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| EDUCATIONAL FORUM |
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| Year : 2016 | Volume
: 48
| Issue : 7 | Page : 10-13 |
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Medical curriculum and pharmacology: An appraisal
PSRK Haranath
Retired Professor of Pharmacology and Director of Medical Education, Andhra Pradesh, India
| Date of Submission | 01-Sep-2016 |
| Date of Acceptance | 11-Oct-2016 |
| Date of Web Publication | 2-Nov-2016 |
Correspondence Address:
PSRK Haranath
Retired Professor of Pharmacology and Director of Medical Education, Andhra Pradesh
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0253-7613.193328
Pharmacology was introduced with Western Medical Education in India in 1900s. RN Chopra was the first Professor of Pharmacology along with patient care in School of Tropical Medicine Calcutta. Now Pharmacologists do not have clinical care nor give laboratory services to hospitals. Medical Education advanced in the West in 1960s with more emphasis on Integrated Teaching and Student Self-study and less on didactic lectures. System Based Learning and Problem Based Learning reduced importance of individual subjects. Medical Council of India (MCI) has mandatory regulations with no major changes in the last 5 decades. Universities and Medical institutions have no freedom in teaching programs. In Pharmacology didactic lectures dominate teaching. Practicals started with Dispensing Pharmacy were later replaced with Experimental Pharmacology. At present after restrictions on animals for study practicals are converted to Theoretical Exercises on Prescription writing and Incompatibilities. Students study mostly before examinations with little influence of yearlong teaching. Suggestions in line with Western Countries: Reduce the course of Pharmacology to 6 months. Examinations should be completely Internal with frequent tests by Internal Examiners. MD (Therapeutics) course may be introduced to teach Pharmacology in first semester. MCI rules to be only advisory and not mandatory. Teaching Institutions should form an independent Association and have freedom in teaching programs. A Nonofficial National Board of Medical Examination has to be formed to conduct an Entrance Test for admissions to Medical College and a National test for each graduate before registration.
Keywords: Curriculum, medical education, pharmacology
How to cite this article:
Haranath P. Medical curriculum and pharmacology: An appraisal. Indian J Pharmacol 2016;48, Suppl S1:10-3 |
Pharmacology in medical education has undergone several changes over the years. Gaddum stated, “the pharmacologist has been a ‘jack of all trades’ borrowing from physiology, biochemistry, pathology, microbiology and statistics – but he has developed one technique of his own – the technique of bioassay.”[1] In the UK, pharmacology was preclinical subject during the first 2 years in universities such as Oxford. In Edinburgh, it was termed pharmacology and therapeutics.
In India, pharmacology as part of MBBS courses was started in the early 19th century.[2] Col. R. N. Chopra, MD, MRCP, IMS, from the Indian Army Service was the first Professor of Pharmacology at Calcutta School of Tropical Medicine Teaching at Calcutta Medical College and treating patients at the attached Carmichael Hospital. He trained the early pharmacologists such as B. Mukherji and J. C. David V. Iswaraiah. The school had eminent directors such as Sir Ronald Ross. R. N. Chopra and his successors at School of Tropical Medicine had clinical responsibilities for research. Professors of pharmacology such as S. W. Hardikar and M. Y. Ansari at Hyderabad and K. N. Ojha at Cuttack had clinical wards under their control. Iswaraiah took pharmacology as optional for his MRCP at Edinburgh, thinking it is a clinical subject. However, he was denied access to clinical services in India even when he offered to join the army. He introduced MD (Pharmacology and Therapeutics) in Andhra University with two examiners in pharmacology and two in medicine, with clinical and practical pharmacology examinations. (I had the privilege of obtaining this degree). Later, Medical Council of India (MCI) deleted “Therapeutics” from the MD degree. However, some like UK Sheth and Ashok Vaidya with MD (General Medicine) joined pharmacology and had annex for clinical trials.
In early years, pharmacology was taught for two clinical years. Later, pharmacology was brought to the 1st clinical year. Recently, it was made 1½ years and students appear for all paraclinical subjects at one time. Pharmacology was considered a minor subject compared to pathology. Biochemistry came out of shadow of physiology and microbiology from pathology since they offer laboratory services to the hospital. Preventive medicine (“hygiene”) acquired quasiclinical status with a primary health center attached. Pharmacology neither gives laboratory service to the hospitals nor has access to patients. It is often linked with pharmacy and, in some institutions, kept in charge of hospital drug stores.
| » Advances in Medical Education in the West | |  |
We inherited medical education from the West. However, it metamorphosed over the years. In the USA, Flexner report in 1910[3] stimulated reforms. The Association of American Medical Colleges (AAMC) is formed to act as a bridge among all medical schools. The schools are independent with its own teaching programs and award degrees. Some are full-fledged while some conduct only 2 years preclinical course and students chose clinical course elsewhere. At its annual meeting, AAMC discusses the relative merits. The degrees granted by the medical schools do not entitle them to practice. Each state insists on a separate examination for accreditation. In this context, National Boards of Examinations (NBE), a nonofficial organization, was formed. It conducts nationwide examinations at preclinical, clinical, and residency levels. It also conducts USMLE which is accepted for granting license in most states. Thus, every one American or Foreign faces another test even after graduation. This ensures the standard of emerging graduates. AAMC conducts Medical College Entrance Test MCAT for aspiring students and communicates its marks to colleges of the students’ choice. Thus, the merit is ensured at admission and also after graduation by two nongovernmental agencies.
In the UK, Royal Commission on Medical Education interviewed students, staff, specialists, practitioners, and public 1965–1968 and concluded that “Medical education is for the student and not benefit of subject.”[4] The General Medical Council (GMC) of the UK has been liberal permitting its universities to choose their own programs to adopt more useful and practical methods of training with the latest advances freely available on the internet.
Some universities introduced the “system-based teaching” in place of “subject-based teaching.” For example, a “heart” module would include anatomy and physiology of the heart, clinical examination, clinical cardiology, and cardiothoracic surgery in one module. Exposure to clinical sciences begins at the 2nd year itself. Lectures are reduced with greater emphasis on making the student to study, understand, and learn for himself/herself while staff only guide the student to find relevant sources.
Universities such as Liverpool in the UK and Stanford in the USA and several medical schools opted for “problem-based learning” in the last two decades favoring early clinical exposure. “Integrated teaching” increased student responsibility in self-learning from the hospital and internet. Small groups (10) of students are given a clinical problem each week for example, “Fracture of femur in adult aged 40 years with diabetes.” The group studies and prepares relevant basic and clinical information from the internet under the guidance of a staff member. Problems of wide range are covered in the 1st year itself. From the 2nd year onward, they attend the hospital and learn clinical diagnosis and treatment under guidance of tutors. They do not attend any nonclinical department or laboratory and visit anatomy museum only by appointment. GMC of Great Britain is liberal and recognized their degrees and postgraduate (PG) qualifications. Examinations are conducted by its own staff each year. Failed candidates are reexamined after a month. Second failure in any subject leads to termination from the course. This serves as deterrent in the UK and USA for students learning.
| » Medical Education in India | | |
Medical education under control of MCI is many decades behind the Western world. MCI started originally to grant registration to graduates, slowly acquired mandatory authority. It published ‘minimum requirements for 100 admissions’ prescribing duration of courses, subjects to be taught, division of semesters, timetables, curriculum, examinations, number of papers, marks distribution. It specifies the space, staff, qualifications for departments, and the hospital. These are only marginally changed over years. An occasional directive “integrated teaching may be encouraged” makes hardly any impact. MCI sends commissions for starting and recognition of medical colleges.
There is no freedom for reform to the teaching institutions. Universities merely conduct examinations and award degrees. However, MCI has no control over the merit of students admitted which is subject to various tests, reservations on the basis of region, caste, and sex. It does not test each emerging graduate before registration. Anyone admitted into a medical college can someday emerge as a graduate!
Under a misleading formula of doctor/population ratio, the government is opening more medical colleges. At present, there are 426 colleges with 53,455 MBBS seats. However, qualified graduates decline to go to rural areas with 80% population. They are not confident to treat patients independently without the institutional diagnostic support. They prefer to join PG courses with stipends spending internship preparing for the PG entrance test. There are 235 institutions offering PG courses – MS 2249, MD 4820, DM 221, MCh 289, and Diplomas 1405 (total 8,984) seats with PG stipend.
Each PG qualified in his/her specialty is disqualified from general practice. This perpetuates the scarcity of medical services to rural areas.
Medical education with the high yearly fees in government and private medical colleges has become expensive, more a business than education. Although there are several lucrative alternate courses such as engineering, technology, computers, and commerce, parents and students flock to medical courses.
| » Pharmacology in Medical Curriculum | | |
Subject of pharmacology presents drugs, routes of administration and fate, groups of drugs for systemic diseases and specific conditions. Details are not necessary in view of rapid advances and new drugs. There are many good pharmacologists and students. However, let us view the prevailing pattern of study in pharmacology. Education comprises teaching, learning, and assessment.
| » Teaching Includes Lectures, Demonstrations, and Practicals | | |
Lectures
Didactic lectures should be minimal. They should be pruned to avoid historical references. Only when presented with its relevance to clinical practice, students get interested. For example, lecture on antimalarial drugs should start with the life cycle of the parasite with a representative drug effective at each stage. However, the same topic is repeated in different subjects such as pathology, microbiology, and medicine.
Demonstration
Pharmacology is a biological science. A selective demonstration on a live tissue is quite impressive like a clinical case in the ward. Video demonstrations are no substitutes. One cannot learn swimming from a video. If the staff rehearse it a few times before, success is assured.
Practicals have undergone a sea change over the years. “Dispensing pharmacy practicals” are dispensed after the advent of pharmaceutical preparations and the staff transferred to hospital pharmacies. “Experimental pharmacology” was next introduced by the MCI with detailed list of equipment. These practicals were adopted slowly awaiting staff to be trained and equipment obtained. However, the results in the laboratory have been disappointing both for staff and students, facing straight lines on the drums. The experiments on isolated tissues succeed on using all-glass/stainless steel distilled water and ANALAR grade chemicals. Should be added to test solutions for perfect responses. Drums have to be kept oiled and organ bath glass tubes have to be cleaned with detergent to remove traces of drugs of previous experiments. Pyrex glassware is preferred to soft glass which is alkaline.[5] In the meanwhile, legislative restrictions on using animals for teaching snuffed out any hope of improvement.
Theoretical practicals on prescription writing, drug interaction are introduced as an alternative. The components of practical experiment, observation, and inference are not present in these practicals. Drums are replaced by computers for each student. Imagine these classes for 200 admissions. The main flaw in these exercises is (a) the students are not exposed to treatments in hospital in the 1st clinical year and (b) the pharmacologists conducting these classes have no background of patient care. Pharmacologists neither treat even their own family nor have private clinics. Prescriptions from the consultants show only trade names of drugs and even pharmacologists have to refer to MIMS, drug indices, or the internet to know their components and action. These theoretical practicals can be replaced with two or three lecture classes to be taken by a clinician.
| » Learning by Students | | |
Unfortunately, student learning in India is not synchronized with teaching. Students wait for the completion of the subject by teacher and study before examinations with textbooks and notes. Their objective is just to pass the examination. When on strike, they seek postponement of examination stating “portions are not finished by teacher!”
It is imperative to stimulate self-study by students. The detailed teaching program of all the topics for the whole semester/year should be planned with dates including internal and final examinations and notified both to staff and students. This schedule should be adhered to strictly. Teaching is only to detail vital areas and not from A to Z. The onus of study is to be on the student from day 1 to come prepared for discussion at the tutorials. The staff should be updated to explain to students.
| » Examinations and Assessment | | |
The Only Stimulus to Study is an Examination
At present, students are indifferent to internal examinations though these marks are included for final assessment.
Ideal to Make Examination Wholly Internal
When the final examination includes external examiners, the scope of the subject is not defined and students are forced to study unnecessary details. Internal examinations conducted by staff; each semester should count up to 50% of final examination. Staff should be trained to prepare multiple-choice questions (MCQs) each week after they complete a topic. These should be screened by all the staff and added to the question bank in the department. Final theory examination should consist mostly of MCQs and few short note questions. With MCQs, personal bias is excluded. These papers can be evaluated by technical staff or sent to an external examiner. External examiners are not necessary to conduct viva. They are necessary only for PG examinations. Viva is best done by the staff who taught them.
Second failure in any subject should be followed by removal from the course. It acts as a deterrent to make the students study hard.
| » Postgraduate Coursess | | |
MD (Pharmacology) is needed for medical education and also for drug development, screening, testing, and clinical trials before introduction to market. They are essential for pharmacy, dentistry, veterinary sciences, and the pharmaceutical industry and research. PG students should be trained to do research and sent to research centers with special facilities. Journal clubs every fortnight should familiarize them with the current topics of development and research in pharmacology and allied sciences in Indian and foreign journals.
MD (Therapeutics). The reason advanced against entrusting pharmacologists with patient care is that they are not trained in medical diagnosis and treatment in hospitals. The alternative is to introduce MD (Therapeutics) on par with general medicine, but with a module of pharmacology added in the first 6 months. They can teach pharmacology along with patient care.
DM (Clinical Pharmacology) is introduced as a superspecialty. Diplomas and certificates are given for nonmedical graduates for “clinical trials.” What is the extent of patient care involved in these courses? Is it only monitoring the results?
| » Research and Animal Experiments | | |
Pharmacology is a biological science vital for medical education and research. It involves experiments on animals for development, screening, testing, and clinical trials before marketing them. In the West, biological sciences formed a “Research Defence Society” to educate the general public and Parliament on the need for research with animals to save the human population. British Pharmacological Society is encouraging nonmedical graduates to take up qualifications in pharmacology. They also conduct courses in experimental pharmacology and bioassay. Bioassay is a simple, specific, and cheap preliminary screening procedure for drug research. It is a pity that amphibian tissues such as frog are under prohibited list. Even in India, restriction applies only to use of animals by students and not for research. Over enthusiastic Ethical Committees are raising frivolous objections and blocking research projects even at the start. This made medical faculty move away from research. Research publications are now mostly from pharmaceutical concerns and pharmacy colleges not much targeted by the regulations. Researchers outside India without these restrictions are publishing their papers in Indian Journals.
India has only a small percent of vegetarians. Fish, chicken, and mutton are in liberal use at home and hotels. Poultry and fish farms are promoted and slaughter houses are permitted. There should be no objection for discarded tissue from them in research. Eggs, placenta, blood components, surgically removed tissues, yeast, bacteria, and even germinating plants can be subjected to research.
| » Suggestions | | |
Emphasis in medical education in the West is mostly on student learning by self-study of medical subjects direct from books and the internet with minimal didactic teaching during the 1st year. This is followed by progressive clinical training for 3 years under the guidance of staff in the hospital. It is necessary for a delegation of Deans and Vice Chancellors from India to visit the UK and the USA to study their approach and plan release of Indian medical education from rigid outdated rules. A reform is long overdue:
- MCI rules should only be advisory and not mandatory
- There should be academic freedom to the universities and teaching institutions to plan and reform their teaching program
- There should be an association of medical institutions to meet annually and review teaching methods, hospital practices, and nursing education similar to AAMC of the USA
- An independent National Board of Medical Examinations to be formed (as NBE in the USA) to conduct an entrance test and test every medical graduate before registration
- Student learning supported by self-study from the internet has to be introduced without didactic teaching to cover the entire subject
- Pharmacology course can be shortened to 6 months
- An MD (Therapeutics) can be started with a module of pharmacology. It teaches pharmacology for the first semester and patient care and therapeutics in the rest of the clinical years
- At undergraduate level, the examination system has to be totally internal. The monthly or bimonthly examinations should add up to 50% marks. The final written examination mostly MCQ and few short notes can be sent to an external examiner. The final practical and viva also should also be by internal examiners who know what the students are taught
- Failed students should be examined within 1 month. Second failure in any subject should be followed by expulsion from course
- Competence in the subject, continued learning, simplicity in communication, and love of teaching and students are the hallmarks of a good teacher
- Eagerness to learn, acquire knowledge, respect to teachers, and service to humanity are the goals of a good student.
Financial Support and Sponsorship
Nil.
Conflicts of Interest
There are no conflicts of interest.
| » References | | |
| 1. | Gaddum JH. Drugs in Our Society. Baltimore, Maryland: The John Hopkins Press; 1964. p. 17-26.  |
| 2. | Haranath PS. Reflections on the evolution of pharmacology in India during twentieth century. Indian J Pharmacol 1999;31:1-13.  |
| 3. | Flexner A. Medical Education in the United States and Canada. New York: Carnegie Foundation for the Advancement of Teaching; 1910. |
| 4. | Report of Royal Commission on the Medical Education (1965-1968): Presented to Parliament, U.K. in April 1968. Her Majesty’s Stationery Office, London; 1968. |
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