The reported harassment of a medical student by his teachers has sparked off a heated debate in Kerala. The student, the son of a former state legislator, committed suicide, apparently after teachers intentionally failed him in the final examination (1). Following extensive press coverage, the state government referred the matter to the Petitions Committee of the Kerala Legislative Assembly. The Committee, which is chaired by a senior legislator and has eight other legislators as members, concluded that the student’s suicide was a result of intentional harassment by teachers (2). It named the responsible teachers and recommended punitive action against them.

‘Some amount of rough behaviour’ is justified

The Kerala Government Medical College Teachers’ Association immediately refuted the Committee’s findings and demanded that the government ignore its recommendations. It stated that there was no harassment but that ‘some amount of rough behaviour from the teachers’ is inevitable to equip students ‘to face future threats from patients and the public’ (3).

Medical college teachers are expected to impart the highest levels of academic excellence. They must also provide mental and emotional support to students. This responsibility is all the more important when they are dealing with students who may be physically or emotionally disturbed. Medical students must cope with heavy academic requirements, time pressures and stress related to clinical work. In this situation, medical college teachers must play the dual role of physician and teacher. Such support was almost always forthcoming in the past.

A crisis in medical education in Kerala

Today, however, there is a crisis in medical education. This assumes greater significance in a state where governments— irrespective of their political leanings—have always given priority to health. Over the years, the private health care sector has grown without regulation, and medical care is becoming big business. As of March 2000, the state had only six medical colleges, with five in the public sector and one in the cooperative sector, with a total of 800 students for the MBBS course (4). By March 2003, five more medical colleges—four in the private sector and 1 in the cooperative sector—were started, adding another 500 MBBS seats (5). At least three other institutions are waiting for approval to start medical courses. Investors in these colleges use every means to maximise profit and consolidate their position once they get approval to start medical courses, and the government has so far been unable to control the admission policy and fee structure in these private colleges. The matter is now being considered by the apex court and the state is planning legislation to exercise control over these colleges.

Some professional organisations are also reported to have protected members who are unethical in their professional conduct. Such allegations were made regarding the recent reports of kidney sales in Kerala and the involvement of some private hospitals. The report of the Ethics Committee of the Indian Medical Association (IMA), Kerala state branch, was reportedly modified to protect IMA members—a charge refuted by the IMA.

Medical college teachers: a powerful lobby

In Kerala, government doctors, including medical college teachers, are permitted to do private practice. Recently, salaries and perks of medical college teachers were revised with the intention of banning private practice. However, the government was pressurised and state government doctors managed to retain the right to private practice while enjoying revised salaries and perks almost at par with their central government counterparts. Both the bureaucracy and political leaders keep their hands off medical college teachers because they often rely on them for the treatment of their medical problems. These doctors manage to stay close to the centres of power and retain their benefits and favours.

This has a high cost. Most teachers in clinical specialties who have reasonably good private practices, hardly find time to teach. They do not seem to have time to read anything other than the brochures of drug companies. Students and teaching are ‘inconveniences’ to such teachers. For them, teaching plans and academic calendars are unheard of. Good and conscientious teachers, who constitute a minority, often find it difficult to follow serious academic pursuits in this atmosphere. Students also tend to believe that the teacher with the largest private practice is the best doctor and try to follow in his/her footsteps, perpetrating a vicious cycle.

Another racket is the ‘foreign and private employment’ of medical college teachers. Their attachment to a medical college is only for its resumé value as ‘medical college professor’, enabling them to regularly go ‘on leave’ to private sector enterprises or abroad. Some even go without sanctioned leave, because they are confident of ‘sorting things out’ when they return. Such ‘transient teachers’ return to job only when promotions are due, and go back on another assignment as soon as possible. The tussle that follows when many return from leave to take the same ‘promotion berth’ might be seen as comic if it were not for the consequences to the public and to medical students.

Yet another scam is the way that reservation quotas have been used to block postings while teachers go on leave for lucrative assignments. Since these teachers do not resign, and their absence is never reported, their posts cannot be filled. The Public Service Commission does not recruit new staff, nor does the department fill the vacancies by promotion. So there are shortages of specialists in medical colleges, though such specialists are abundant in the ‘open market’. Those who are affected by this practice are patients and students. The latest example of this problem is the plight of Thrissur Medical College. Surgeries have come to a virtual standstill because there are no anaesthesiologists in the medical college, though there are plenty in the state waiting for placement.

Serious teaching and research have been affected badly. Medical colleges in Kerala do not figure among the first 50 in India in academic excellence or in research publications. Students rarely get encouraged to take up research. The few who are enthusiastic are disheartened by the uncongenial atmosphere. This is evident from the paucity of research publications from the medical colleges in the state. Unfortunately, doctors can acquire a postgraduate degree without even setting their eyes on a ‘peer-reviewed indexed journal’.

It is in this scenario that a medical college teachers’ association can state that students should tolerate ‘rough behaviour’ from teachers for their own benefit.

Are we going in the right direction?

Medical education is undergoing drastic changes in many parts of the world. Ethical considerations are becoming important. It is acknowledged that patients’ autonomy and integrity must be honoured. Students must be inculcated with a gender perspective, equipped to deal appropriately with patients and their relatives, and sensitised to human rights. Senior teachers and professors are role models for their students. In their daily work they live out the ethical principles and etiquette of dealing with patients, showing by example how to address a patient, how to elicit consent for examination, how to interact with patients’ relatives and so on. Such things cannot be taught in classroom lectures.

Unfortunately, ethical considerations are often of least importance in medical colleges in Kerala, as is true in many other parts of the developing world. Patients often undergo examinations, sometimes even intimate ones, by any number of students without valid consent. Internationally, there are heated debates on difficult ethical issues such as allowing students to conduct intimate examinations (7). Students here are rarely sensitised to ethical issues.

If the statement of the Medical College Teachers’ Association truly reflects the opinion of the majority of its members, one has to realise the implications of such a statement. In such a situation, teachers rather than students must receive immediate attention. Their mindset of viewing patients and their relatives as potential enemies should not be allowed to further infect the student community. Teachers must be trained to change their perspectives. Our future doctors must be sensitised to human rights, ethical considerations and gender issues during their medical education, if not earlier. The key players in this effort are medical college teachers.