1 Medical education and nutrition training, IndiaDr. Anand Ahankari BDS MPH FRSPH PhD student at Nottingham, UK Additional contributor: Ms Rinku Banerjee Communications Manager, NNEdPro Network India
2 Contents Indian medical and paramedical education systemStrengths and limitations, nutrition education? Example: NNEdPro February 2015 workshop, Kolkata, India Survey: Aim, objectives and method Result and analysis Main highlights Challenges Take away
3 0.25 million medical/paramedical students qualify each yearIndian medical and paramedical education system Indian population: 1.21 billion Medical MBBS: 381 medical colleges/schools (160 Govt and 221 Private). 63,800 seats in total. Paramedical 1) BDS 2) BAMS 3) BHMS 4) BNYS 5) BSMS 6) BUMS Add-ons 1) BSc and MSc Nursing 2) B. Pharm and M.Pharm 3) BPT MPT (Physiotherapy) 4) BASLP MASLP 5) BOT (occupational therapy) 6) BSc Laboratory technology 7) BSc Neurosciences 0.25 million medical/paramedical students qualify each year
4 Pathways Scored in top 5%, Government college, Med seats at subsidized10+2 (GCSC+ secondary college) (Plan at 16) (Government Med School Test) Scored in top 15%, Private colleges Med seats at subsidized Good scores and little money Private college entrance Low score (minimum 50%) and ability to pay more Deemed Universities Test, scores and money Rich doctors Government or private paramedical branches Bad luck CHINA, RUSSIA, UKRAINE and many more Money MCI exams
5 Paramedical medical systemB.A.M.S., Bachelor of Ayurvedic Medicine & Surgery B.N.Y.S., Bachelor of Naturopathy & Yogic Sciences B.U.M.S., Bachelor of Unani Medicine & Surgery B.S.M.S., Bachelor of Siddha Medicine & Surgery B.H.M.S., Bachelor of Homeopathic Medicine & Surgery (Postgraduate studies also available) Factors that influence medical treatment Urban and rural cultural differences, healthcare access Socioeconomic status, purchasing power Education, knowledge
6 Strengths and limitations, nutrition education?1) More diseases -- more opportunities to learn treatment skills 2) Flexibility – developing healthcare system 3) Capacity to operate in limited infrastructure Limitations 1) Complex education system 2) Absence of research opportunities and limited infrastructure Threats? Nutrition education? 1) Influence of political systems on quality of medical education (private colleges/deemed universities) 2) Challenges and resistance to reforms 3) Diverse culture, multiple languages and lack of uniform policies
7 A 24 year old doctor, recently graduated in medicine and now planning for MD studies…“ I scored highest marks in the entrance in my batch, however that wasn't enough to get admission in government college, so my dad had to manage finances for private college, which he did. Being a good student, yes I got first class every year and now I am planning for my post-graduation. But you know, I need to learn some basic practice skills like how to measure blood pressure, prescriptions and all that. I think I should work at least for one year with some GOOD doctor, so I can understand some signs and do the right diagnosis. But I think I should start my post-graduation first otherwise it will be late, then I will get these skills anyway as a PG student. You only get to see patients and undergraduate students prepare for PG entrance test, if they are wishing to pursue a MD or Super-Specialty…”
8 NUTRITION Example 19 September 2005 Anatomy Physiology BiochemistryDental materials Lab based Prosthodontics Microbiology Pathology Pharmacology Pre-clinical dentistry General medicine General surgery Oral pathology Community dentistry 7 subjects, core dentistry: Endodontic, Prosthodontics, Oral medicine, Pedodontics, Oral surgery, Periodontics and Orthodontics. 9-10 Feb 2015 WCP 2015
9 Survey (20th - 30th July 2015) AimTo understand view and attitude of clinician and healthcare professionals towards the integration of nutrition education in the current medical/paramedical education systems Objectives To understand views of clinicians and healthcare professionals about nutrition education To understand the current status of nutrition education as a component in medical/paramedical education systems To identify opportunities to include nutrition training and referrals within the existing government healthcare system Methods Five questions via with some basic demographics information Basic analysis to identify opportunities to work in nutrition education
10 Results: overview of survey samplesTotal approached: 30, Received acknowledgment: 20, Declined: 3, Failed to reply within timeframe: 3, Replied: 14 (3 states, North 2, central 10, south 2) Age: Range 28 – 65 years, Mean years, SD 10.68, n=14 (ND) Experience: Range 1– 40 years, Mean 20.21, Mode 15 Profession: MBBS/+Diploma/+MD – 12 BDS/+MDS – 1 BAMS/BHMS – 0 Healthcare professionals (research staff/public health/social activist) – 1 a) Academic – 6 (closely observes students) b) Non-academics – 8 (closely works within the healthcare system)
11 Do you think the current medical/paramedical education systems in India have sufficient focus on nutrition education? Do you think current doctors have sufficient training to assess the nutritional status of patients and to provide necessary referrals/treatment? No, generally the practice of modern medicine in India does not focus on the nutritional aspects of the treatment plan sufficiently. Largely, because of lack of time and training (P2). The focus of treatment is on drug therapy rather than actual improvement of the diet. Training is mostly prescribing supplements rather than dietary changes (P8). Currently, the medical education system in India is focused more on clinical diagnosis, investigations and drug/surgical management of patients. Clinicians themselves focus more on diagnosis and management of patients (P10). Nowadays, the general public have greater awareness of Non Communicable Diseases (NCDs) and how to prevent them through diet and physical activity. Even if they do not know, at the time of seeking health care, they expect guidance from the doctor regarding diet and physical activity. It’s a good thing that people are aware of NCDs but it is the responsibility of the doctor to provide guidance to the patient (P13).
12 Do you think currently India is able to generate comprehensive doctors/paramedics to support patient-centered nutrition treatment? Current dental health professionals fails to tackle the underlying problem because of the lack of training in nutritional education ( P1). Doctors are not competent enough to deliver nutrition related knowledge. Nutrition as a paper is not included in any of the semesters of the medical curriculum in India. Only a small part of it is taught in community medicine classes (P5). Only protein energy malnutrition and nutritional anaemia are discussed theoretically (P9). Doctors often do not feel comfortable, capable and confident of providing nutrition counseling to their patients. A possible reason could be inadequate knowledge about nutrition deficiency diseases, nutrition conditions and nutrition interventions. With the advent of a growing economy and changing lifestyles, obesity is an emerging problem which I think is not dealt with properly in the current medical curriculum (P 13). Patient-centred nutrition programmes cannot be delivered or led by doctors alone. There are also separate nutrition programmes where dieticians and nutritionists receive training (P12).
13 Is there an established nutrition referral system in India (other than private multi-specialty hospitals)? If not, then can you suggest how this could be developed within the current government health system? In the sub-centre, when the nurse finds a malnourished child, she is supposed to refer him/her to the doctor in the Primary Health Centre. If a doctor in the Primary Health Centre cannot manage a particular case of malnourishment, s/he is supposed to refer the child to the Rural Hospital (P3). Recently, the government has carried out a pilot to establish a NCD cell at the district hospital level where a nutritionist can be posted and affordable services can be offered to the community (P4). Sufficient numbers of nutritionists are to be appointed in tertiary care hospitals to look after and supervise the diet plan of every patient (P5). Private multi-specialty hospitals simply aren’t affordable to the vast majority of our populace (P7). A small number of private practitioners and family physicians give dietary advice in hypertension/diabetes but even diabetes specialists do not have nutritional advisors in their clinics (P8).
14 Do you think that doctors in India need the support of nutritionists to plan diet alongside the regular treatment (mainly for those having systematic diseases and being admitted at tertiary centres)? Yes, doctors need support from nutritionists to plan diet in the present system (P6). Yes, mainly because the doctors here are required to see too many patients (P2). Yes, they need support from nutritionists as they lack sufficient training in the practical application of nutrition. Busy practitioners do not have enough time for detailed nutritional history and nutritional counselling of the patient (P8). Most of the private and corporate hospitals have started these services now (P4). I doubt whether a separate cadre of nutritionist is affordable in every medical centre in India. Doctors should be capable of doing this job with some additional training. However for those having systematic diseases and being admitted at tertiary centres, yes, we should have nutritionists for such cases (P3). Yes, ONLY with the help of a nutritionist can a doctor deliver a customized diet plan to the patient (P5).
15 Do you think we need to include nutrition education/training in the current medical or paramedical education systems? Do you think there are any additional benefits to patients as a result of this inclusion? Extensive nutrition education and training is definitely needed for medical students/interns/doctors and paramedics (P9). Of more importance is the promotion of practical applications of nutrition training in regular practice. India is a diverse country where dietary factors (patterns) vary. Hence students must address the local population’s needs as well the availability of resources (P1). Proper disease specific nutritional knowledge can help doctors to deal with the patient in a more efficient way. Patients will also benefit in terms of early recovery, less days in hospital and a lower pill burden (P5). Providing adequate nutrition to more than 120 crores of population with limited resources is a big challenge which requires specialized training and research (P8). Yes. The syllabus should have more emphasis on nutrition education. But the objective of the medical curriculum, to produce doctors not nutritionists, should be kept in mind. A doctor can enlist the help of a nutritionist in most cases (P14).
16 Main highlights The current medical/paramedical education system in India does not have sufficient focus on nutrition and doctors are not adequately trained. In the current medical curriculum, India is not equipping doctors with the nutrition knowledge and training to adequately look after patients’ nutritional needs. Although, a formal nutritional referral system does not exist, this may be developed through small, progressive changes to the current government health system such as NCD cell at the district level hospital. Doctors in India need the support and expertise of nutritionists for diet-planning alongside other regular treatment The practical application of nutrition training in the doctor’s practice is of paramount importance in a country like India with a widely diverse population.
17 Challenges Population Diversity Environment, diseasesCultural influence on food preparation and dietary practices Religious concerns (fasting in pregnancy) Health resources and infrastructure Skills, training, lack of ability to use standard protocol in medical practice
18 Challenges State Profile Kerala
19 State Profile Bihar Challenges
20 Takeaway If a balance is achieved between the provision of nutrition training to students in the Indian medical/paramedical education systems and the practical application of this training in doctor’s practices country-wide, there is a strong and positive chance to improve the overall nutritional health of the Indian population in order to strengthen the public health systems.
21 Thank you Research interests: Maternal health, Nutrition, Tobacco control, Adolescent health and Applied epidemiology Specific interest: Anemia and Hemoglobin If you are interested in collaborating, please or To know more about the current affiliation in India, please visit Conflict of interest: None to declare Acknowledgment: We thank all respondents for providing information through the questionnaire formally and informally over the telephone. © Dr. Anand Ahankari and Ms. Rinku Banerjee