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A licence to practice
A well designed national examination for medical licenses can help restore public confidence in the competence of medical practitioners by ensuring uniform quality standards across the country and help build trust deficit between physicians and patients
The National Medical Commission (NMC) Bill 2017, tabled recently in the Lok Sabha and currently under consideration of Parliamentary Standing Committee of Health, has invited a lot of attention and debate. Amongst its various clauses, the provision regarding National Licentiate Examination (NLE) has invited particular interest.
The Bill provides that NMC shall conduct a uniform NLE for students graduating from medical institutions for granting a licence to practise medicine and for enrollment in the register of medical practitioners.
Presently, students after clearing the final year MBBS examination and completing one year of compulsory internship, are eligible for enrollment in the register of medical practitioners, which qualifies them to practise medicine.
Critics argue that the failure of MBBS graduates to qualify NLE may lead to further shortage of medical practitioners thus worsening the already adverse doctor-patient ratio. Besides, it will cause needless harassment to students who will have to qualify yet another examination to be eligible to practise medicine. Supporters, on the other hand, contend that it will ensure minimum quality standards in MBBS education across India.
In view of conflicting opinions, a look at certain facts may help clarify the issue. First, the fact that the quality of medical education varies widely across the medical colleges is not in dispute. Every now and then, news of ineptitude on the part of poorly trained doctors is reported in the media. Besides, trust deficit between physicians and patients is on the rise.
In this situation, it is important to restore public confidence in the competence of medical practitioners by ensuring uniform quality standards across India. This is also crucial from the perspective of patients, considering the present level of consumer awareness in our country.
In fact, a transparent framework of making NLE scores available in the public domain can even nudge the colleges to improve their quality of medical education. Apprehension among critics points out that NLE may result in shortage of doctors. This is obviously a premature prediction since the examination is yet to start.
Second, anecdotal evidence suggests that most medical students aspire for post graduation (PG) and, therefore, spend considerable time preparing for PG entrance examination (NEET-PG). The Bill provides that NLE shall be the basis of admission to post graduate courses. Therefore, rather than casting additional burden on medical students, introduction of NLE will serve the twin objective of obtaining a license to practise as well as admission in PG courses.
Third, since NEET-PG assesses students only on theoretical knowledge, acquiring clinical and soft skills during MBBS course tends to be neglected. A carefully designed NLE can shift the focus away from just learning the theoretical concepts towards a more balanced approach of acquiring clinical knowledge and skills as well.
Many developed countries require licentiate examination for medical practitioners. Studies have indicated a positive correlation between scores in medical licentiate examinations and the performance of doctors in primary care settings which suggests that a well designed NLE can ensure quality of care for patients.
However, design of NLE will be critical in ensuring that it delivers on its promise. Various models can be considered in this regard. The existing model in India is Foreign Medical Graduates Examination (FMGE), which tests candidates who have acquired MBBS or an equivalent degree from a foreign country before allowing them to practise in India. FMGE tests candidates only on theoretical knowledge without testing them on their clinical and soft skills. It is, therefore, not an ideal model for NLE.
Globally, licentiate examinations have evolved considerably and a lot can be learnt from international experience. United States Medical Licensing Examination (USMLE) assesses candidates on their ability to apply knowledge, concepts and patient-centered skills for safe and effective patient care. Similarly, in the United Kingdom, Professional and Linguistic Assessments Board (PLAN) assesses candidates on their ability to apply knowledge to the care of patients. Such models can be studied and suitably adapted as per our requirement.
Under NLE, a two-step assessment process can be considered.
In the first step, candidates can be assessed on theoretical knowledge of subjects using well-designed questions testing candidates on applied medical knowledge. A computer-based test imparted in dedicated testing centres can be designed for first step assessment.
Second step can be a more rigorous assessment of candidates on their skills, professional values, behaviour and clinical knowledge. This being a critical step, the Government can consider designating a few select centres for this purpose.
Needless to say, ensuring transparency and objectivity in assessment will be extremely important. This will require evolving appropriate criteria and standards in consultation with various stakeholders. A well designed NLE may be a harbinger of significant improvement in the quality of patient care in our country and may also restore public confidence in medical practitioners.
(The writer is joint secretary, Cabinet Secretariat. Views expressed are personal)
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