he Medical Council of India (MCI) must be
commended for its efforts to introduce definitive criteria for
appointments and promotions for teachers in medical institutions. On
June 8, 2017, the MCI issued a circular [1] to amend the Minimum
Qualifications for Teachers in Medical Institutions Regulations, 1998
(henceforth Regulations, 1998) [2]. The amendment clarifies the minimum
qualifications required for various postgraduate teaching positions in
medical colleges. It indicates MCI’s sustained engagement with
qualifications of teachers in medical colleges, with the aim of
enhancing the quality of teaching and thereby the quality of medical
professionals passing out. However, we believe that these efforts
continue to be inadequate in addressing the varied issues that face
medical education and the educators in India.
Some of these issues are: (i) the lack of
transparency in the manner in which new medical colleges are approved, (ii)
the variation in the proportion of private and public medical colleges
across states, (iii) the lack of change and innovation in the
undergraduate and postgraduate medical curricula to keep up with
changing needs, (iv) the poor uptake of newer teaching–learning
methods, (v) the poor quality of teachers in several medical
colleges, (vi) methods used to assess teachers during selection
and promotions, and (vii) failure to assess the impact of policy
changes (such as a recent increase in the number of postgraduate seats)
on the quality of medical education and training.
In this editorial, we focus on one of these issues,
ie, the appointment and promotion of teachers in medical
colleges. The MCI had on September 3, 2015 [3] stated its requirements
with regard to research publications for eligibility for promotion of
faculty members in medical colleges. This had been critiqued [4,5]
mainly on four counts: exclusion of publications in ‘electronic-only’
journals from consideration for assessment of performance; awarding
points only to original research articles or papers; awarding points
only to first or second authors; and, the choice of indexing services
for assessing the quality of a journal. While lauding the MCI’s efforts
towards improving the standards for teaching faculty at medical colleges
in India, these critiques argued that an ill-informed framework for
determining eligibility for promotion is likely be self-defeating and
even harmful to the profession.
A few steps forwards and a few steps backwards
The 2017 Amendment [1] is noteworthy for it states
that in order to be eligible for assessment, a paper must be published
in "indexed" journals. This appears to be a step in the right direction
because indexing indicates that a journal meets certain standards and
quality within a specialty, specific to a particular index. However, in
this amendment, the MCI has not specified any particular index(es).
Thus, possibly the list of indexes previously specified in its 2015
order will continue to apply. Let us look at this issue more closely.
Accepting only the MEDLINE-indexed journals would exclude some research
in valuable allied fields, such as medical humanities, basic sciences
and social sciences as applied to medicine. Thus, inclusion of other
indexes may be useful for recognizing these diverse related disciplines
beyond the pure health sciences, although with due diligence. For
example, some indexes have little credibility as they are known to
include pseudojournals (also known as ‘predatory journals’) in their
listings. Hence, it is important that MCI specifies only those indexes
which are reputed to have quality journals. The 2015 MCI list of
eligible indexes has been faulted on this score [5]. Aggarwal and
colleagues [5] had suggested the following list of acceptable databases:
Medline, PubMed Central, Science Citation Index, Embase/Excerpta Medica,
Scopus and IndMED. The latest amendment missed out on an opportunity to
revise the list of eligible indexes.
The amendment does not specify whether or not papers
published in "e-only" indexed journals are acceptable for assessment.
Here too, possibly the stipulation in the 2015 order, that e-journals,
are not included, will continue to apply. Currently, many e-only
journals (e.g. PLoS group, BioMed Central, etc) are
comparable in quality to, and at times even better than, those published
as hard copy. Their inclusion would allow a much wider range of journals
for the faculty to choose from for publishing their work.
Unfortunately, as with Regulations, 1998 [2], the
2017 Amendment [1] also limits the credit for authorship to only some of
those listed on the author byline. Unlike the first version in which
those listed as the first and the second authors were eligible, the
amendment gives the credit for a paper to only the first author and the
corresponding author. As critiqued earlier, this approach inhibits
collaborative research and could be counterproductive by undermining the
advancement of knowledge. Some of the best research today is
multidisciplinary and multi-author.
Problems untouched
The MCI regulations, even after the recent amendment
[1], are problematic in other aspects too. These lay down two criteria
to assess a candidate’s eligibility for a particular position: duration
of service and number of research publications. One would expect the
parameters assessed during appointment and promotion to be aligned with
the responsibilities of teachers in medical colleges, with a strong
convergence suggesting appropriateness and sufficiency of the criteria.
In clinical or paraclinical departments, medical teachers have three
primary activities; providing clinical or laboratory/imaging service,
teaching, and doing research; which vary for different specialties
However, in most medical colleges, irrespective of specialty, the
research activity forms a small part of the total work of a medical
teacher. Hence, any assessment of only research output without an
assessment of the other two domains does not appear to be reasonable.
What about the other two activities? Provision of clinical or laboratory
services and teaching are integral to the core work of a medical faculty
member. The assessment, if any, of these domains is only by the years of
service put in. This appears unfair. The MCI regulations should address
the issue of assessing medical faculty in all the three activity
domains. Undue focus on research and not on the other two domains might
prove to be detrimental both to the training of medical students as well
as to clinical work.
Failure of the faculty to do research is a
well-documented problem in Indian medical colleges. It has been argued
[6] that this is due to commercialization of medical education in the
country. However, we believe that this phenomenon is multifactorial. One
major reason may be a lack of interest and training to do research on
part of the teachers, or of lack of infrastructure to facilitate
research on part of the institutions. Also, good research requires
financial resources – and most of the institutions, whether funded
publicly- or privately have no or little funds dedicated to this
activity. These factors may need to be corrected first, before we can
expect research to be an important criterion for assessing eligibility
for appointment and promotion of medical teachers.
Lack of adequate funding too discourages the MCI’s
approach. India has nearly 450 medical colleges. Let us assume that each
college has around 100 teachers, and that each of the nearly 45,000
teachers needs to publish a research paper every three years. This
translates to around 15,000 research papers a year. In addition, around
20,000 students join a medical postgraduate course every year in the
country, and each of them has to write a thesis. Let us assume the "most
optimum" case scenario – that each thesis results in a paper with a
student and his teacher-guide as the two eligible authors. Even with
this unlikely scenario, we would require to generate at least 20,000 new
research ideas every year – a formidable task. For these research works
to be novel and publishable, a large proportion of these ideas would
need funding – which is currently not available.
Another important consideration is whether there are
sufficient peer-reviewed, "indexed" journals to publish this large body
of work. The requirement to publish by teachers in Indian medical
colleges and universities has seen a proliferation of "predatory
journals" in India [7-9].We are not arguing that research may be
altogether abolished as a criterion for eligibility and assessment of
medical faculty. It is known that good research institutions globally
and in India are sought after by students and patients alike, as these
are considered better centres for learning and providing a better
quality of care. However, whether the quality of teaching and patient
care can necessarily be improved by mandating research of whatever
quality remains uncertain.
Thus, it is not reasonable to make an assessment for
promotion of a medical teacher solely on the basis of research activity
– that too by counting the number of publications.
The way forward
It is evident from the above that the assessment of
medical teachers must encompass all the three domains of their
activities. Furthermore, the assessment should focus not on quantity, as
is done currently by counting only years of service or number of papers,
but on the quality of work in each sphere. Unfortunately, we will be
told that "assessment of quality" would not be objective, and would be
liable to bias and manipulation. However, this is an excuse for not
doing what seems to us the right thing to do. Around the world, as in
many fields in our country, employees are assessed using the so-called
"subjective" criteria, with sufficient reliability. Setting up such
systems – though admittedly hard – is not impossible. These will surely
take time, effort and commitment to set up. But if we unquestioningly
accept the simplistic tools such as publication count, we will never
move to a higher plane. Hence, as a profession, we need to initiate
debate for moving towards better systems of assessing quality. Such an
assessment system would necessarily mean a multi-pronged evaluation – by
peers, students as well as administrators.
Variation is an important rule of nature and all
medical teachers cannot be expected to have exactly the same skill set.
Thus, one of them may be an excellent researcher, but not a particularly
good teacher. Similarly, someone else might be better at providing a
laboratory service than doing research. This is in fact desirable since
it allows some persons to excel in one specific area beyond the average
skill level expected, and should be encouraged. This requires that
individuals with different skill sets and inclinations be provided the
opportunity to do more of what they are good at and less of what they
may not be so skilled at. The proportion of time spent on the three core
activities referred to above could thus vary between different teachers.
Thus, it would be reasonable that the assessment of medical teachers for
the quality of work would be a weighted average of the quality of work
in the three domains, with the weights decided by the pre-defined
proportion of time spent by each teacher on activities in these domains.
Clearly defining each faculty member’s job description at the time of
appointment or during the course of service will facilitate and/or
enable such an approach to assessment.
Each core activity could be assessed using different
parameters. Teaching should be assessed by the end user; ie, the
student and the performance of students in an assessment should be part
of the assessment of a teacher. Similarly, peers should sit in on
teaching activities and provide a peer evaluation. These suggestions are
neither exhaustive nor necessarily tested to be appropriate for our
milieu. Hence, a constant evaluation and evolution of these methods
would be essential.
Research should be evaluated but not by the number of
publications. The quality of a medical faculty’s research output should
be assessed. This would include a peer evaluation of the individual’s
select few publications – a smaller number at the time of selection and
an increasing number with each step in the academic ladder. For example,
two best papers at the time of initial selection as a faculty member,
five best at the next level, and seven and ten in the further steps. As
almost all medical faculty positions in India are tenured, there are few
who would make the effort to write a grant application and obtain
funding. Those who do so should be assessed on the quality of their
grant applications or the amount of funding obtained.
How does one assess the service component of the
medical faculty? This could be difficult to do but an effort should be
made to use laboratory and clinical audits, and peer and patient
assessment and feedback.
All this must be done transparently. The assessors,
the method and process of assessment and the final evaluation must all
be transparent. Anybody can make errors and hence there must be a
transparent system of appeals and evaluations of appeals. Questioning a
decision with sound reasoning must be permitted but the process must be
free of corruption.
We are aware that some of these suggestions may
appear radical in the current Indian scenario. We believe that the
Indian medical education system is in urgent need of radical corrective
steps, if we are to prevent it from continuing on the slippery slope
that it presently is on. Minor tinkering, such as the MCI seems to be
engaged in, will not do.
References
1. Medical Council of India. Amendment Notification.
New Delhi: 2017 June 5. Available from: http://www.mciindia.
org/Rules-and-Regulation/Gazette%20Notifications%
20-%20Amendments/TEQ-08.06.2017.pdf. Accessed June 13, 2017.
2. Medical Council of India. Minimum Qualifications
for Teachers in Medical Institutions Regulations, 1998 (Amended upto 8th
June, 2017). Available from: http://www.mciindia.org/Rules-and-Regulation/Teachers-Eligibility-Qualifications-Rgulations-1998.pdf.
Accessed June 13, 2017.
3. Medical Council of India. 2015. Clarification with
Regard to Research Publications in the Matter of Promotion for Teaching
Faculty in Medical Colleges/Institutions. Document No.
MCI-12(1)/2015-TEQ/131880.
4. Bandewar SVS, Pai SA. Regressive trend: MCI’s
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5. Aggarwal R, Gogtay N, Kumar R, Sahni P, for the
Indian Association of Medical Journal Editors. The revised guidelines of
the Medical Council of India for academic promotions: need for a
rethink. Indian J Med Ethics. 2016;1:2-5.
6. Ray S, Shah I, Nundy S. The research output from
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2016;6:49-58.
7. Moher D, Shamseer L, Cobey KD, Lalu MM, Galipeau
J, Avey MT, et al. Stop this waste of people, animals and money.
Nature. 2017;549:23-5.
8. Prasad R. Fake journals: ‘Make in India’ gone
wrong. Available from:
http://www.thehindu.com/sci-tech/fake-journals-make-in-india-gone-wrong/article7800231.ece.
Accessed December 5, 2017.
9. Seethapathy GS, Santhosh Kumar JU, Hareesha AS.
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