Correspondence THE MEDICAL PROFESSION IN INDIA AND

ITS EDUCATION

oir,?In view of Colonel McRobert's article on Indian egrees for Indian Graduates, the experiences of two

^ndidates for the recent M.R.C.P. examination held Poona may be of interest. Both foiled, though one

Ufv1Ved to the semi-final round and the other to the

Jj^al round. Both had failed more than once at the ~ ; ? examination of their respective Indian univer- ses. Both assured me that they would appear again ?r ^he MH.C.P. with hope and confidence, but dreaded "other appearance at their M.D. The reason given

J.,as, that all the M.R.C.P. examiners appeared to wish em f0 pasgj ^hile some of the M.D. examiners

opfnnsd to wish them to fail. In other words some the M.D. examiners were hostile.

ti, as Colonel McRobert points out, medical examina- even for the higher degrees, should be conducted

ha ^or e PurPose ascertaining if the candidate ?reached the required standard in the subject in

th u is being examined, then there is no place for

? hostile examiner. "e hostile examiner-is even more of a menace in

dinl examinations for the ordinary pass degree or

^iti * wotdcl count as hostiles, those puffed "up self-importance who will not abide by the rules

their guidance, and for example by passing only a

ti0 ?entaSe, convert a pass examination into a competi- exa1 ^hose lack the qualities necessary for a good can?-J?er' tact, courtesy, and patience with the

?Henf r 0| an<^ a symPathetic knowledge of student

Part 0^" These latter have been cast in the wrong

hy e remedy lies with the examining bodies, who

the-an adequate system of inspection should ensure

the-r examiners are competent and are conducting examinations according to the rules laid down.

ai0ns ar as the licentiate class is concerned, with whom So

e my experience lies, that such inspections are

inVo^om carried out is mainly because of the expense eleyCent'ate education is the responsibility of the

?f Provinces, _ while graduate education is that

*Qdia ^entre acting through the Medical Council for

^orp6 ?'^rov^ncea have a great many other interests, far

edllp important to them, than that side of medical

are n which has been thrust upon them. They

It ra>s disinclined to open their purse strings. edupnr?U^ realized that a subject so vital as medical Wh0]p 1 cannot but be treated as a whole for the

contm 11 ^ndia, including the Indian States. It is

the Q Ua''y forgotten that the States comprise l/3rd

continent ^th of the population of the sub-

one^ ̂ .^/hcal education in India were controlled by ^hen th t P ̂ su?h as the Medical Council for India.

h*sist th \ ?dy by withholding recognition," could at those responsible for medical educational

establishments, provided them with proper equipment, staff, buildings and finances, and that examining bodies and their examiners conducted their examinations on a sound basis. Uniform central control would enable the second

point raised by Colonel McRobert, that licentiates should be given facilities to obtain a degree, to be treated radically. If medical education was treated as a whole and not in bits, and the profession was one body not two, then the licentiate and his diploma would fall into their natural place as the foundation

of the system on which the profession and its education were based.

It is overlooked that both the graduate and the

licentiate start from the same common point, the

matriculation or its equivalent. This, then in practice is the standard of general education demanded as the portal for either party to enter the medical profession.

It is true that before entering a medical college the would-be graduate has to pass the Intermediate Science Medical Group, and that admittedly the average student entering a medical college is better educated than the average student entering a medical school. But the reason is not that two years' study of science has improved his general education, but the fact the expenses involved in the two years' course at a science college, and the prospects of the expenses of the five years at a Medical College limit the intending graduates to a wealthier and therefore a generally better educated class than the average intending licentiate. Who would not rather be a graduate rather than a licentiate, if he could afford it ? It is overlooked that the licen- tiate is considered to be a doctor all over India. In large areas he is the only doctor practising western medicine. He exists in far larger numbers than the graduate. He has been admitted into the I.A.M.C. as a doctor, where his position with regard to the graduate is not, unlike that of the graduate to his colleague with a higher degree ranking as a specialist. The standard of qualification required of the licentiate

is therefore in practice the minimum standard of qualification required for a doctor in India. Why not recognize the fact and build up the system

of medical education in India, and organize the medical profession, with the licentiate as the foundation ? At the conference on medical schools held at Delhi

In 1938, Sir Hari Lai Gosalia, an experienced adminis- trator and the only layman present, pointed out that the abolition of the licentiate in favour of the far more expensive graduate, would set back the extension of the health services into the country districts, perhaps indefinitely. With the news from France as it is, rightly attention

is being given to post-war reconstruction. The calculation has been made as to the number

of doctors India now possesses, and the number she should possess in that bright future which we are

told is before us. The answer to that sum is a very large figure. The calculation as to what the cost of producing and maintaining the large number of doctors required for the future has not I think yet been made. When it is it will be found that the final figure is colossal.

India is a relatively poor country and the finding of colossal sums for this and that is beyond her capacity. There is no shame in being poor, or of having to cut

one's coat according to one's cloth. Britain is poorer than the^ U.S.A. and Scotland than England. What Scot admits inferiority to the Englishman, or English- man to the Yank ?

If the very large number of doctors that India

undoubtedly needs are to be provided, the majority of them must be produced cheaply, so that the money spent on their training will be commensurate with what they may expect to earn when trained.

In any profession, when the ordinary earnings of the

average man do not offer a reasonable return on the

time and money spent in entering that profession, then the loss indubitably will be made up, inevitably by dubious means.

58 THE INDIAN MEDICAL GAZETTE [Jan., 1945

Before this war many medical graduates were forced by economic stress to accept posts usually held by licentiates, and on the pay of licentiates. Labouring under such conditions, is it to be wondered at that the ethical standards of the medical profession in India are not hieh ? The fault lies not with the individual mem-

bers of the profession, but with those who allow such conditions to arise. ...

Let the foundation of the medical profession in India be the licentiate, primarily providing what all systems of medical relief must rest on, the general practitioner. The licentiate should be produced as cheaply as is

consistent with the acquisition of a sound general knowledge of that aspect of his profession he will

ordinarily be engaged in, i,e. that of a general practi- tioner in the country. While ensuring that the school and hospital in which

he is trained are not allowed by financial starvation to remain in the pitiable condition portrayed by General Sprawson in his note on Medical Schools of 1935, it should be recognized that it is not necessary for these establishments to be equipped with every latest gadget, to be housed in palaces, or be staffed entirely by holders of the F.R.C.S. and M.R.C.P. There is a happy mean not impossible to arrive at,

and maintain, provided there is one strong single body to exercise control. In devising the curriculum it should not be necessary to demand the steps of ad- vanced operations which the student is never likely to have to perform. Endeavour should be made to concentrate on the common diseases, their recognition, treatment, and prevention, under conditions the student will probably deal with them in the future, that is to say, without (he nid of a large well-equipped hospital behind him. Too much time need not be spent on

midwifery, The assumption should be that the student, unless a woman, is unlikely to practise midwifery as

the British G.P. used to and now does not. Since the majority of this class of practitioner will never leave India, it is unnecessary to insist on a standard that will gain recognition for registration by the General Medical Council of Great Britain.

It should be remembered that, examinations can be made easy without any lowering of the standard. The London M.B.B.S. used to be more difficult to pass than fhe English Conjoint, because it was held only every six months, and all subjects in each of its two groups had to be passed together. The Conjoint was held quarterly, and each subject could be passed separately. Its standard however was the same required for the London MJ3.B.S., possibly higher, as with a far less penalty for failure, the examiners tended to be stricter. It would certainly lessen the cost of obtaining the Licentiate Diploma if the examinations were held quarterly and if the subjects could be passed separately. What the lensth of the licentiate course should be

is debatable. The need for economy points to the retention of the present average of four years for the preclinical and clinical courses, but I doubt if the hare essentials required can be covered in under five years by the class of student that has to be dealt with. A sound grounding in science is no doubt an excellent

foundation for a medical career, for those who can

afford the time and money to undertake more than the bare essentials. The bare requirements in science should not take two years to attain. The London Uni- versity only requires nine months to be spent of the pre'-professional course. Let there be a special pre-professional course for

licentiate not exceeding nine_ months, but including, besides the usual science subjects, a strong course in

English designed to enable the student to marshal his thoughts and express them clearly and concisely. The

medical colleges should lead to decrees and diplomas the equivalent of the present Schedule I and as such be

recognized as registrable by the G.M.C. of Great Britain. The licentiates might form a third schedule, Schedule III. The medical colleges should be left to those with

the time and money to pass through them. Such students would be the counterpart of the British student

lucky enough to have, or to gain by scholarship, the means to proceed to Oxford or Cambridge, rather than to the degree of a more prosaic Provincial University, or to the diploma of one of the Conjoint Boards.

If unification of the medical profession in India is to be attained, it is essential that at least the best of the licentiates can proceed without too much expendi- ture of time and money to a Schedule I degree or

diploma. This could be achieved by allowing all who pass their intermediate licentiate examination with honours to proceed to a Schedule I degree or diploma without further examination in anatomy or physiology. Those failing to obtain honours could be allowed to

proceed after a further six months' period of study for, and the passing of, a special examination of the standard of a 2nd MJ3.B.S. To proceed to the finals of a Schedule I degree or

diploma, consideration should be given to licentiates passing their own_ final with honours, or who have put in a recognized time, at a recognized institution, in a

recognized post as H.S. or H.P. Such a system would probably necessitate the

affiliation of licentiate granting bodies with universities, or other bodies granting Schedule I diplomas. A central authoritative guiding body would go far to help bring about such measures. No system of medical education could be complete

without those diplomas for the special subjects, the necessity for which, and whose proper use are so ably explained by Colonel McRobert. Again to ensure that those who are responsible do

not pervert their use and allow all members of the

profession to have reasonable access to them would be difficult without that central body controlling all medical education in India which it is the object of this letter to advocate.

M. A. NICHOLSON, LIEUTENANT-COLONEL, I.M.S.,

Chief Medical Officer, Central India and Superintendent, King Edward Medical School, Indore

Indore, 19//; September, 1944.