key: cord-0921526-dddf5u75
authors: Patil, Poorvaprabha; Chakraborty, Stuti
title: Where Does Indian Medical Education Stand Amidst a Pandemic?
date: 2020-08-26
journal: J Med Educ Curric Dev
DOI: 10.1177/2382120520951606
sha: 23e1d909fe87901040245f318dacec407c97a55b
doc_id: 921526
cord_uid: dddf5u75

The recent outbreak of COVID-19, declared a pandemic, has affected medical education globally. The scenario is no different for medical students in India as they find themselves at a crossroads in their careers, with clinical and elective postings called off. Missing out on the opportunity to learn from “first-hand” clinical observation stands to threaten the quality of medical education and learning procured by Indian medical students which is extremely essential to deal with the vast patient load that awaits them in their impending future as healthcare professionals. Is the Indian medical education system being able to cope with the challenges imposed by the increasing burden of COVID-19? The authors propose few administrative and on-ground interventions that must seek to work collectively with all government and private medical institutions in order to help students/interns and residents in coping with stress, anxiety or academic losses incurred due to the pandemic.

Health outcomes are immensely affected by the structure of health systems and policies and also play a pivotal role in determining how various healthcare services are delivered. Due to the presence of a federal government in India, shouldering the responsibility of running health care systems' operations and governance have been divided amongst the Union (Central) and individual State governments. Medical education in India is governed by the union and state governments in unison. India's healthcare system consists of a combination of private and public healthcare services and facilities-both providing medical education either under directives of the State/Union governments or through private institutional affiliation. 1 The formal training for Indian medical education spans a long time and was initiated before India's independence from colonization in 1947. Over the years, medical education has evolved significantly to where it stands todaybeing one of the most competitive fields of education to secure a future in, for Indian students. A total of 536 medical colleges recognized by the MCI (Medical Council of India) provide approximately 79 498 seats for more than 1.5 million medical aspirants (as per 2019) who take the National Eligibility cum Entrance Test (NEET). Once an aspiring student secures a place amidst the grinding competition, she/he is expected to undergo five and a half years of medical training and education, including a period of 1 year of compulsory internship. In addition to studying various clinical subjects, medical students are expected to complete compulsory clinical postings with moderated number of hours in each clinical subject, are subjected to continuous clinical and paper-based evaluation/assessments, need to fulfil clerkships, elective postings-all while dealing with the anxiety and stress that comes with course load completion before final exams. [2] [3] [4] [5] 

The recent SARS CoV-2 (also known as COVID-19 or Novel Coronavirus) disease outbreak was declared as a pandemic by the World Health Organization (WHO). The rapid spread of the infection has disrupted daily life and put even the best healthcare systems across the world to a test. This has put an insurmountable amount of pressure on all medical services, including medical education. Medical students across the world stand at a difficult juncture amidst this unanticipated situation. Currently, several governments and medical schools around the world have taken measures to curb electives and clinical teaching in its entirety while some have chosen to maintain a few. Nevertheless, medical students find themselves at a painful crossroad of being the future of healthcare in their respective countries and at the same time being unable to provide services during this crisis as a result of not being fullfledged, licensed professionals. [6] [7] [8] [9] Scenario in India COVID-19 has impacted the journey of medical students in proportions far beyond what could possibly be fully mitigated.

Most medical schools in the country have cancelled face-toface lectures, clinical postings, practical classes, demonstrations, and have moved to online lectures.

Impact on medical students. In India, students preparing to be medical doctors study Anatomy, Physiology and Biochemistry in the first year of their five and a half years coursework. 10 During the first year, in addition to lectures, students visit the dissection hall almost on a daily basis where they learn about the human anatomy. Dissection hall sessions help them in building an understanding of how the intricate structure of the human body functions and lays the foundation for a better understanding of more advanced subjects like Orthopedics and Surgery. This is further supplemented by practical classes, demonstrations, seminars, small group tutorials and hospital visits. In light of the lockdown, medical students in their first year have been walloped, with most of these lessons now being attempted to be delivered online, which makes it challenging to understand the relationship of different human anatomical structures in the body and eliminates the "learning by doing" component of education by performing dissections.

Hospital postings/clinical rounds are undoubtedly the most crucial component of medical education that follows after the first year. Budding doctors learn how to take a case history, identify signs and symptoms, interact with patients, and observe interesting cases while they also shadow doctors on rounds. Everything that they spend hours and days learning from books finally starts to fall into perspective on witnessing findings in patients. A lot of medical students have at least once heard during the course of their education, "What you read, you might forget. What you see (in clinics), you will always remember". COVID-19 has taken away the chance for medical students to learn through clinical rounds; thousands of them are engulfed in uncertainty and fear of how they will be able to make up for this academic loss. With the rapidly evolving nature of the current situation, most medical schools across the country have not been able to decide on how they will make changes to the existing curricula and annual plan to be able to do justice to their students. Several colleges have resorted to assigning humongous portions as "self-study" modules failing to take into account familial conditions and the possible disruptive environment in homes while mental health issues and domestic violence are at a steep rise during the nationwide lockdown. 11 This is an even bigger concern, especially for many Indian students, residing in joint families, consisting of a large number of family members, where the environment encountered might not always be conducive for academic pursuits. 12 Final year students, just a year away from finally being doctors, are anxious about how they will make up for the academic loss and cope with the added burden of an already extremely intense course year.

Impact on interns and residents. The condition of medical students is not particularly promising but interns and residents undoubtedly have it far more difficult. While residents learn specialty-specific skills during their post-graduation, a 1-year-long internship is the last component of undergraduate medical education where interns apply and develop their clinical skills, under the guidance of senior doctors. At some health facilities, senior doctors and specialists are not attending to patients, leaving the entire responsibility to interns and resident doctors. 13 Several interns and residents have been working extra duty shifts in resource-deprived conditions, with a gross lack of Personal Protective Equipments (PPEs)-away from their families and homes. At a few centers, PPEs strangely seem to be following a hierarchy-the senior doctors get the best of what is available, residents follow, and interns are left with barely any quality equipment to protect themselves adequately. 14 In a study conducted in May 2020, around 37% of all respondents also perceived discrimination based on hierarchy (eg, senior doctors vs junior doctors, nurses vs interns) or departments, in the distribution of PPE. 15 A large number of doctors have been reusing masks, gloves, and scrubs. Moreover, faced with a shortage of personal protection equipment (PPE), India's healthcare workers have been reduced to using raincoats and garbage bags instead. 16 While stories are surfacing all over social media and internet globally, calling doctors and health professionals COVID heroes and sentinels, there have been far too many instances of doctors being assaulted in India over the past weeks. While having put themselves and the lives of their families at risk to protect their communities from the pandemic, there are reports of health professionals facing discrimination and stigmatization, being removed from homes, fighting for proper PPEs, being beaten and ill-treated. Such incidents doing rounds on social media and news broadcasts could have a long-lasting and indelible impact on aggravating the anxiety and panic of the impending future on the minds of medical students and young doctors. 17, 18 How this will impact the current generation of budding doctors, in the long run, remains a mystery.

Amidst the long-standing anarchy that presently shrouds India which has been on lockdown since March 25th, 2020, the future of medical education for millions of Indian medical students is at stake, and the stakes are high.

Impact on career paths. It is not just the impact of the pandemic on the mindsets of budding doctors that is worrisome; it is also the uncertainty that looms over the future prospects of these medical students. With international licensing exams being called off, admission processes halted within and outside the country, examinations for many postgraduate medical courses postponed, there have been numerous qualms, making the mental impacts of the pandemic on some medical students worse than the others. Postponement of national level competitive entrance exams proposes another threat to continuity of the supply of trained doctors and health workforce, which might result in a crunch in trained workforce in a few years. Hence, the impact is being experienced not just by existing medical students, but future medical aspirants as well. 19 Patil and Chakraborty 3 Conclusion COVID 19 has put healthcare education and health systems around the world to a stress test. The future of healthcare in India, and the world at large, depends on how our institutions collectively mitigate the damage to healthcare education caused as a result of this pandemic. There ought to be administrative interventions into the functioning of medical institutes across the nation to ensure that concrete efforts are made to help students to cope with stress, anxiety and the academic losses they incurred due to the pandemic. Examples of which could be:

(1) Extension of semesters in institutions across the country to provide adequate time for medical students enabling completion of recommended hours of coursework and hospital rounds at an appropriate pace. (2) Postponement of exams on the horizon enabling students adequate time for preparation. (3) Allowing students with more opportunities to retake/ reappear in written or oral examinations that may have been conducted during the lockdown period which might have warranted for poor performance for students unable to cope with the psychosocial and emotional stressors of dealing with the pandemic (especially students who might have a family member with positive diagnosis). (4) "Self-study/homework" and online lectures are widely being used as a way out, but it is essential to reconsider and reassess the complete reliance and effectiveness of these methods in Indian medical education during these times of disquiet; and take into thorough consideration the academic disadvantage a number of future doctors will suffer from, compared to their peers, due to veiled hindrances like distressing familial conditions and unpleasant environments within homes preventing them from reaching their full academic potential.

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All authors understand and meet the ICMJE Authorship criteria. Both authors contributed to conceptualisation, evidence, literature search, drafting and editing of the manuscript.

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