Lately, there has been a lot of discussion over the shabby state of medical education in India. A number of reports and articles have expressed concern over the sorry state of affairs; and a number of things, right from the inept handling of matters across the echelons of medical administration to the deficient air of medical research in the country, have been held responsible for the same. In a recent conversation with a renowned medical journal, I was asked to comment on the use of journals by Indian medical students, and the potential benefits e-learning could provide in the current scenario. The context from which this question arose is clear: there is certainly a meagre use of alternative learning resources (like journals) and advanced tools like e-learning in our medical schools. But my answer to it followed a different, and rather interesting, trajectory, which I find important enough to reserve this article for. Unlike the common references to things like student attitude, faculty participation and curriculum planning, my answer had a prominent mention of the general nature of our examinations.
The way the destination dictates the different aspects of the journey, exams play perhaps the biggest role in shaping studies and learning. You can think of an exam like the rate-limiting step of a multi-step chemical reaction. Being the terminal point of an academic course, the nature of exams has a tremendous impact on everything from the choice of study materials to faculty and student attitude. Simply put, and more so practically, how we design our exams largely determines ‘what’ is studied, and ‘how’ it is studied. Obviously, a facet of education can exist only along with the corresponding facet of evaluation. You cannot have one without the other, excepting the fleeting, rather tragic, existence of either of them in exclusion.
The use of journals and similar resources in addition to conventional textbooks conveys a sense of unrestrained learning. These are tools primarily used to fortify your knowledge, and hone your skills of solving clinical problems and making the right decisions: the keys to becoming a successful physician. Accordingly, incorporation of such resources into the medical school curriculum would also need a sound system that tests those key areas: knowledge, problem solving ability and conceptual understanding. Falling short of designing an adequate evaluation system would discourage the use of such resources and quickly end their run in the medical school.
Even a cursory survey of our examinations would show how they lack many of the fundamental traits of a well-rounded evaluation system, and how they discourage the use of alternative/advanced learning resources. A good portion of our evaluation system demands more of memorization than problem solving ability and understanding of concepts. Our exams display our prominent ‘essay culture’ where a high proportion of questions require a descriptive, essay like answer. There is little focus on problem solving and application of core concepts. Such a system has a lot of pitfalls, from voluminizing the syllabus to degrading the overall quality of education.
Descriptive questions are, by nature, an inefficient and rather primitive way to test the understanding of core concepts. They can shift the focus away from reasoning and understanding of the relationships in the studied material, and promote rote learning. In addition, they call for much more than just knowledge and understanding of facts, and are thus significantly wasteful of time and effort. Writing a descriptive answer requires a lot of unnecessary memorization, and demands work on certain areas highly irrelevant to becoming a doctor. Descriptive questions are indeed important in the right place and in the right amount, but an undue focus on them increases the burden of the syllabus, undermines the growth of relevant skills, and confines study to course books.
Application-oriented questions (those testing the application of concepts/problem solving ability), on the other hand, can test the most pertinent areas and skills in a much more efficient manner. Think of their many benefits: they demand less time and effort; they can bridge theoretical and practical medicine; study can be less taxing and more engaging for the student; and the right practices with an unfettered learning environment can be cultivated. Currently, there is a gross inattention towards them in our university papers. Multiple Choice Questions in the initial segment of the question paper are mostly based on random facts. This is followed by vast tracts of the traditional Long- and Short answer questions that treat concepts and facts alike. This inattention also reflects in our PG entrance exams, where the stress is a lot more on the knowledge of discrete facts than on clinical problems and scenarios.
It’s staggering to know that we haven’t yet caught on to the numerous downsides of the current nature of our exams. Considering the already limited duration and the vast curriculum of MBBS, it’s easy to understand how a predominantly descriptive exam system throws students into a ceaselessly gruelling journey that begins and ends inside the textbook; and why they hardly develop the drive to explore beyond it. Few would find it wise to invest in alternative/advanced learning resources when the examination mainly requires memorizing and throwing up paragraphs, especially in the presence of an already massive, unnecessarily burdensome syllabus. While frequent, application-oriented exams have proven to be a beneficial model in a number of places around the world, we are yet to realise the importance of such a model- and a concomitant failure to keep up with advances in learning methods is like living in the stone age of medical education.
We need to build an entirely new paradigm of evaluation in medicine. Moving on to alternative/advanced learning resources from the predominant ‘textbook culture’ is about evolving into an entirely different attitude, something which cannot be brought about without a change in the most decisive step in the academic pathway. They cannot make their way into our system unless there is an adequate focus on the development of the true skills of a clinician, and not realising this will destine us and our system to perpetual backwardness.
— Dr Soham D Bhaduri is a medical graduate and a Philosophy of Mind enthusiast, and takes keen interest in writing on Healthcare and Medical Education. He blogs at The Free Thinking Medic.