Problems, more problems, and solutions

The so-called non-medical teachers possessing medical M.Sc/Ph.D qualifications who are working in various capacities ranging from Tutors to Professors & HOD are protesting against the unjust norms set by the NMC.

Clarity on the medical M.Sc courses:

The majority of MBBS graduates typically opt for specialization in clinical disciplines, and they consider pursuing postgraduate studies in non-clinical disciplines as a last resort, often after numerous unsuccessful attempts to secure clinical seats. As a result, thousands of postgraduate seats in non-clinical subjects remain vacant each year.

With the establishment of more medical colleges and an increase in MBBS seats within these colleges, the shortage of faculty members has become more pronounced. This shortage is particularly acute in newly established colleges, as well as those situated in remote, hilly, and suburban areas. Due to the scarcity of medically qualified teachers, the education system resorted to appointing non-medical teachers starting in the 1960s. However, historically, the permissible ratio of non-medical teachers was limited to 30% (50% in Biochemistry).

Medical M.Sc courses in the five non-clinical subjects were initially included in Schedule-I of the Indian Medical Council Act. However, as MBBS graduates began to show less interest in these courses and opted for MD programs in the same subjects, the Medical Council of India (MCI) gradually stopped taking interest in these courses. In the late 1980s, MCI stopped granting permission to medical colleges to initiate these courses, and eventually, it completely withdrew its support from them.

At one point, over 100 medical colleges used to offer these courses, but now the number has dwindled to less than 30, including in AIIMS. These courses are primarily conducted within medical colleges, utilizing identical curricula, syllabi, and resources as MD programs. They run concurrently with MD courses, guided by the same teaching methods and faculty. However, regardless of their chosen specialty, all students are required to complete a mandatory one-year study in human anatomy, physiology, and biochemistry, mirroring the curriculum of first-year MBBS students.

All aspects of the M.Sc. course, including university examinations, resemble those of the MD course. Successful candidates are awarded their degrees by the health university under the faculty of medicine. Although there may be differences in the graduate degrees between medical and non-medical teachers, their postgraduate degrees are quite similar. Consequently, aside from clinical practice, both groups of degree holders are well-suited for similar roles and employment opportunities.

It is unfortunate that the regulatory body consistently provides inaccurate information in its affidavit when referring to the medical M.Sc courses. It appears to use misinformation as a political tool to advance its agenda.

Appointment of non-medical teachers:

The practice of appointing non-medical teachers to instruct in non-clinical subjects, which form the foundation of medical sciences, is not exclusive to India. In fact, the percentage of non-medical teachers varies widely in different countries, ranging from 30% to 100%. Only 8-11% of teachers in non-clinical subjects at medical colleges in the United States hold medical qualifications, while the majority are non-medical professionals.

The appointment of non-medical teachers in the non-clinical subjects should be a matter of policy, rather than a temporary measure extended to medical M.Sc postgraduates. The regulations outlined by the World Federation of Medical Education (WFME) emphasize the importance of balanced participation from both medical and non-medical teachers.

The presence of teachers with either set of qualifications brings dynamism to teaching, a fact emphasized by the Board of Governors in supersession of MCI when rejecting a demand to exclude non-medical teachers. Non-medical teachers should be an integral part of medical education to prevent a monopoly of one-degree holders, which can lead to stagnation. Both sets of degree holders can complement each other, rather than compete with each other.

It is incorrect to assume that possessing a specific qualification or lacking it has a direct impact on the quality of teaching. Within both sets of qualifications, there are excellent, mediocre, and subpar teachers. The crucial factor determining a teacher's ability to educate effectively is their postgraduate degree, whether it's a medical M.Sc or MD; the undergraduate degree may have minimal influence. Thus, the quality of teaching ultimately depends on the individual's knowledge, skills, and attitude as a teacher. Medical education should draw benefits from both sets of qualifications, and the selection should prioritize the best candidate, regardless of their specific qualification.

MD in non-clinical subjects:

In many developed countries, medical colleges do not provide MD programs in non-clinical subjects. Typically, these subjects are primarily taught by scientists holding Ph.D. degrees, with only a few doctors who have a keen interest in research. MD programs are primarily offered in clinical subjects. In contrast, India has a significant number of non-clinical doctors, who are included in the count of doctors for calculating the doctor-patient ratio. However, these non-clinical doctors do not engage in patient care or contribute directly to healthcare services. Therefore, offering MD degrees in non-clinical subjects in India is irrational. Instead, these programs be replaced with medical M.Sc courses for MBBS graduates, as was the practice in the past.

Monopoly, dominance, and NMC's abuse of position:

Both the MCI and the present NMC are predominantly composed of medical professionals. In contrast, the General Medical Council in the UK maintains an equal representation of both medical and non-medical individuals. Initially, there was a proposal to limit the composition of medical professionals to 60% in the NMC, but this proposal was thwarted by the medical community, ultimately resulting in the dominance or hegemony of doctors in the NMC.

 Despite divisions among doctors regarding clinical and non-clinical specialties, they consistently unite when their interests are at stake. They tend to prioritize their own interests and often restrict or exclude non-medical individuals from various competitive arenas. This behavior can be seen as an abuse of their dominant position. 

When the NMC solicits public feedback, the majority of the responses come from the medical community, which represents a substantial majority. Conversely, the feedback from non-medical individuals constitutes a small minority and can easily be overshadowed. Consequently, it's important to recognize that all feedback received by the NMC tends to be inherently biased.

Over the years, the NMC has systematically eroded the authority of non-medical teachers and has consistently modified regulations to place them at a disadvantage. These changes in norms are inherently discriminatory and are intended to disenfranchise non-medical teachers. This pattern of denials and restrictions can be attributed to the underlying concepts of pride and prejudice within the medical community.

The pride that doctors take in their qualifications often leads to a prejudice against non-doctors, resulting in a general unwillingness or resistance to extend the same rights or dignity to non-doctors as they afford themselves. This sense of self-supremacy, which is seen as a 'superiority complex', prevents them from treating others with the same level of respect and equality. In essence, this is nothing but 'academic apartheid'. When the regulatory body itself practices discrimination at the highest level, it sets a discouraging precedent, encouraging individuals at the college level to perpetuate discriminatory practices.

Discriminations, and denials of opportunities:

Unjust Ph.D. Requirement: There is an unwarranted insistence on requiring a Ph.D. for the Assistant Professor position, despite the absence of such a mandate by the UGC. The demand for a Ph.D. for entry-level demonstrator roles appears to be a deliberate attempt to undermine the value of a Ph.D. and restrict the appointment of non-medical teachers. Equating postgraduate and doctoral qualifications (MSc+PhD) with an undergraduate degree (MBBS) is both belittling and unfair.

Discrimination Against Medical MSc: Despite the equivalent quality of medical MSc and MD courses, medical MSc is unfairly treated and not recognized as a basic qualification. Medical MSc is intentionally excluded as a postgraduate qualification in the NMC's faculty declaration form, despite there being a substantial number of graduates, ranging from 5000-8000.

Exclusion from Faculty Training programs: Non-medical teachers are systematically and unethically being denied/excluded from faculty training programs like the revised basic course workshop, CISP, and AETCOM.

Denial of Examiner Opportunities: Fundamental roles of a teacher to serve as undergraduate examiners are being denied to non-medical teachers despite possessing decades of teaching experience.

Limited Tenure for Tutors/Demonstrators: The tenure for tutor/demonstrator roles has been restricted to a mere 3 years, seemingly designed to discourage non-medical teachers from continuing in these positions.

Rejection of Feedback and Appeals: Feedback and appeals submitted by non-medical teachers or their associations are persistently rejected as if we don’t exist or our issues don’t matter.

Denial of HODship: Senior professors possessing non-medical qualifications are unfairly denied the opportunity to head departments despite seniority and decades of experience.

In essence, non-medical teachers are subjected to a second-class status, characterized by restricted roles, rights, and privileges. 

Political lobbying and the after-effects:

As the MCI transitioned into the NMC, a group of non-clinical medical professionals made concerted efforts to exert pressure on the NMC in order to exclude non-medical teachers from the medical education system. Their previous attempt to influence the MCI had proven unsuccessful. 

The NMC responded by significantly reducing the allowable percentage of non-medical teachers, lowering it from 50% to 15% in Biochemistry and from 30% to 0% in both Pharmacology and Microbiology. While these changes were initially meant to apply to new medical colleges starting from 2020 onwards, they were, in practice, being applied retrospectively to all colleges.

Existing non-medical teachers, particularly tutors and demonstrators, were facing termination of their contracts or non-renewal, citing the new regulations. Even those with four years of teaching experience and M.Sc qualifications were being denied promotions to the Assistant Professor position. Previous guidelines that required a Ph.D. for the Associate Professor and higher positions were being ignored. Instead, a Ph.D. was being demanded for the Assistant Professor position in MSR 2020 guidelines, a requirement not mandated by the UGC. Taking it a step further, NMC has now mandated a Ph.D. as a requirement for the lowest entry-level non-teaching position of tutor in the MSR 2023 guidelines. This change appears to be aimed at discouraging non-medical candidates from entering the field of medical education. Furthermore, the term of employment for tutors was limited to three years, seemingly to prevent them from getting promoted to higher posts.

Individuals in Pharmacology and Microbiology were among the hardest hit by these changes, as they were effectively barred from applying for teaching positions in any other institution. They faced restrictions on transferring to different colleges or relocating to other cities. In essence, they found themselves trapped within the same college and were at the mercy of the college management. These limitations hindered their opportunities for career advancement and their ability to explore new job prospects. Such restrictions appear to contradict the principles enshrined in Articles 19(1)(e) and 16, which uphold the rights of citizens to move freely between states and seek employment anywhere within India.

It's all about jobs for doctors and filling vacant PG seats:

The persistent vacancy rates of 40-50% in postgraduate (PG) seats within non-clinical specialties are expected to perpetuate the shortage of medical teachers in these fields. Additionally, medical colleges are grappling with revenue losses stemming from these unoccupied PG seats. In certain states, private medical colleges have established agreements with the government, obliging them to allocate a specific percentage of PG seats at reduced fees. Consequently, these institutions allocate non-clinical PG seats to the government quota while retaining the more lucrative clinical seats for themselves. 

Given the lack of interest among MBBS graduates in non-clinical seats, medical colleges are compelled to relinquish the clinical seats, which negatively affects their interests. Thus, there is a pressing need to address the vacancies in non-clinical seats. To address these vacancies, efforts have been made to attract MBBS graduates by offering incentives such as freebies, lowering the qualifying percentile to accommodate lower-scoring MBBS students for PG seats, reducing tuition fees, or even providing the seats free of charge.

Most MBBS graduates aspire to pursue clinical practice, as non-clinical subjects do not provide opportunities for clinical work. Typically, careers in non-clinical fields are centered around teaching in medical colleges. While there is some competition for teaching positions from M.Sc/Ph.D. candidates, this is a relatively minor factor that discourages MBBS graduates from pursuing PG studies in non-clinical subjects.

Despite the numerous vacancies in PG seats, a significant number of MBBS graduates are currently pursuing MD degrees in non-clinical subjects with the hope of securing faculty positions in medical colleges. The association of non-clinical medicos has actively lobbied the NMC to create provisions that would facilitate job opportunities for these individuals.

As a result, the undergraduate board of the NMC made the decision to significantly reduce and eventually stop the appointment of non-medical teachers. This decision serves a dual purpose: firstly, it aims to encourage the occupancy of MD seats in non-clinical subjects, and secondly, it seeks to create job opportunities for medical postgraduates, albeit at the expense of non-medical candidates.

The primary role of the NMC is to establish policies and guidelines that maintain the quality of medical education, rather than engaging in political strategies to occupy PG seats or secure jobs for doctors. By doing so, the NMC appears to be behaving more like an association of doctors focused on advancing their self-interests, rather than fulfilling its role as a regulator.

Role of ministry in ensuring justice:

While the MCI and NMC primarily are bodies 'of the doctors, by the doctors and for the doctors' furthering the interests exclusively of doctors, the union government is entrusted with the responsibility of safeguarding the welfare of all stakeholders. While the regulatory body tends to be self-centered, the policies of the Ministry of Health and Family Welfare (MoHFW) are grounded in reality and uphold principles of universal justice and equality. The NMC Act empowers the government to supersede the NMC on any matter, including policies. Given the inherent bias of the NMC, it is unlikely to ensure a level playing field for non-medical individuals. Therefore, the ministry's intervention is entirely justified. However, it is shocking that the NMC, after initially submitting an affidavit to the Delhi High Court to comply with the ministry's directives, later reversed its stance and exhibited defiance.

Unjustifiable pretexts - myths vs facts:

The rationale employed by the NMC to disqualify non-medical teachers appears to be weak and unsubstantiated. For individuals who have already covered Anatomy, Physiology, and Biochemistry in the first year of their medical M.Sc. program, integrating these subjects for non-medical teachers should pose no significant challenge. In practice, integration with clinical subjects has been ongoing for many years, albeit under the term "applied aspects," even if it was not formally recognized as "integration." Non-medical educators have successfully implemented these integrations since their introduction a few years ago. It's worth noting that while some non-medical teachers may have been excluded from participating in teacher training programs, many have actively participated in critical training sessions, including the revised Basic Course Workshop (rBCW), Curriculum Integration Support Program (CISP), and Attitude, Ethics, and Communication (AETCOM).

The integration component constitutes only a minor portion, approximately 20%, of the overall syllabus. It's crucial to recognize that the fundamental aspects of health and illness, such as the human body, diseases, and diagnostic and treatment methods, remain constant. A shift in curriculum, therefore, does not alter these core principles. The new curriculum cannot be used as an excuse to disqualify teachers who have been teaching for years/decades or prevent them from the academic role of examiner. Furthermore, the early clinical exposure component comprises just 9 hours in each subject. This relatively minimal requirement can easily be fulfilled by medical teachers, who already make up a significant majority, ranging from 70% to 100%, of the faculty.

Non-medical teachers constitute a small minority, with some colleges lacking any non-medical teachers at all. At most, they can make up to 30% of the total faculty strength. The majority of faculty members in these institutions are medical teachers. Hence, the claims of subpar teaching quality cannot be solely attributed to this minority group of teachers.

Proposal to shift non-medical teachers into research:

The NMC's current proposal plans to relocate non-medical teachers, some of whom have served as Professors for several years or even decades, to research positions, ostensibly to create job openings for doctors. However, this plan is illusory, as there simply aren't enough doctors to fill these positions. Forcibly redirecting an individual's career against their wishes is not only unethical but also inhumane. The process of shifting will not happen as envisaged. While permanent government employees may be accommodated into new positions, privately-run institutions are more likely to terminate the employment of non-medical faculties resulting in job loss of thousands. 

It is to reiterate that medical M.Sc courses are historically meant to create teachers for undergraduate teaching, these are no different from MD courses and the false notion that M.Sc courses are meant for research has to be debunked.

In conclusion, what needs to be done?

1. The presence of non-medical teachers should be an integral part of medical education, and colleges should have the freedom to appoint them on merit up to a limit of 30%.

2. All forms of discrimination against non-medical teachers must be abolished.

3. The NMC Act should be amended to ensure that every board, committee, or sub-committee includes 50% non-doctors to ensure fairness and equity.

4. All discriminatory and contested guidelines in the CBME and MSR 2023 should be amended immediately or withdrawn.

5. In order to strengthen and regulate the standards of medical M.Sc courses, a new body 'National Commission for Scientists in Healthcare and Medical Education' must be framed.

It's all about securing jobs and filling empty PG seats under the guise of prescribing quality

The current landscape of medical education in India has been marked by a series of challenges and controversies, particularly concerning the roles and actions of the National Medical Commission (NMC), the Union Government, and the petitioner association, the National M.Sc Medical Teachers’ Association (NMMTA). These issues have raised concerns about the fairness, transparency, and inclusivity of the system, as well as the balance between medical and non-medical professionals.

Roles of the NMC:

The NMC, as the regulator of medical education, holds significant responsibilities. It is empowered to set standards and guidelines, making it essential for them to engage in discussions and gather feedback from stakeholders while framing these standards. Additionally, the NMC is expected to follow prescribed quorum procedures when framing guidelines or adopting resolutions. Moreover, it should operate under the guidance and policies set by the Union Government and adhere to the norms established by international bodies such as the World Federation of Medical Education. The NMC should ideally maintain a bipartisan, fair, transparent, and inclusive approach in its practices and not let policies be dictated by personal or collective pride or prejudices.

Roles of the Union Government:

The Ministry of Health and Family Welfare (MoHFW) plays a pivotal role in setting the overarching policies for medical education and directs the NMC to follow these policies. The Union Government holds the authority to ask the NMC to amend or withdraw issued guidelines as needed.

Roles of the Petitioner Association (NMMTA):

The NMMTA serves as a vital entity in safeguarding the interests of its members, who are dedicated educators and professionals with non-medical backgrounds. They hold medical M.Sc postgraduate degrees in specialized fields such as Anatomy, Biochemistry, Physiology, Pharmacology, and Microbiology, often accompanied by Ph.D. qualifications. The association can file feedback on guidelines or appeals with the NMC or the MoHFW and seek legal remedies.

Current Issues:

One of the key issues that have emerged is the association of non-clinical medicos lobbying with the Medical Council of India (MCI) and later with the NMC to exclude non-medical teachers from the medical education system. Initially, the MCI proposed to amend the guidelines, reducing the permissible percentage for non-medical teachers to 15%. The Ministry of Health intervened, leading to the proposal's abandonment. However, the association continued to lobby with the NMC, which resulted in alterations to the guidelines.

The NMMTA appealed to the NMC, but their appeal was rejected. Subsequently, they filed a second appeal, leading to the Union Ministry directing the NMC to revert to the previous norms. However, the NMC submitted an affidavit agreeing to comply and later defied the ministry's directives.

The reasons behind the NMC's actions are a combination of explicit and implicit factors. Explicitly, the introduction of Competency-Based Medical Education (CBME) with horizontal and vertical integrations, coupled with the perceived availability of sufficient medical teachers, served as reasons for the changes. Implicitly, these actions are seen as an attempt to create job opportunities for medical professionals at the expense of non-medical candidates and to fill the vacant MD seats in non-clinical subjects, which have historically been undersubscribed.

Several thousand non-clinical MD seats in non-clinical subjects remain vacant each year, leading to significant revenue loss for medical colleges. One hypothesis suggests that medical colleges tend to retain pricey clinical seats and offer non-clinical seats to government quotas to fulfill their obligations. However, non-clinical subjects remain unpopular among MBBS graduates, who overwhelmingly prefer clinical practice. Non-clinical subjects are often pursued out of desperation after failing to secure clinical seats, and competition from non-medical candidates adds to the complexity.

Despite the persistent vacancies in PG seats in non-clinical subjects, hundreds of candidates continue to enroll in these courses. As they cannot practice in any clinical specialty, they rely on teaching positions for employment. Consequently, the NMC has taken it upon itself to disqualify non-medical candidates and provide jobs to medical graduates.

The association of non-clinical medicos and the subsequent framing of guidelines by the NMC appear to be primarily motivated by facilitating jobs and filling vacant MD seats, all under the guise of a new curriculum and syllabus. Global norms set by the World Federation of Medical Education (WFME) advocate for a balance between medical and non-medical faculties, yet the NMC seems to be disregarding these norms to favor its own members. The NMC is increasingly resembling an association of doctors, akin to the Indian Medical Association. The original draft of the NMC Act proposed that only 60% of its members would be doctors, but this ratio was changed to grant doctors full control. In contrast, the regulatory body of the United Kingdom includes 50% laypersons, a practice that helps keep a check on doctors' self-interests. It is no secret that doctors may sometimes prioritize their self-interests and attempt to disregard any unethical practice (as discussed in detail in this Times of India article: https://timesofindia.indiatimes.com/blogs/staying-alive/how-docs-have-fought-to-keep-pharma-funding-going/).

The NMC may assert that its decisions align with general feedback received from the public. However, it is essential to note that the medical community, encompassing both clinical and non-clinical professionals, has collectively advocated for the exclusion of non-medical individuals. Given the substantial majority held by medical professionals in this feedback, it is evident that it may be inherently biased. In situations of conflict of interest, doctors tend to prioritize their own interests, indicative of an abuse of the dominant position. 

While the NMC seems to operate as 'of the doctors, by the doctors, and for the doctors,' the Union Government has a broader responsibility to accommodate all stakeholders and protect everyone's interests. Therefore, it is justifiable for the Union Government to direct the NMC to revert to the old guidelines, ensuring a fair and balanced representation of medical and non-medical professionals. It is essential to note that when there is a conflict of interest, doctors often tend to favor themselves. This apparent abuse of dominant position involves changing yardsticks, shifting goalposts, and amending rules to portray one group as eligible and another as ineligible, all to promote self-interests.

In conclusion, the current challenges and controversies surrounding Indian medical education call for a balanced and fair approach that upholds the principles of inclusivity and transparency. The struggle for balance between medical and non-medical professionals is a critical issue that requires careful consideration and a commitment to providing quality education and opportunities for all stakeholders.