Combined Bachelor of Medicine & Bachelor of Surgery-Doctor of Medicine (MBBS-MD) course to meet the national health manpower needs.

The foremost function of medical education is to generate skilled manpower, both generalists and specialists, to meet national needs for health and medical services. Sixty years ago, the major health problems were severe malnutrition and communicable disorders that could be controlled through better nutrition, improved sanitation, a good source of water, and vaccination. Further, causative agents were by and large known and could be effectively treated with appropriate antibiotics. Medical education was tailored to this health scenario. Community medicine, which was earlier taught as an ancillary subject of “Hygiene” became a major teaching discipline. A number of Primary Health Centers (PHCs) that were manned by generalists [Bachelor of Medicine, Bachelor of Surgery (MBBS)], was established to take medicine to the rural people. The health scenario has now changed. Health impact of non-communicable disorders (NCDs), which now account for 60% of mortality, and can no more be ignored.[1] Their etiologies are ill-defined described more in terms of risk factors. Their control and prevention need services of specialists and super-specialists. The World Health Organization (WHO) recommends a minimum doctor population ratio of 1:1000 for provision of reasonable services. However, the recommendation is on weak scientific footing as it is based on health parameters that are in the domain of paramedics and do not require doctors. Furthermore, for the purpose of computation of the ratio, generalists and specialists have been lumped together.[2] Today, both rural and urban India urgently need a large number of specialists and super-specialists to deal with the changing health scenario.[2]

The training of specialists and super-specialists requires several years of quality education. In the present scenario, this may take many decades. To overcome this problem, the author proposes a combined course of MBBS-Doctor of Medicine/Master of Science (MBBS-MD/MS). The duration of the course, in which every medical student is assured of a postgraduate (PG) seat, would be 8 years (16 semesters), the period students take currently just to qualify for the PG admission test. Because rural services would be an integral part of the after MBBS education, at least basic specialist services would be made available to the rural population in the shortest time. In addition, the course will address the compulsory rural posting and perhaps stem the brain drain to the West.

Entry-level educational requirements and admission procedures in vogue for the MBBS course will be followed for the admission to the combined MBBS-MD/MS course that will consist of the following three dovetailed components [Figure 1]:

Figure 1

Summary: Combine MBBS-MD/MS degree program (Diagram not to the scale) FRRP = Foundation rotating residency program

The “basic course”, named MBBS for historic reasons, will have the curriculum similar to the MD course in the USA with periodic assessment.[3] The first four semesters are spent in pre- and paraclinical disciplines, simultaneously preparing students for clinical work. The last four semesters would be devoted to rotating “clinical clerkship” that would additionally include rural posting at the PHC/ Community Health Centers (CHC). During the “clerkship”, students will be put in charge of few beds and will be made to attend night calls.

“Foundation Rotatory Residency Program (FRRP)”, which is somewhat similar to the “Foundation Course” for newly qualified doctors in the UK,[4] will consist of two streams of rotatory residency (i) in General Medicine, Pediatrics, and intensive care unit (ICU) and (ii) in General surgery, Obstetrics and Gynecology (OBGYN), and ICU. The duration of the FRRP will be 4 semesters. Additionally, residents will be posted for one semester in the second year in the CHC, where they will hold independent charge and provide specialist services in the respective disciplines to the village folks.

On completion of the FRRP, students will be admitted to 4 semester Senior Residency programs leading to a MBBS-MD/MS degree in medicine/surgery or one of the related major disciplines. Semester-wise contents of the course are highlighted in Table 1.

Table 1

Highlights of the proposed MBBS-MD/MS course

Semesters	Disciplines	Remarks
Eligibility	Current requirements for admissions to MBBS: Higher secondary or premed with Physics, Chemistry, Biology, and English	No change in eligibility requirements
MBBS (8 semesters) common to all
Preclinical (2 semesters)	Physiology, Biochemistry, Anatomy, Community Medicine
	Examination 1st semester (MCQ+practical test)	Curriculum to be on the pattern of MD in the USA taking into account MCI Vision 2015 document
Paraclinical (2 semesters)	Pathology, microbiology, pharmacology, forensic medicine, community medicine, introduction to patient care	Three months are reserved for “rural clerkship” at CHC/PHC
	Examination 2nd semester (MCQ+practical test)	Training should be more hands-on and patient oriented
Clinical (4 semesters)	Four semesters of rotatory clinical clerkship covering all major disciplines including 3 months of rural health services at CHC/PHC	Didactic teaching should be minimum
	Practical aspects of social medicine (humanities, ethics, and communication skills) should be part of training	Use of virtual teaching models, Problem Based and Case Based learning should be promoted
	Examination leading to MBBS (MCQ+test for clinical skills)
Foundation Rotatory Residency (4 semesters)
	Every successful candidate will be automatically admitted to residency in one of the two streams: General medicine, pediatrics, and emergency medicine	Village posting to be done only after 2/3 semester of residency in a medical college hospital that will enable him/her to provide basic specialist services at the CHC
	General surgery, OBGYN, and surgical ICUResidency in medicine/surgery in a teaching hospital for 2/3 semesters followed by one semester residency at a rural health center
		Rural posting should be a part of the residency program
Residency leading to MD/MS (4 semesters)
	Residency in medicine/pediatrics or surgery/OBGYN including writing of a thesis or dissertation
	MD/MS examination at the end of 8 semesters of Residency

PHC is the cornerstone of our rural health system that is geared, even today, for the prevention and control of malnutrition and communicable disorders. In view of the fast changing health scenario, it is necessary that amenities for the control of NCDs are made available to villagers on a priority basis. One approach could be to make CHC that should be preferably located at a tehsil town, as the main hub of rural medical and health services. All residents as well as medical students should be posted at the CHC that should be equipped with modern amenities — ICUs, magnetic resonance imaging (MRI), advance investigative facilities, and well-equipped operation theaters. Every village home has a mobile telephone that would facilitate communication with the CHC. The farthest radial village from a tehsil-town is generally only 13 km. It should be possible to comfortably cover the distance in about 30 min, which is less than the average time taken by an acutely ill patient to reach emergency services in large cities such as Mumbai, Maharashtra, India. Although, details need to be worked out, the proposed restructuring of the rural health services is somewhat on the pattern of Comprehensive Rural Health Service Project at the Ballabgarh tehsil in Haryana, India, established by the All India Institute of Medical Sciences (AIIMS), New Delhi, India 60 years ago.[5]