A bitter pill to swallow

  • Dr Govinda KC has legitimate demands, ones that affect the quality of your healthcare directly.
- JIWAN KSHETRY, Kathmandu

Apr 21, 2019-

One day, a decade ago, an MBBS intern came rushing to me in the emergency department of a medical college and made a strange request: ‘Can you please teach me how to insert an intravenous cannula?’ She said that it was the last day of her internship, and that she was moving back to India with an MBBS degree the following day. I was shocked, not least because this apprehension and eagerness to learn clinical skills had gripped me after finishing the basic sciences in the second year of medical school. This student had apparently spent four years in clinical postings without learning any life-saving clinical skills.

That is a rather extreme, but by no means exceptional, case illustrating the sorry state of medical education in Nepal. All this student was supposed to do before facing patients with potentially life-threatening conditions was  rote-learn answers to multiple choice questions for the licensing examination set up by the Medical Council of India. She had already prepared herself for the task by skipping the clinical postings to parrot ready-made answers from exam guides.

A decade later, the owner of the same medical college mentioned above was charged for illegally fleecing would-be medical students, and was to be prosecuted for criminal fraud and go into hiding. Even as the student-victims of this well-publicised fraud now have hopes for justice, those forced to seek medical treatment from unskilled and under-qualified doctors—due to the poor quality of education—are unlikely to receive it. This is because, unlike financial fraud, the compromise in the quality of education is hard to measure and verify—while being far more detrimental to our healthcare delivery system.

Over the years, Nepal’s medical education sector has constantly been in the news for all the wrong reasons: defrauded students; fake patients and faculty members presented at the time of inspection; organised cheating in board exams; rigged entrance examinations; appalling rates of success in licensing examination; among others. Over the past several months the massive amounts extorted by private medical colleges from students have made  headlines. Not captured by those headlines, however, is the persistent quality deficit aggravated by the immoral business practices of private medical colleges. The prevailing assumption is that with university boards and the medical council there to ensure the quality and clinical acumen of medical graduates, their quality can be taken for granted. But a closer examination of the situation tells otherwise.

Medical education is not all about ensuring that students have enough knowledge and skills. Even if imperfectly, the practical university board exams measure the skills of the students. But preparing a doctor is more than robustly instilling the necessary knowledge and skills. As they are going into the business of treating people and not fixing machines, the students have to develop an entire value system founded on the knowledge and skills. While making life-and-death decisions about the management of a patient, those values matter as much as the knowledge and skills.

What kind of value does a college, whose owner is a fugitive (or a convict) in a criminal offense, instil in the students? How does a professor instil the values of morality and fair-dealing in students while the college holds the students themselves for ransom to extort huge sums illegally? A teacher surely cannot instil the values of judicious, evidence-based clinical practice in the students while the teaching hospital has the ethos of maximising profit at any cost, including indulgence in plainly unethical practices. A college cannot discourage students from rote-learning and cheating when it is only able to fill the wards with real patients twice a year—during inspections and board exams. How are the students expected to learn, when the college deprives them of critical learning opportunities? And how do you combat all these problems while the regulatory bodies, tasked with reviewing the quality of education, are toothless because of institutional collapse caused by political interference?

It was in this bleak backdrop that Dr Govinda KC started his crusade and led the movement to reform Nepal’s  medical education. Soon, it was discovered that the rot in the political leadership, which had creeped into the universities and the medical council, had also extended to vital state organs that were supposed to ensure rule of law. Lokman Singh Karki, the then chief commissioner of the Commission for the Investigation of Abuse of Authority, for example, was busy ensuring affiliation and bloated seat numbers for two private medical colleges owned by his family members. Courts at multiple levels were busy passing brazen verdicts that allowed some medical colleges—deemed unfit to run a single post-graduate course by the regulatory bodies—were awarded with dozens of seats in multiple specialties.

The ecosystem of patronage, bribery, kickbacks and impunity involving all the relevant state organs—with the corrupt politicians at the centre—was thriving so well that crusading Dr KC had to practise Satyagraha sixteen times to expose and fight it. While this movement has been able to expose the layers of wrongdoings prevalent in the sector, the attempts at reform and change have seen patchy at best. The report of the expert committee led by Kedar Bhakta Mathema has only been partially implemented: in the capping of seats and fees for MBBS and BDS programs, mandating a merit-based admission in paid seats in Nepal and making entrance tests mandatory for those seeking to get doctor’s degree abroad. Yet, there has been stiff resistance from the political circles in implementing other vital recommendations.

Where does this leave us then? Are Nepal’s private medical colleges still producing graduates lacking even basic clinical skills? The private medical colleges, organised around a cohesive cartel, are getting more innovative by the day in fleecing students. The replacement of textbooks by guides—whose micro-photocopies are perfect for cheating during exams—has been near total as the attention spans of students keep shortening in the era of social media. The efficiency of cheating has leapfrogged with technological advancements.

If you feel flummoxed and detached reading all this, imagine that the surgeon about to perform your appendectomy may have received his degree from a college deemed unfit to run the course by regulatory bodies, only for a corrupt judge to intervene. After imagining this, perhaps, you won’t be confused about why an ageing doctor keeps going on hunger strikes and makes demands for change.

 Kshetry is a pathologist and activist.

Published: 21-04-2019 12:09

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