford to fund their own research. Neither the college nor the MCI or government has any scheme to enable these persons to undertake Ph.D. They are destined to stagnation and suffering.

Despite being denied of several academic roles and subjected to a variety of humiliations on a routine basis, non-medical teachers have always felt proud of being a part of the medical education system and have rendered duties with utmost sincerity and dedication.

Why the assault on our role in diagnostic laboratories?

By definition, the process of examining the patient and offering suitable treatment is the practice of medicine. Performing a test on a sample obtained from the patient and interpreting the result is not the practice of medicine. The sub-section 2 of the Section 15 of the Indian Medical Council Act, 1956 states, "....shall be entitled to sign or authenticate a medical or fitness certificate or any other certificate required by any law to be signed or authenticated by a duly qualified medical practitioner". There is no mention of diagnostic laboratories in this act and this should not be misconstrued as such. Issuing a laboratory test report should not be deemed as the practice of medicine. By MCI's own admission, persons with medical M.Sc were initially being registered in the MCI/state medical councils, which was mysteriously stopped. By deliberately keeping us out of the council, we are being denied the right to practice in the diagnostic laboratories. Our repeated pleas with the Health Ministry to get us registered in the MCI/Sate medical councils have not been fruitful. Unless the medical M.Sc degree holders are registered in a council, it would be difficult to serve with accountability in the healthcare sector.

From the documents available in MCI's website, it is clear that the role of MCI is medical education, registration of doctors and ensuring proper standards in the practice of medicine.  It would be wholly unreasonable to believe that laboratory practice is also the practice of medicine. MCI has claimed that it does not have jurisdiction over hospitals, nursing homes, and the diagnostic laboratories. Why has the MCI transgressed into deciding who should sign laboratory reports?

MCI's recent response to the long-pending NABL's letter was totally uncalled for. In 2005, the executive committee along with the members of the Adhoc committee appointed by the Supreme Court approved the decision of the ethics committee that M.Sc holders, with or without Ph.D could independently sign diagnostic laboratory test report. Why was this reversed in 2017? Why the U-turn now? Is it ethical on the part of MCI to overrule the ethics committee? This decision projects natural bias in the MCI. It is fortunate that NABL did not pay heed to MCI's biased opinion and sensibly reverted back to its previous guidelines of giving signatory authority based on their ability and training rather than the mere possession of a requisite degree.

Although this was a reply given to the NABL, it is causing far-reaching consequences that MCI might not have foreseen. While the MCI's reply was supposed to be in the context of NABL accredited laboratories, it is being misconstrued as a "rule" or an "order" from MCI and is being extended to all diagnostic laboratories, including those attached to teaching hospitals. It is not known if this was intentional or not. As a fallout of this letter and its misuse, many persons with medical M.Sc degree are being humiliatingly asked to keep away from diagnostic laboratories and many are facing imminent job loss. Not only the humiliation, psychological trauma but also livelihood is at stake. Many of us have trained and taught principles and practice of laboratory diagnosis to MD students; it is illogical that while our students are eligible, we as teachers are not. MCI is guilty of inflicting this damage upon us.

Some of us have initiated the laboratories, set SOPs, got the system in place and kept them functioning because no one else was available. Once a MD candidate is available, they have been asked to step outside citing eligibility. Why this misuse and abuse? Life is getting tougher each day for non-medical persons in the healthcare sector. Even those who were happily contributing to medical education and the healthcare needs of the society are now apprehensive of their future. Everybody wonders why after such long useful periods of service, are we being disowned and degraded? Why are attempts being made to establish a monopoly in the healthcare system by excluding biomedical scientists? In several accredited diagnostic laboratories in Europe and the US, one does not have to be a doctor to sign a diagnostic test report. These countries don't consider laboratory services as the practice of medicine.

In many European countries and the US, non-doctor biomedical scientists are held in high esteem, who sign and interpret test reports and also go on to become laboratory directors and policymakers in the healthcare setup. Here in India, the biomedical scientists are equated with laboratory technicians. While the developed western countries give credence to training and skills, we the perpetually developing country, give importance to the nomenclature of degrees. This is where we fail. The pride and prejudice have a blinding effect on our policy makers here.

MCI is responsible for this mess.

Rules are continuously being modified to enable us to be used as 'disposable' or 'expendable' commodities. Things were rosy when the medical education system wanted us; now that the replacement is available, all sorts of deficiencies are being discovered in us. Slowly, we are being deemed unqualified although not much has changed in the system of medical education in these decades.

Due to the reduction of the faculty strength and an increase of the PG seats in pre- and para-clinical subjects by the MCI, there has been an increase in the competition for teaching jobs in the medical colleges. With fewer jobs in the medical colleges, the competition for jobs in diagnostic laboratories too have surged. Thus, a need was been felt to eliminate the non-medical biomedical scientists in the guise of quality, eligibility, and reliability. In the guise of "paradigm shift" in the "regulation of health care", even the qualified biomedical scientists are being excluded.

What options do people with medical M.Sc degree have?

Without anyone to regulate this course and a policy-paralysis in the government, too many medical colleges started medical M.Sc courses in the five aforementioned subjects. Any medical college with existing MD course could start medical M.Sc course without MCI's approval. Since non-medical persons could be hired for low salaries and denied promotions for years together, they have been hired by many medical colleges. But, the increased competition for jobs has changed the scenario. Even MCI has asked medical colleges to hire doctors with MD as the first preference. Even for teaching jobs, a freshly passed MD candidate is preferred over a non-medical teacher with Ph.D, relevant publications and a decade of teaching experience. Such is the disadvantageous position of non-medical teachers.

With a postgraduate degree exclusively in the medical subjects, these degree holders don't have anywhere else to go. They find themselves total misfits and ineligible for jobs in non-medical establishments. With constant efforts to push medical M.Scs out of medical education and healthcare system, where are these persons to go? Out of frustration, the majority of persons with these degrees have moved away to professions that have nothing to do with their education. Barely 13% of teaching faculties in the medical colleges are non-medical.

There is no record of the number of persons with medical M.Sc degree in India, but many of them are working abroad as these countries know the value of scientists in basic medical sciences. In developed countries, the non-medical scientists have risen to occupy the highest chairs in the healthcare setup, something which is unthinkable in our prejudiced setup. It is unfortunate that our country has failed to recognize, uphold and promote biomedical scientists. Pride and prejudice have got the better of people.

People often carelessly suggest that persons with medical M.Sc degrees should take part in research. Are there sufficient avenues for research in India's healthcare? Even for healthcare research, doctors are preferred. From the information obtained through the RTI Act, it was found that only ten people with medical M.Sc degree are working as scientists in all of the central government's medical research establishments. How many medical colleges in India engage in genuine research? What has MCI done to promote research in medical colleges? In most medical colleges, the term research is restricted only to its name. Research in basic medical sciences is a sham in our country. In many western countries, research in basic sciences is compulsory along with teaching. Unfortunately, the quality of research is even more neglected than medical education in our country. Under such appalling conditions, how can we even think of research as an alternate profession?

We need recognition, not sympathy

Is a competition for jobs and promotions the sole motive for the denigration of biomedical scientists? In the developed countries doctors and non-doctors don't engage in an unhealthy competition, instead, they are complementary and supportive of each other. Why can't India do the same? Both the medical and non-medical degrees can jointly contribute to the society. We don't seek equality; we simply seek our rightful place so we can work with dignity. We seek to be considered as a natural part of the medical education and healthcare. We should be seen as assets but we are being treated as liabilities. The policy makers must not confuse between the eligibility (which is mere possession of a prescribed academic degree) and the qualification (which a person acquires through education and traninig). Mere possession of eligibility doesn't mean one is also qualified for the job.

MCI has presided over a variety of discriminations thrust upon us; this could happen because there is none to represent us or safeguard our interests at MCI. Neither the MCI nor the Ministry of Health can prevent our routine abuse for what we are, but this can be contained to some extent by upholding medical M.Sc degree and recognizing it as in important participant in India's healthcare system and medical education. Unless the MCI and the government uphold medical M.Sc degree, denigration and humiliation of the degree holders will continue unabated.

Despite being a Kunti-putra, Karna never got the recognition of being a Pandava, will we ever? MCI is about to be replaced by the National Medical Commission. We only hope that MCI goes out with a benevolent and a just act that is expected of it. We can only hope that with this awareness, justice will be done to biomedical scientists with medical M.Sc degree in both medical education and diagnostic laboratories.

If it is felt that medical M.Sc degree holders have no avenues for biomedical research, are unwanted in the medical colleges and are denied to work in laboratories, why is the government permitting medical M.Sc courses to be run? Why is the future of youngsters being destroyed? It is the ripe time for the decision making bodies in the government to take up the issues and resolve them amicably. The Prime Minister must ask the NITI aayog to take it up with both the ministry of health and the human resource development ministry to take it forward. The neglect of India's biomedical scientists is a sign of poor policy making. This policy paralysis needs urgent attention.