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PERSPECTIVE
Year : 2022 | Volume
: 17
| Issue : 6 | Page : 287-291
Improving research milieu in the medical colleges in India: Challenges and solutions
Gitanjali Batmanabane1, Rituparna Maiti2
1 Pro Vice-Chancellor (Medical Sciences), GITAM Institute of Medical Sciences and Research, Visakhapatnam, Andhra Pradesh, India
2 Department of Pharmacology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
Correspondence Address:
Dr. Gitanjali Batmanabane
Pro Vice-Chancellor (Medical Sciences), GITAM Institute of Medical Sciences and Research, Gandhi Nagar, Rushikonda, Visakhapatnam - 530 045, Andhra Pradesh
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/0973-3698.364669
The quality of the research output of an individual or an institution is the currency by which the caliber of a scientist or an educational institution is judged by peers. In India, the quality of research conducted in medical colleges and scientific institutions leaves much to be desired. The educational system in schools does not foster creativity and originality. The medical undergraduate training focuses mainly on making medical students good clinicians and does not have the curricular time for research. At a postgraduate level, residents are overburdened with clinical work or stifled by the lack of ideas and enthusiasm of their guides. The Indian Council of Medical Research has introduced a short-term studentship for undergraduate students and a research grant for postgraduate students in a bid to encourage research. The National Medical Commission has made it mandatory for postgraduates and faculty to undergo online training in research methodology. The thesis has been a part of the postgraduate curriculum with the idea that as the resident does the project, they will also learn how to do research. In a bid to translate the thesis into publications, many professional bodies conduct workshops and courses during conferences on various aspects of scientific writing. However, many postgraduates do not want to spend time in an activity that is seen as nonrewarding. Unless a drastic change in the postgraduate curriculum is made and the issue of research training is adequately addressed, along with a change in the outlook of faculty, the status quo is likely to continue.
Keywords: Dissertation, medical curriculum, postgraduate training, research methodology
Publishing in academic journals has long been considered a mark of scholarship and the currency by which one is judged by peers. Educational institutions are assessed by the research output, and many of the coveted leadership positions in medical health care and scientific institutions are offered to scholars with brilliant research backgrounds.[1] Oftentimes, at interviews, prospective faculty for medical institutions are asked for their h-index and i10 index, which are fast becoming key performance indicators. In India, the National Medical Commission (NMC) has mandated a certain number of publications to be considered in the selection of faculty for medical colleges. While this is one way of ensuring academicians with a good research background are given the recognition they should be getting, this is also leading to a myriad of other problems, such as numbers over quality and unethical publication practices. There are more than 500 medical colleges in India, and barring a few exceptions, we are not able to produce a reasonably good standard of research in most of these medical colleges.[2]
Why Cannot We Write Well?
Good research stems from good ideas, whereas good scientific writing is a must for the dissemination of research outcomes. This does not necessarily mean fancy writing, but clear conceptualization, the ability to put your thoughts into writing, and the skill to explain your research with clarity are extremely important and necessary for scientific writing. Many medical students in India are not able to express themselves with clarity. One of the reasons is perhaps the schooling system in India does not acknowledge creativity, originality of thought, and expression, especially in the sciences, which makes students less keen to put in the extra effort to write. In addition, too many multiple-choice questions-based examinations have killed the ability of our students not only to formulate their thoughts and write independently but also to think creatively and argue coherently. There is also the problem of writing in English, a language which is rarely spoken in their homes.
Medical Research during Undergraduate TrainingIn the early eighties and nineties, hardly any undergraduate (UG) medical student in India took up research or published papers. This changed significantly when the Indian Council of Medical Research (ICMR) announced the short-term studentship (STS) award for UG medical students in 1979 with the aim of promoting interest in research among medical UGs and providing a platform for the students to familiarize themselves with research methodology and statistics by doing an independent project or by being associated with an ongoing project.[3] The STS is perhaps the first effort of ICMR to identify and address the fact that the seeds of a research bent of mind needed to be sown early.
The Challenges Faced by Medical Students in Doing Research during Their Undergraduate TrainingMost medical UGs do not even know that they can do research during their course if they are interested. The time available for other interests during the medical training is so limited because the coursework is very heavy in content. Unless the senior students or faculty inform students regarding the ICMR STS and encourage students to take up small topics, they do not have the courage to ask the faculty on their own. Research methodology has now become more complex, and learning research methodology or biostatistics is limited to what is in the textbooks of community medicine. In India, the focus of UG medical training is to produce good clinicians. The knowledge that good researchers are better clinicians is a relatively new idea that many teachers belonging to the old school do not believe or can relate to. Hence, students are not actively encouraged to do research by faculty, who are often burdened with an extensive teaching and clinical workload.[2]
What Can Be Done?The UG curriculum is already overloaded, and we need to steer clear of making it more so. However, the real opportunity for us as trainers is to make them aware that research can be enjoyable and should be a part of their professional growth. To inculcate a research bent of mind, small community projects, group exercises using research tools, data analysis, and interpretation should be included within the existing course curriculum. When the Medical Council of India (MCI) revamped the curriculum in 1997, research methodology and data analysis in the form of modules were introduced for the first clinical year students in pharmacology at the Jawaharlal Institute of Medical Education and Research (JIPMER), Puducherry.[4] Students enjoyed the interactive sessions, in which they presented their protocols for given hypothetical problems and answered questions regarding outcome measures, alternative study designs, methods of eliminating bias, and so on. A few interested students then took up research projects. The Seth GS Medical College in Mumbai also introduced a course in research methodology for UG students, which was voluntary and initiated by the students. There may be other such initiatives being done at institutions which would perhaps bear fruit later on.
UG students need to be exposed to research presentations and lectures by well-known scientists and allowed to interact with researchers. Small modules on various aspects of research can be built into the curriculum, in which students are expected to present and defend, such as an audit or data collected from hospital patients or from the community. Students can be encouraged to plan and conduct workshops on research methodology and scientific writing with help from faculty. This was successfully done as an annual event at AIIMS, Bhubaneswar, known as “Wissen,” and in JIPMER, Puducherry, as “Connaissance” with participation from students from other colleges as well. As the number of UG students in each batch is 250 in many colleges, conducting courses in research methodology and scientific writing becomes a challenge for faculty because interactive sessions in smaller groups are needed for these courses to be effective. During the internship, interns can be given small assignments to observe and write up a report to encourage them to start asking “good” research questions. Unfortunately, most of the internship is taken up by preparation for the postgraduate (PG) entrance examination, and there is not much interest shown by the interns.
Courses in Research Methodology for PostgraduatesMany institutions conduct research methodology courses for their PGs. This is not mandated by the NMC, and hence it is left to the individual institutions and universities. From the mid-80s onward, the PGs in JIPMER had a 3-day sensitization program in research methodology. This included basic biostatistics and scientific writing. By the late 90s, this program in research methodology was split into two: with the first one (held within a month of admission) focusing on writing a research protocol and the second (held 6 months before submission of the dissertation) focusing on data analysis, interpretation, and writing the dissertation.
At AIIMS, Bhubaneswar, 25 hours of teaching–learning in the form of interactive lectures are held twice a year (in March for the January session and in September for the July session) with the option of the PG to appear for the training at any given slot. Other institutions such as PGIMER-Chandigarh and AIIMS-New Delhi also conduct such courses (by in-house or external faculty). The main objectives of these trainings are to ensure that PGs know the basics of research methodology and scientific writing before they start doing their thesis or writing it.
From 2019 onward, the NMC has made it mandatory for faculty and PGs to attend an online training course in basic research methodology which is being conducted by the National Institute of Epidemiology, Chennai. This is a welcome move by the NMC, even if the course itself is an elementary course which is more of a primer to sensitize the learner to research methodology.
Training courses will not have the expected impact if the assessment is not built into them. At AIIMS, Bhubaneswar, a full paper in research methodology and biostatistics, which needed to be passed by the PGs students at the end of the 1st year (second semester) to be eligible to appear in the final examination, was introduced in the PG curriculum for specialties and super specialties. This “must appear; must pass” paper was of 3-h duration with 20 short questions. The introduction of this examination forced the residents to take the research methodology seriously. Initially, there was resentment from the students as AIIMS, Bhubaneswar, was the first among all AIIMS to include such an examination in the PG program in 2018. AIIMS, New Delhi, started it in 2021. Some of the objections came from faculty who saw it as an additional burden for the students. With time, there has been acceptance, and the performance of students has improved.
The Challenges Faced by Postgraduates in Doing ResearchThe mantra in the medical colleges in India, barring a few, has always been “patients first, teaching next, and research last.” If PGs are in one of the institutions where research is given a lot of focus, they are exposed to a culture of scientific inquiry, scholarship, and mentoring. In many state government and private medical colleges, even though the faculty has excellent clinical skills, research is not a priority, or incentives are lacking to motivate faculty. It has been reported that 57.3% of the medical colleges in India did not produce even a single publication over the period from 2005 to 2014.[5] Nearly 10 years after the publication of this paper, despite the MCI and now the NMC trying to insist on publications, the situation had not improved.[6]
In addition, the number of PGs in each specialty has increased considerably; hence, clinical material in the form of patients, needs to be shared among the increased number of PGs for thesis work. Activities such as presentation in journal clubs come once in 3 months, even if the frequency of such activities is increased. The vacancies in faculty positions, especially in government medical colleges, along with the fact that in many private colleges, “ghost faculty” is plenty, means that the numbers needed to guide and train the residents on a day-to-day basis are less, even if the PG teacher/trainee ratio is met on paper.[7]
Improving the Quality of the Thesis/DissertationThe ICMR, to encourage the PGs to address good research questions, sanctions Rs. 50,000 per PG student for students who apply for this grant from all over India. This grant serves as an incentive for PGs to aim to do better research. A few of the first batch of PGs of AIIMS, Bhubaneswar, applied for the ICMR grant in December 2016, and only one was successful. By 2021, 5 students, and in January 2022, 11 PGs received grants from ICMR, a notable number as the total number of grants given by ICMR is only 100/year all over India. This could be considered proof that the training and examination included in the curriculum encouraged both faculty and PGs to ask better research questions and write better protocols. Unfortunately, still, there is a lack of knowledge and information about research funding among PG students and their mentors, which is an important factor, especially in a resource-limited setup.
Some of the medical colleges have introduced elements in the examination pattern that are “forcing” the PGs to learn research methodology and critical appraisal of research papers. At JIPMER, Puducherry, two exercises were introduced in the practical examination for M. D. pharmacology examination:
Critical appraisal of a research paper – The PG is given a paper and asked to give his comments. The examiners could then ask him/her questions on the critiqueDesigning a study – The PG is given a clinical problem and asked to design a study to address the problem. Information is given to calculate the sample size and other requirements for selecting the appropriate study design.In the totality of the examination, if the defense of the thesis is included, there is substantial importance given to research methodology and scientific writing. Including the critical appraisal of a research paper was done in all specialties and super specialties of the AIIMS, Bhubaneswar, PG curriculum. This has now been introduced in the NMC curriculum as well. However, unless the examiners are trained in critical appraisal of a research paper, or they already are aware of the elements to assess in a critique of a paper, this too will become a meaningless exercise, and the idea behind including this in the examination will not be fulfilled. PGs are also expected to present a paper and poster at a national conference and submit proof of sending a manuscript to a journal for publication or have published their work. These are welcome initiatives which, if done in the spirit of how it was proposed, can have an effect on improving the scientific output.
Will These Interventions and Training Courses Lead to Better Quality Research and Publications?There is no proof that the time spent in training students and faculty will ultimately translate into better-quality research and publications. Many institutions and professional bodies organize workshops in scientific writing, research methodology, and so on with the aim of translating the research done at institutions into publications.[8] However, the publication process is so complex, tiring, and exhausting that unless someone has good mentorship, a motivating environment, and incentives, the tendency is to give up. One of the worrying issues is the unethical practices which are becoming so deeply rooted that it seems to be accepted as the norm among many PGs. Firms are providing ghostwriting services, outsourcing data analysis, and using the same topics done at other institutions with a change of title; the list goes on. Although MCI mentions revoking a degree in case of unethical practices in the thesis, a strict implementation at the institutional level is expected. If any malpractice is found, the thesis should not be signed by the guide and should not be submitted. The PG students and faculty members should inculcate the skills of scientific writing and data analysis; otherwise, the basic objective of professional growth will be defeated. Unethical publication practices range from the very subtle to the frankly obvious, to which many faculty turn a blind eye. Even though these are not new and have been known to plague science for a long time, the ease with which it can be done using technology is a cause for concern. Hence, unless there is a constant focus on addressing unethical practices and taking appropriate action, these will become a much bigger problem and compromise the training at these courses. Insisting on ethical research and publication practices should be the mandate of every faculty, administrator, and institution. Conferences of professional bodies and their journals should amp up the dialogue on these issues to inform PGs and their guides of the far-reaching adverse implications of unethical research and publication practices.
What is most needed is to change the mindset of the faculty and students that research cannot be considered a luxury for a few working in some institutions known for their research output. It is everyone's duty as medical practitioners to conduct meaningful research and publish the work done; to have our own data and not rely on information from other countries which may not be applicable to our patient population and ecosystem. If this is accomplished, faculty and students will find a way to inform themselves about scientific writing. There are a plethora of books, videos, and online courses on scientific writing, which are well within reach of anyone interested to look for it.
There should be continuous training of faculty and residents in various aspects of research and scientific publication. This has to be done by individuals who are passionate about research so that their enthusiasm and passion can rub off a bit. The results of these courses may not be immediate but will eventually be seen in the form of increased extramural grants, publications in high-impact journals, and enthusiasm for undertaking challenging, complex, and collaborative research projects. Furthermore, the power of learning and inspiration, which happens during informal one-on-one encounters with a preceptor, should not be underestimated, which sadly is becoming less and less given the large numbers of PGs in each batch.
Some Thoughts on How to Change the Current ScenarioThe issues and hurdles regarding research in medical colleges have been documented,[2],[5],[8],[9] and the NMC may find practical measures to resolve some of them in the future. It is obvious that given the limitations faced by the PG students and their guides, a new approach to teaching research methodology and scientific writing is necessary, and there are different models of doing that other than producing a thesis.[10] Perhaps a batch of PGs in a department can work on various aspects of a health problem and produce a group report. For example, four to five PGs in community medicine can study various aspects of anemia in their service area. Rather than testing a hypothesis, PGs may be stimulated to ask pertinent research questions that can arise at the end of this type of activity. A group project may be a solution to the paucity of clinical material. It will also promote teamwork, facilitate supervision, and encourage guides and PGs to focus on local issues and perhaps cut across disciplines, such as PGs in general medicine working on medication safety issues or financial aspects of health care.
Under the present UG curriculum, 2 months of posting in electives of choice is permitted, which is a window of opportunity to motivate UG students to work on a small research project in the subject of their elective and submit a report. For the UG students, time needs to be apportioned by removing duplication and redundancy from the present curriculum.
If NMC makes a research course mandatory for PG education, modules using a blended approach with self-directed learning and hands-on workshops conducted by handpicked institutions in every state will help to get things started. These courses can be tweaked to be a training of the trainers under the supervision (initially at least) of the NMC and can train faculty who have a keen interest in research. Furthermore, along with the completion of the thesis or dissertation, writing the manuscript should be made mandatory. Secondary research such as meta-analysis and post hoc analysis should also be appreciated and encouraged.
As a part of strategic initiatives focusing on building a research-oriented culture, incentives may be planned to motivate faculty and facilitate research. Incentives such as intramural research grants, awards for exemplary research, monetary reward, salary increment, and fast-tracking of promotions may help to turn the tide toward a better research culture. With these measures, the interest could be instilled in medical students in our country which in the long term may result in better quality research being published.
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Nil.
Conflicts of interest
There are no conflicts of interest.
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