NMC chief’s mantra for regulating medical colleges: ‘Friendly handshake, less policing’

The National Medical Commission (NMC) plans to introduce third-party evaluations and public ratings for medical colleges by the next academic year while maintaining its focus on quality education, reveals its chairperson BN Gangadhar. The Padma Shri-awarded psychiatrist and a former director of National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, took charge last July, and emphasises a less policing-oriented approach towards regulation while addressing challenges like faculty shortage, lack of infrastructure and student well-being. Edited excerpts from a conversation with Careers360:

What have been your priorities for medical education since you took over as NMC chairperson?

The most important thing is ensuring quality in medical education. The second priority is quality, and it is also the third priority. At the same time, we need to meet the social demand as more and more people are aspiring to join the medical profession. We have to increase the number of seats and colleges. In order to meet doctors' aspirations, we must create more opportunities for specialisations – PG seats. This will enhance human resources in the medical profession.

The opportunities to learn clinical skills come only with quality clinical care. Although there are many stakeholders in clinical care, we are doing our part. There are three important ingredients for quality medical education: happy students, committed teachers and satisfied patients – not necessarily in that order.

And of course, there’s another concern in the public mind: we have to be clean in our affairs.

There’s a sizeable clinical population available for students to learn from, but we have not been able to tap even 50% of clinical resources for teaching. The consultants and specialists are supporting clinical work in medical colleges and this will improve healthcare in the hospitals attached to them.

Hence, we are facilitating the transformation of specialist doctors into faculty. With minimal training, specialists and consultants can serve as teachers as we want to increase the quantity.

There’s a sense among some that pursuing both quality and quantity is inherently contradictory. How can you strike a balance between the two?

It’s common sense that simply increasing the quantity won’t do. We believe in ensuring adequate quality in training of UG and PG students and, at the same time, providing the best clinical care to patients.

Teachers are expected to possess a postgraduate (PG) degree and good clinical experience. All the teachers will go through a brief training to improve their pedagogical skills. We are also mandating some research publications for promotions at different levels.

Will drawing non-teaching doctors into academia impact clinical services in hospitals?

That’s not true. “Non-teaching” is a misnomer. All senior doctors are capable of training juniors. They are already doing such ‘training’. Higher clinical skills make them good teachers. Good teachers, in turn, are also good clinicians. In medical education, academics and clinical practice go hand-in-hand. In fact, good academic centres, such as the All India Institute of Medical Sciences (AIIMS) and other central institutes, attract large patient flow.

Allowing ‘non-medical’ postgraduates to teach anatomy, physiology and biochemistry has become a contentious subject. Where do you stand on it?

We are open to both viewpoints. Earlier, the faculty from basic science backgrounds – we want to avoid the adjective ‘non-medical’ – was capped at 30%. We believe that they have good input to provide. But there’s another viewpoint, which says that medical teachers would ensure a different level of communication, imparting better clinical knowledge.

Our current position is that the eligibility to teach in these departments is MBBS and MD/MS, and if qualified faculty is not available, up to 30% of these posts can be filled with MSc and PhD holders.

At the same time, we are asking all colleges to have a research unit, as teaching research in basic sciences at the undergraduate level is important. The basic scientists should have an opportunity and reason to collaborate with medical scientists. Only time will tell how it pans out.

What changes have been brought in the curriculum through the competency-based medical education (CMBE) curriculum?

Until now, the medical curriculum has more or less been about memorising subjects and facts. Now, the focus is on building competencies. We are integrating subjects horizontally and vertically. So, when the students are studying, let’s say, anatomy, they also need to study its clinical aspects.

The early exposure to clinical practices and small group discussions integrate basic science subjects with clinical subjects. They are also required to undergo family adoption programmes, where they start interacting with families at the beginning of the course and follow up on their health throughout the programme duration. This helps their communication skills.

What is the feedback from students and teachers about CBME? And what changes have been observed at medical institutes?

It’s implemented in almost all colleges. At some point in time, we need to do an impact assessment as CBME is a recent introduction. We have to take feedback formally from teachers on how much they have stressed on the changes or not. But informally, students and teachers have given positive feedback.

One of the repercussions of CBME was a reduction in teaching hours for certain subjects. Has that impacted the faculty's ability to teach?

The traditional class lectures of the past have been compensated with small group discussions.

During the last few years, NMC has permitted a large number of medical colleges across the country. Has that helped improve healthcare delivery?

The number of medical seats has indeed been doubled during the last decade, together by NMC and by [its predecessor] MCI [Medical Council of India]. The expansion has, to an extent, been able to meet the aspirations of the youngsters. However, the rapid development of medical colleges has come with its own set of challenges.

One of the ways the challenge is addressed is by increasing postgraduate (PG) seats. Today, there are as many PG medical seats as the intake capacity of MBBS five years ago. In other words, theoretically, almost all recent medical graduates have higher education opportunities, though not necessarily in a specialisation of their choice.

Having said that, there’s a huge backlog of PG aspirants who couldn’t be enrolled due to a number of factors, including not qualifying for their preferred specialisation and not being able to afford private institutes. As a result, we have twice as many aspirants as the number of seats. And perhaps, this situation will never change even if one equates the number of UG and PG seats. Increasing PG seats in excess of UG seats is one of the solutions. I am unsure if this is practical

But should student aspiration even be the main consideration in expanding medical education? Will super specialty seats be multiplied next? Isn’t it a better idea to counsel aspirants to look for other career opportunities, say in allied healthcare professions, instead?

You’re right. Counselling students is an option we can’t exclude. However, there are numerous state-level specialities and PG choices available to students. Being in their 20s, they have enough maturity and can also educate themselves. This is not to say that the state and the national bodies don’t have a role to play. Besides, the market forces are dynamically changing, which the students are extraordinarily aware of. These forces will determine the future course.

I agree that, for various reasons, a doctor's business is placed on a high pedestal, socially. . And that’s why they choose the medical profession. I am not saying it’s wrong or right – it’s up to the students and parents to decide. The situation may evolve ten years down the line, considering the rapid changes in the medical sector.

But wouldn’t leaving it all to market forces risk subjecting medical institutes to the same fate that befell many of the technical schools that sprang across the country?

I completely agree. We are not leaving it completely to market forces. They can very well put their shutters down if the circumstances and demand change. But I also believe that, medical being such an honourable profession, the institutes will continue to find takers.

Many of the new colleges lack adequate infrastructure and teaching staff. Will it affect the quality of medical education?

We are continuously monitoring it. This has been a challenge. We are monitoring the colleges every year. They need to give an appraisal of their faculty and infrastructure. Please understand that there are always teething troubles. When the colleges start the annual monitoring, they will rise up to meet the challenge. Every college is expected to have a website, so that students can check information about it.

We are also going to be rating the medical colleges. They would want to be high on the list. Hopefully, by the next academic year, they will undergo a third-party evaluation. Making this information available to students will help colleges live up to the expectations.

From this year, we mandated that all requirements for 100 or opted numbers of students are met right from day one. For a long time, this was not the picture. Colleges could start with half the resources, but this has been changed

But there was a report that NMC didn’t adhere to the new Minimum Standard Regulations Under-Graduate (MSR-UG) 2023 norms for approvals and instead followed the 2020 rules.

The 2023 norms were followed, but some margin was given to colleges, as we were using them for the first time. We will increase our standards in a year or two. There was a trade-off between enforcing standards and being practical. In the days to come, people will start seeing reason in it.

The recent Comptroller Auditor General (CAG) reports and government response in the parliament has highlighted the faculty shortage in medical colleges across the country, including AIIMS. How can this situation be mitigated?

We have asked the colleges to adhere to the Aadhaar Enabled Biometric Attendance System (AEBAS) as it ensures that we have an authentic faculty count and the attendance is monitored by a national regulatory body.

But this system wasn’t introduced only to monitor. Earlier, when the inspectors went to colleges, they would do a manual head count of teachers. Our faculty and doctors need much more dignity than this. Now the inspectors need to verify the biometric data.

We should believe and trust colleges, as we are talking about a highly noble profession. The frequent inspections and flagging of lacuna are meant to provide feedback to the colleges. They may not be aware of some deficiencies. The idea is to point this out. The ratings, attendance, availability of information on websites and insistence on high level of standards will culminate in improving the situation.

Were the recent notices to medical colleges in Tamil Nadu also part of this routine monitoring?

Yes, it was a routine exercise. Notices should be seen as feedback from NMC. It could have happened due to different reasons - I don’t want to divulge them. But it’s a service to ensure that both quality and quantity are preserved. These colleges could be doing very well in other areas.

The notices don’t mean that they are incompetent colleges; notices simply highlight their blind spots. It’s a friendly handshake between the regulator and colleges. We have to be largely facilitating and somewhat regulatory with a hope that colleges fill the gaps once pointed out.

The Supreme Court has asked NMC to revise its guidelines related to PwD candidates. What reforms can be expected?

SC has made an observation. Currently, when locomotor and some other disabilities are more than 40%, the candidates are eligible for reservation. But when does that disability come in the way of them becoming doctors? Our threshold for that is 80% disability. The hon’ble court wants a more qualitative assessment of the competencies that they can acquire in medical education.

We are working on it.

We will soon come out with a manual. MBBS is a five-year course and we don’t know if a disability will remain static in this period. The science also keeps changing, with some of the manual tasks being replaced by machines.

We have already made an expert committee. We will have the document out shortly. We are removing the clause that merely demanded less than 80% disability. We will be looking at a case-by-case basis. The disability will be assessed individually, though it’s going to be a time-taking process.

The court has also criticised the Non-resident Indians (NRI) quota in medical admission as ‘fraudulent’. Will there be any reforms related to it?

We will examine and come out with our position on this appropriately.

What about the domicile quota?

I don’t have authentic information about it right now.

You mentioned happy students as a key ingredient for quality education.

For students to be happy, the college milieu has to be very good. The UG and PG medical education should be without stress. Being a psychiatrist and the head of the regulatory body, I think that students should be extraordinarily supported.

The first cause of stress is academics. The students are expected to study bulky textbooks, though many people have now simplified them with more handholding by teachers. The second reason is ragging. The third issue is that at least half the students end up studying in colleges outside their hometown. In hostels, they may face language barriers and other concerns.

With the increasing cost of medical education, some might have taken loans, adding to the financial stress.

Besides anti-ragging regulations, we have facilitated a mentor-mentee programme, where every student is attached to a faculty member, with whom they remain for five years. Since the mentee group of each faculty includes students at different levels of education, there’s a hope that it will result in some sort of brotherhood reducing events of ragging.

We have also introduced yoga as part of the foundational course, and other set of yoga-related activities that culminate in the International Day of Yoga. This will help in stress management. Most colleges have a well-being centre.

All these measures will be a deterrent to ragging and the passage of medical graduates will be smoother and stress-free.

There’s some intervention on the academic front, too. Earlier, the learners needed to get 50% marks individually in theory and practical tests. This discounts the fact that some students can be good in theory, while others can perform better in practicals. Now, they can score a minimum of 40% in one of the tests, but they must compensate in the other. This ensures some amount of matching up of the individual talent with desired competencies.

Is anything being done to ease financial stress?

It’s difficult to comment on finance. The fee regulation is a sensitive area. I believe we have to reduce the fees. There are many people to advise on it. Even NMC had also put forward a fee regulation document some time ago.

As of now, we are demanding that the colleges display their fees and stipend amounts online so that the students have clarity.

Will NMC play a role in addressing stipend-related complaints?

There are many entities involved in determining stipends – colleges, state medical education directors and universities. Of course, we also come into the picture. We are coming up with a guideline to determine where we should step in. The aggrieved students should first go to their university and then escalate it to the director of medical education, if needed. At the third level, they can bring it to NMC. Stipend is declared by the college. So the students should first approach them.

The foreign medical graduates (FMGs) have been facing many issues. They are stuck due to the low success rate in FMG examination (FMGE), while there are delays in internship appointments.

FMG is a fairly complex subject. Those who got admission in colleges abroad before 2018 and 2019, are supposed to have gone there with eligibility certificates. They went without them and came back and we are still issuing these. It has been seven years and I am hoping all such students have obtained the certificates by now and we can stop this service.

Students having gone for studies after 2018/2019 have been certified based on the NEET UG eligibility.

The quality of foreign medical colleges is not authenticated by NMC. Hence, we won’t be responsible if they don’t pass FMGE. And that’s why we should increase the number of seats at home. Why go into untested territories? We have also asked them to do an extra year of internship. The colleges have been allowed to admit interns as supernumerary seats, but we can’t make it obligatory for them.

There’s a demand for centralised counselling to place FMGs.

If we do that, we would be endorsing those colleges and presently NMC is not doing this.

In 2023, NMC had cancelled offline admissions in several states, but later said that those cases are being reviewed. What's the update on it?

[The offline admissions] shouldn’t happen. There’s a monitoring cell looking into it.

Why has NMC not been able to fill its vacant posts?

They are not under my control, surely the government is at it.

NMC has updated its draft framework for medical colleges’ accreditation and rating. How will this process be rolled out?

It’s not accreditation in the sense that the college does not lose recognition on this rating alone.

We have done some pilot work on the rating document. After this study, we found some redundant aspects and added others. The colleges need to go through it. We have already received some comments. We will soon prepare a final version.

Any rating agenda is a continuous process due to the dynamic nature of education. There will be constant changes and newer versions of the framework will come out every year. I can’t get into the micro-examination of the current document.

We want to ensure the quality of education. We believe that all colleges believe in it. We should trust them. Policing should be reduced. I am sure colleges will measure up to the expectations. NMC, for various reasons, prescribes minimum standards. But we want all colleges to cross those benchmarks.