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Oct-Dec2003-11(4)
ARTICLE
Medical college teachers and
some ethical issues in Kerala
V Mohanan
Nair
The reported harassment of a medical student by his
teachers has sparked off a heated debate in Kerala. The student, the son of a
former state legislator, committed suicide, apparently after teachers
intentionally failed him in the final examination (1). Following extensive press
coverage, the state government referred the matter to the Petitions Committee of
the Kerala Legislative Assembly. The Committee, which is chaired by a senior
legislator and has eight other legislators as members, concluded that the
student's suicide was a result of intentional harassment by teachers (2). It
named the responsible teachers and recommended punitive action against them.
'Some amount of rough behaviour' is
justified
The Kerala Government Medical College Teachers'
Association immediately refuted the Committee's findings and demanded that the
government ignore its recommendations. It stated that there was no harassment
but that 'some amount of rough behaviour from the teachers' is inevitable to
equip students 'to face future threats from patients and the public' (3).
Medical college teachers are expected to impart the
highest levels of academic excellence. They must also provide mental and
emotional support to students. This responsibility is all the more important
when they are dealing with students who may be physically or emotionally
disturbed. Medical students must cope with heavy academic requirements, time
pressures and stress related to clinical work. In this situation, medical
college teachers must play the dual role of physician and teacher. Such support
was almost always forthcoming in the past.
A crisis in medical education in
Kerala
Today, however, there is a crisis in medical
education. This assumes greater significance in a state where
governments-irrespective of their political leanings-have always given priority
to health. Over the years, the private health care sector has grown without
regulation, and medical care is becoming big business. As of March 2000, the
state had only six medical colleges, with five in the public sector and
one in the cooperative sector, with a total of 800 students for the MBBS course
(4). By March 2003, five more medical colleges-four in the private sector and
one in the cooperative sector-were started, adding another 500 MBBS seats (5).
At least three other institutions are waiting for approval to start medical
courses. Investors in these colleges use every means to maximise profit and
consolidate their position once they get approval to start medical courses, and
the government has so far been unable to control the admission policy and fee
structure in these private colleges. The matter is now being considered by the
apex court and the state is planning legislation to exercise control over these
colleges.
Some professional organisations are also reported
to have protected members who are unethical in their professional conduct. Such
allegations were made regarding the recent reports of kidney sales in Kerala and
the involvement of some private hospitals. The report of the Ethics Committee of
the Indian Medical Association (IMA), Kerala state branch, was reportedly
modified to protect IMA members-a charge refuted by the IMA.
Medical college teachers: a powerful
lobby
In Kerala, government doctors, including medical
college teachers, are permitted to do private practice. Recently, salaries and
perks of medical college teachers were revised with the intention of banning
private practice. However, the government was pressurised and state government
doctors managed to retain the right to private practice while enjoying revised
salaries and perks almost at par with their central government counterparts.
Both the bureaucracy and political leaders keep their hands off medical college
teachers because they often rely on them for the treatment of their medical
problems. These doctors manage to stay close to the centres of power and retain
their benefits and favours.
This has a high cost. Most teachers in clinical
specialties who have reasonably good private practices, hardly find time to
teach. They do not seem to have time to read anything other than the brochures
of drug companies. Students and teaching are 'inconveniences' to such teachers.
For them, teaching plans and academic calendars are unheard of. Good and
conscientious teachers, who constitute a minority, often find it difficult to
follow serious academic pursuits in this atmosphere. Students also tend to
believe that the teacher with the largest private practice is the best doctor
and try to follow in his/her footsteps, perpetrating a vicious cycle.
Another racket is the 'foreign and private
employment' of medical college teachers. Their attachment to a medical college
is only for its resumé value as 'medical college professor', enabling them to
regularly go 'on leave' to private sector enterprises or abroad. Some even go
without sanctioned leave, because they are confident of 'sorting things out'
when they return. Such 'transient teachers' return to job only when promotions
are due, and go back on another assignment as soon as possible. The tussle that
follows when many return from leave to take the same 'promotion berth' might be
seen as comic if it were not for the consequences to the public and to medical
students.
Yet another scam is the way that reservation quotas
have been used to block postings while teachers go on leave for lucrative
assignments. Since these teachers do not resign, and their absence is never
reported, their posts cannot be filled. The Public Service Commission does not
recruit new staff, nor does the department fill the vacancies by promotion. So
there are shortages of specialists in medical colleges, though such specialists
are abundant in the 'open market'. Those who are affected by this practice are
patients and students. The latest example of this problem is the plight of
Thrissur Medical College. Surgeries have come to a virtual standstill because
there are no anaes-thesiologists in the medical college, though there are plenty
in the state waiting for placement.
Serious teaching and research have been affected
badly. Medical colleges in Kerala do not figure among the first 50 in India in
academic excellence or in research publications. Students rarely get encouraged
to take up research. The few who are enthusiastic are disheartened by the
uncongenial atmosphere. This is evident from the paucity of research
publications from the medical colleges in the state. Unfortunately, doctors can
acquire a postgraduate degree without even setting their eyes on a
'peer-reviewed indexed journal'.
It is in this scenario that a medical college
teachers' association can state that students should tolerate 'rough behaviour'
from teachers for their own benefit.
Are we going in the right
direction?
Medical education is undergoing drastic changes in
many parts of the world. Ethical considerations are becoming important. It is
acknowledged that patients' autonomy and integrity must be honoured. Students
must be inculcated with a gender perspective, equipped to deal appropriately
with patients and their relatives, and sensitised to human rights. Senior
teachers and professors are role models for their students. In their daily work
they live out the ethical principles and etiquette of dealing with patients,
showing by example how to address a patient, how to elicit consent for
examination, how to interact with patients' relatives and so on. Such things
cannot be taught in classroom lectures.
Unfortunately, ethical considerations are often of
least importance in medical colleges in Kerala, as is true in many other parts
of the developing world. Patients often undergo examinations, sometimes even
intimate ones, by any number of students without valid consent. Internationally,
there are heated debates on difficult ethical issues such as allowing students
to conduct intimate examinations (7). Students here are rarely sensitised to
ethical issues.
If the statement of the Medical College Teachers'
Association truly reflects the opinion of the majority of its members, one has
to realise the implications of such a statement. In such a situation, teachers
rather than students must receive immediate attention. Their mindset of viewing
patients and their relatives as potential enemies should not be allowed to
further infect the student community. Teachers must be trained to change their
perspectives. Our future doctors must be sensitised to human rights, ethical
considerations and gender issues during their medical education, if not earlier.
The key players in this effort are medical college teachers.
References
1. Editorial in the Malayalam news magazine Chithragiri, July 7, 2003.
2. News item in the Malayalam news magazine Chithragiri, July 7, 2003.
3. News item in the Malayalam daily Desabhimani, June 27, 2003.
4. Government of Kerala: Economic Review 2000; Kerala State Planning Board, Thiruvananthapuram; 2002.
5. Government of Kerala: Economic Review 2002; Kerala State Planning Board, Thiruvananthapuram; 2003.
6. Government of India. Statement on National Health Policy, New Delhi; Ministry of Health and Family Welfare, 1982; p. 9.
7. Coldicott Y, Pope C, Roberts C. The ethics of intimate examinations-teaching tomorrow's doctors; BMJ 2003;326:97-101.
References
1. Editorial in the Malayalam news magazine Chithragiri, July 7, 2003.
2. News item in the Malayalam news magazine Chithragiri, July 7, 2003.
3. News item in the Malayalam daily Desabhimani, June 27, 2003.
4. Government of Kerala: Economic Review 2000; Kerala State Planning Board, Thiruvananthapuram; 2002.
5. Government of Kerala: Economic Review 2002; Kerala State Planning Board, Thiruvananthapuram; 2003.
6. Government of India. Statement on National Health Policy, New Delhi; Ministry of Health and Family Welfare, 1982; p. 9.
7. Coldicott Y, Pope C, Roberts C. The ethics of intimate examinations-teaching tomorrow's doctors; BMJ 2003;326:97-101.
V MOHANAN NAIR, Achutha
Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for
Medical Sciences and Technology, Medical College PO, Thiruvananthapuram 695011,
Kerala, India. e-mail:vmnair@sctimst.ac.in