MBBS Curriculum: Why are Respiratory Medicine Specialists at Loggerheads with NMC
New Delhi: For the last year, Indian chest and respiratory medicine specialists including pulmonologists have been at loggerheads with the apex medical regulator, after the latter's sudden decision to remove Respiratory Medicine from the MBBS Curriculum.
As several appeals to the authorities have gone in vain, the Indian Chest Society, an association comprising chest, respiratory medicine specialists including pulmonologists across the country, has filed a plea in this regard before the Bombay High Court. The matter has been listed for further hearing on 25.09.2024.
CBME Setback to Respiratory Medicine- Making MBBS easier or undermining Respiratory Medicine?
Medical Dialogues had reported that last year, the Undergraduate Medical Education Board (UGMEB) of National Medical Commission (NMC) had removed three departments- Physical Medicine and Rehabilitation (PMR), Respiratory Medicine, and Emergency Medicine from the list of departments that every medical college/institution must have to be approved for undergraduate medical admissions on an annual basis. The provision for a separate department for respiratory medicine is also absent in the newly released Competency-Based Medical Education 2024 guidelines.
While the reasoning given by NMC for the move was reducing the burden on MBBS students, as well as explaining the subject matter of respiratory medicine will be taken up by department of General Medicine, the move was immediately met with staunch opposition from chest specialists in the medical fraternity, who highlighted on the growing burden of respiratory diseases in India and the need for better training of young medicos at MBBS level itself by respiratory specialists
Explaining the burden of respiratory diseases in the country, Dr Raja Dhar, Director and HoD of the Pulmonology Department at CMRI Hospital, Kolkata, explained that COPD, Lower Respiratory Tract Infections and Pneumonia, TB and Lung Cancer are four respiratory diseases that rank in the top 10 killer diseases globally as well as in India. "Out of that, the number of patients dying from Asthma and COPD in this country is greater than anywhere else in the world. The same stands true for lung cancer," he said.
Dr. Dhar, who is also the secretary of Indian Chest Society, explained that about 62 million in India have COPD and 38 million people suffer from asthma. "So, that adds up to about 100 million which is the biggest burden in the world. COPD is the second biggest killer out of all the diseases and that is because of the number of patients that we contribute into the global burden of COPD death. The highest number of cancers in this country is lung cancer. Our burden of air pollution is such that the 15 most polluted cities in the world are from India. So, of course, the greatest impact of air pollution is on the lungs and hence the burden of lung diseases of this country. And then there is TB. So, in spite of there being the aim from the Government that we want to eliminate TB by 2025, that still is a dream as we are nowhere near it," he added.
Dr. Dhar also referred to a study conducted by Dr. Sandip Salvi from the Chest Research Foundation in Pune, where he looked at common symptoms with which a patient goes to a General Physician and fever and cough were the commonest symptoms. This shows, the greatest burden on general practice is already respiratory disease, he explained, adding that more numbers of chest physicians are required just to supplement that. The removal Respiratory Medicine Department from MBBS seems to devalue the importance of respiratory medicine and the herculean challenge of the diseases before these specialists.
"If there is such a large burden of disease that you need so many chest physicians to deal with it, if you don't sensitize children (MBBS Medicos) about the diseases which are ordained to be the most common of all diseases in this country, how are these students, when they become seniors, when they pursue their postgraduate training, when they become full fledged accomplished doctors, how are they going to get trained in the long term to treat patients with very common problems on a day-to-day basis?," Dr Dhar added.
When asked about NMC's justification that these subjects are being taught by faculties in Medicine, he explained that unless there were respiratory physicians, it would not be possible to sensitize undergraduate doctors about the magnitude and the severity of the problem. "A physician would never manage to do that because these are milder spectrum of the disease," he said, adding "You abolish this from the undergraduate training, you would actually devalue the importance of this speciality in the mind of an undergraduate doctor."
From Pillar to Post - Doctors' Appeals go in vain:
Upset with the Commission's decision to remove the Respiratory Medicine Department, last year the Indian Chest Society had written several letters to several dignitaries, including authorities as well as ministers including then Union Health Minister Mansukh Mandaviya and Minister for Road Transport and Highways, Nitin Gadkari.
Supporting their plea for reinstatement of the Respiratory Medicine Department in MBBS colleges, the Minister for Road Transport and Highways had forwarded to the former Union Health Minister. However, replying to Minister Gadkari, the President of NMC UG Board, expressed the Commission's inability to give a separate status to Respiratory Medicine in MBBS curriculum.
The NMC explained that for MBBS students, General Medicine (which currently includes various topics of respiratory medicine) and allied subjects are covered by faculty in Medicine and that in addition to TB & Chest Disease, at least 27 other specialities are there that are demanding their space in UG education.
As per response of Dr Aruna Vanikar, President UGMEB, this was overburdening an undergraduate medical student. Further, she pointed out that postgraduate and super-speciality courses in Respiratory Medicine/Pulmonary Medicine in available in medical college training and therefore, interested candidates can pursue their education.
Later in 2023, on behalf of the respiratory medicine specialists, this issue was also raised in the Parliament by M.P Sanjeev Arora, who pointed out that the department of Respiratory Medicine was deleted from CBME 2023 even though it was a key speciality for control of respiratory epidemics like COVID and in spite of the speciality being essential for TB elimination.
In response to the query, the former Union Minister of State for Health, Dr. Bharati Pravin Pawar informed that subjects like Respiratory Medicines were covered by the faculties of General Medicine and allied subjects. She also highlighted that Respiratory Medicine/Pulmonary Medicine were still subjects of specialty and super specialty.
Respiratory Medicine Doctors Unite to Reinstate their Specialisation Status:
Even though Respiratory Medicine was not included in the new CBME curriculum 2024, the doctors are continuing their fight against the NMC decision. Dr. Neel Thakkar, Vadodara-based pulmonologist and a member of the Indian Chest Society initiated an online petition on change.org called "Save the Saviours" demanding reverse the decision to remove Respiratory Medicine from the MBBS Undergraduate Curriculum.
The petition, which has already gathered 10,676 signatures (at the time of writing this article), highlights the need to prioritize the education of future medical professionals in Respiratory Medicine, callong the NMC decision to eliminate Respiratory Medicine a "short-sighted" one, and a blow to the public health.
Speaking to Medical Dialogues in this regard, Dr. Thakkar said, "It is important to understand how the decision to remove this speciality would impact the common man. If an MBBS student graduates without learning Respiratory Medicine properly and they are posted in a rural area or providing treatment as a basic primary medical doctor, they would not be in a position to handle any respiratory medicine-related emergencies or respiratory TB, smoking-related health issues."
He opined that without proper training of MBBS students in Respiratory Medicine, the instances of poor management of TB, COPD, asthma, and pneumonia could also increase- leading to a 15-25% increase in morbidity, with drug-resistant TB cases rising by 30-50%. According to Dr. Thakkar, preventable respiratory disease deaths may surge by 15-30%, and if another pandemic hits India, there can be a 10-15% rise in the fatality rates, due to unprepared medical professionals lacking the necessary respiratory expertise.
Recently, the Indian Chest Society wrote to the President of UGMEB urging the Commission to reinstate the Department of Respiratory Medicine in the MBBS medical colleges by amending the UGMSR 2023 and the CBME Curriculum. In the letter, the treasurer of ICS Dr. Rajesh Swarnakar highlighted that the NMC decision will lead to a generation of doctors who are ill-prepared to handle respiratory diseases; therefore tweaking the public healthcare infrastructure- especially in the rural areas.
The letter also referred to the Indian Public Health Standards (IPHS) 2022 that removed the mandatory requirement of Respiratory Medicine faculty at the district and subdistrict hospitals. This, coupled with the absence of Respiratory Medicine Departments in the medical colleges will leave the patients without access to essential specialized care, leading to their suffering, the letter pointed out.
Commenting on the matter, Dr. Swarnakar told Medical Dialogues, "They have dismantled a department which has been in existence for the past 70 years. This is a gross injustice in the sense that this will affect also the poor of the country. If the students are not taught respiratory medicine at the undergraduate level which has more than 60% burden in any of the OPDs, how are you going to care for the respiratory health of the people of this country?"
Referring to the NMC's justification of reducing the burden on MBBS students, he opined that this decision actually reduces the quality of education received by UG medical students.
Last Resort? Doctors approach Court
With no respite from the authorities, the respiratory medicine specialists have decided to pursue the legal remedy and the Indian Chest Society and Indian Society of Physical Medicine and Rehabilitation have filed a Public Interest Litigation in this regard before the Bombay High Court.
During the last hearing, the doctors' counsel argued that UGMEB requires to function under the Act of 2019 and it is subject to the Regulations made by NMC as per Section 16 (2) of the Act of 2019. Further, the counsel pointed out that as per Section 57 of the 2019 Act, NMC is empowered to frame Regulations, and accordingly, on 28th October 2020, NMC framed Regulations as per which 24 Departments (including Departments of Respiratory Medicine, Physical Medicine and Rehabilitation and Emergency Medicine) were identified to be established by every Medical College and Medical Institution approved for MBBS admissions annually.
Advocate Mandlekar, appearing for the petitioners argued that once the mandate provided under sub-section (2) of Section 16 of the Act of 2019 confers autonomy to the UGMEB, which is required to act in accordance with the Regulations framed by NMC, it is not open by the UG Board to jump the mandate provided under the Regulations. Therefore, he stated that it was necessary to direct the Board to act strictly in accordance with the Regulations 2020.
Although the matter was listed for further hearing on 04.09.2024, neither the Union of India nor the NMC or UGMEB filed their appearance in the matter. On the other hand, the counsel for the petitioners insisted that given the ongoing process of MBBS admission, the matter be heard at the earliest. Taking note of this, the HC bench comprising Justices Abhay J. Mantri and Nitin W. Sambre has listed the matter for further hearing on 25.09.2024.
"Needless to clarify that in case if the respondents have chosen not to file reply, this Court will draw an adverse inference against the said respondents," the Court warned the NMC and GOI on non-appearance.
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