Outreach programme in medical education: Band-aids for compound fractures

By Amitav Banerjee, MD* 

Recently, the National Medical Commission (NMC) of India, introduced two curricular changes in medical education, both at the undergraduate and the postgraduate levels, ostensibly to offer opportunities for quality medical education and to improve health care accessibility among the underserved rural and urban population.

At the undergraduate level, it introduced the Family Adoption Program (FAP), in August 2019 to be implemented for MBBS students from 2021-22 batch as a part of new competency based medical education (CBME) curriculum. The purpose is to provide community-based learning experience to medical students. The FAP starts from the first professional phase to be continued throughout the MBBS course. The NMC stipulates that each student will adopt five families in rural areas or urban slums, in the first year. The medical student will be responsible for monitoring the general health of the family members of the adopted families and advise them on health related issues, guiding and accompanying them to the hospital. The medical student is expected to follow these families till their final MBBS part one, under the guidance of a faculty of Community Medicine.

At the postgraduate level, the District Residency Program (DRP) was launched in 2020 by the NMC to be followed by students admitted 2021 onwards. This is a mandatory three months rotational posting for all post graduate (PG) students, or residents as they are called, in district hospitals.

A number of articles, in peer reviewed medical journals, praising the schemes while glossing over the drawbacks, have been written by academics, with their skin in the game. We require a critical appraisal of these community outreach activities, against the background of the current ethos of medical education and the needs of the underprivileged communities. The NMC enjoys immense authority over the Medical Colleges in India. By granting them recognition it can make or break them. Regular inspections for increase in seats keep the faculty and management on their toes perpetually. Any criticism of their policies is unlikely to come from them.

Anna Ruddock a medical anthropologist from Stanford University, carried out a detailed study of student doctors at All India Institute of Medical Sciences, (AIIMS) New Delhi. After studying the medical landscape and interviewing hundreds of doctors and medical students, she has penned down her deep insights in her book, "Special Treatment." 

As the AIIMS is the role model for all medical colleges in India, her findings describing the ambitions and aspirations of medical students in AIIMS have important take home messages for medical education. They are sobering. Her in-depth interviews with medical students revealed that almost all of them were focused in the future and their MBBS course was only a corridor to specialization and super-specialization. Wise beyond their years, the medical students demonstrated irrefutable logic in this approach given the current medical environment. As one student expressed, "MBBS has become just like a preliminary examination, it's a "pre." So the actual doctor should at least do a PG, otherwise you are not a doctor." Most echoed similar views, and beyond, a considerable number wanted to pursue super-specialization after their PG studies. According to them the medical students were on the cusp of a transition to the necessity of super-specialization without which they would stand no chance of a successful career.

Another articulated, "About 20, 30 years back just MBBS doctors were doing all these things, no PG qualification or anything. But now PG is everything, without PG we cannot do anything. At present if I am postgraduate, I will be just OK in medicine, but in my time in five-six years, I will be doing super- specialization."

Those who fail to secure a PG seat do not necessarily enter general practice by default. A large number keep on appearing and re-appearing in the entrance tests to secure a specialist branch. Dr Raman Kumar, of the Indian Academy of Family Physicians estimates that at any given time India has around 300,000 MBBS graduates who were not in full time work. And many who do not get their desired specialty again reappear in the entrance exam to get the seat of their choice.

This period of the past two or three decades coincides with India's flourishing corporate hospitals and driving health care from a calling to an industry selling a "five star" experience to patients. This transition is influencing the value of particular forms of medical practice in the eyes of patients and aspiring doctors.

The other aspect which the outreach programs purport to address is lack of access to health care by the marginalized population. The Bhore committee laid down the roadmap for health care around the time of our Independence. It envisioned a primary health centre for 10,000 to 20,000 people with a 75 bedded hospital staffed by six medical officers, including the broad basic specialities like surgery, gynaecology, medicine, and supported by other auxiliary staff. About 30 of these primary units were to be overseen by a secondary unit with a 650 bed hospital offering all major specialties. At each district level, it recommended a 2,500 bedded hospital providing tertiary care.

Over the years we have strayed further and further away from this roadmap which would have provided equitable health care to our vast population both at the rural and urban areas. By adopting families, (the very term "adopting" is patronizing), first year medical students without any clinical competence would not mitigate the medical needs of our neglected population overnight. Many would play truant to attend coaching classes for PG entrance as they are doing currently during internship training. They would of course, with a spatter of white coats in the community give an appearance of medical cover at the community level without going deeper than the surface of the malady, like misplaced band-aids over compound fractures. A compound fracture is one in which the skin over the bone is broken, and putting band-aid on the skin will not address the deeper fracture. And due to the commuting from college to community they will lose on precious time taken away from learning tough subjects like Anatomy, Physiology, and other basic medical sciences which is the foundation of a sound professional career.

But of course, these community postings and outreach activities help them pad up their CV enabling them to get admissions and jobs abroad. At the first opportunity for greener pastures in the West, having learned the tricks of the trade, rather than the trade, most fly over the cuckoo's nest instead of serving the community.

From the above dynamics, it would be obvious that the current ethos of health care and medical education does not harmonize with the concept of community outreach activities in medical education. The NMC, though well meaning, seems to be both insulated and permeated by social and health inequalities beyond its ivory tower. For the former it seems to be turning a Nelson’s eye to the deeper malaise in healthcare, while for the latter it is applying band-aids over compound fractures. The concept of FAP originated in Sewagram on the principles community service of Mahatma Gandhi. Given the lure, lucre and survival in the profession, only an occasional Spartan like the "Mahatma" may benefit from these outreach activities.

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*The Author is a renowned epidemiologist, and currently is Professor Emeritus at DY Patil Medical College, Pune, India. Having served as an epidemiologist in the armed forces for over two decades, he ranked in Stanford University’s list of the world’s top 2% scientists in the year 2023 and again in 2024. He has over three decades of teaching experience including undergraduate and postgraduate courses