Revitalizing homoeopathic medical education for the COVID-19 era: Integrating Hahnemannian thought, Principles of Medical Education, and the core of the National Educational Policy, 2020

INTRODUCTION

Homoeopathic education in India imparted under the current regulations does not appear to have succeeded in producing the desired quantity and quality of homoeopathic physicians capable of handling health issues across the country. The evidence supporting this lies in the low rate of committed practitioners of Homoeopathy emerging from the Homoeopathic colleges. The quality of dissertations brought out by postgraduate students is often poor. There is a dearth of PhD theses in homoeopathy on Shodhganga, the INFLIBNET website that hosts PhD theses.^[1] The paucity of good clinical and research papers published in accredited journals in India and a dearth of quality research proposals received by Ministry of AYUSH for extramural research studies from Homoeopathic institutions is evidence that all is not right in the field of Homoeopathic research as well.^[2,3] The silver lining lies in the CCRH having initiated undergraduate student research fellowships, which have taken root in select colleges.^[4] Some universities have supported undergraduate research.^[5] However, very few colleges have been so bold as to publish the results of undergraduate research.^[6] The Ministry of AYUSH and the CCRH, New Delhi, have taken the initiative in pushing for a role for Homoeopathy as an adjuvant in managing the COVID-19 pandemic. We now await the results of these interventions.

We need to take a look at the fundamentals of our own discipline and see what Medical Education has been grappling with globally. We also need to look at the changing health needs in the country, particularly in the COVID-19 era. Gaining this knowledge will enable us to clarify the objectives we need to bring about the transformation of which Homoeopathy is capable. No doubt, the changes expected through the adoption of the National Education Policy (NEP) 2020 will have a significant impact.

REFLECTIONS ON THE PRINCIPLES UNDERLYING HOMOEOPATHIC EDUCATION

In the first six aphorisms of the Organon of Medicine, Dr. Hahnemann has provided the fundamental principles of Homoeopathic education and training. Combined with Hahnemann’s seminal contributions in the Lesser Writings, namely, the Medical Observer^[7] and On choosing the Family Physician,^[8] the teachings may be summarized as follows [Table 1]:

Our current efforts have extensively elaborated in the Aphorisms 3 and 4 above, since information is the easiest to impart. The others involve either promoting an enabling attitude (adopting the mission in the personal lives of the care giver) or utilizing well-defined human processes (interview techniques to understand what ails the patient). Unfortunately, little progress is reported by way of advances in educational methods. The settings in which cure occurs and which can be demonstrated, namely, the hospitals and community clinics, need to function robustly with a fair amount of documentation that can be reviewed. At present, there are very few NABH-accredited Homoeopathic hospitals across the country. Hence, we do not have reliable data on the status of systems in operation in teaching hospitals. Assessment methods utilized in the university examinations at the undergraduate and postgraduate levels are fairly basic and do not really evaluate and certify live clinical performance.

DEVELOPMENTS IN WORLD MEDICAL EDUCATION

It would be pertinent to examine the developments in the world of Modern Medical Education and Technology and note their relevance for us in light of the instructions placed by our Master, Dr. Hahnemann. The World Conference on Medical Education (WCME) in 1988 released the Edinburgh Declaration (after six regional meets across the world) to bring about a change in the approach to Medical Education worldwide.^[9] It put forward 12 recommendations, of which the first 7 are also relevant to us as Homoeopathic educationists, the other 5 being addressed to policy makers. These 7 recommendations are given below (emphasis in italics is mine). These are:

1. Enlarge the range of settings in which educational programs are conducted, to include all health resources of the community, not hospitals alone

2. Ensure that curriculum content reflects national health priorities and the availability of affordable resources

3. Ensure continuity of learning throughout life, shifting emphasis from the passive methods so widespread now to more active learning, including self-directed and independent study as well as tutorial methods

4. Build both curriculum and examination systems to ensure the achievement of professional competence and social values, not merely the retention and recall of information

5. Train teachers as educators, not solely experts in content, and reward educational excellence as fully as excellence in biomedical research or clinical practice

6. Complement instruction about the management of patients with increased emphasis on promotion of health and prevention of disease

7. Pursue integration of education in science and education in practice, also using problem solving in clinical and community settings as a base for learning.

After 30 years, Medical Education, a prominent journal in the field, carried out a review of the status of some of these recommendations. Through a series of articles, some of the findings indicate the distance that needs to be traveled to realizing the intentions of the WCME. Bandiera et al. pointed out that “the addition of psychology, human factors engineering, anthropology, and business into medical education will help to create a generation of providers better equipped to deal with the challenges facing health care today.”^[10] Berkhout et al. postulated that the key to effective lifelong learning is the development and use of self-regulated learning.^[11] Irby and O’Sullivan assert that although teachers are more recognized and more rewarded than 30 years prior, large disparities still exist.^[12]

It would appear that our educational system has as yet to grapple with most of the above issues. In the meantime, two useful initiatives have evolved, namely, Outcome-based education^[13] and Competency-based initiatives in undergraduate and postgraduate medical education.^[14,15] The significant difference in these approaches with respect to the current practice is identification of the desired end points for graduates (or postgraduates) and patiently building student capacity to achieve the desired proficiency level, which is certified. Inbuilt into this process is a formative assessment process that provides constructive feedback to enable the student to proceed at the pace deemed by them to be suitable to their temperament. In light of the two initiatives mentioned above, it becomes imperative that we turn our attention to the quality of the product we are turning out to serve the needs of the community.

The UGC itself has proposed a Choice-based Credit System approach to all professional education.^[16] This is a semester-based system with the structuring of courses in the form of Core, Elective, and Foundation Courses. A totally new way of approaching medical education, it is at once challenging and pregnant with immense possibilities. Some of the best world class medical schools use these ideas to advance their students’ careers and Lumb and Murdoch-Eaten have afforded a blueprint on how one may proceed in thinking conceptualizing and implementing the elective program.^[17]

INTEGRATED HOMOEOPATHIC MEDICAL EDUCATION

Before the WCME recommendations of 1988, Dr. M. L. Dhawale had worked extensively on evolving the conceptual model of Homoeopathic Education, Training, and Research, based on his experience as Principal of the erstwhile Bombay Homoeopathic College and running the training programs at the ICR.^[18] Later, as the Hon Director of Father Muller’s Charitable Institutions (1985–1986), he worked on the idea of Integrated Homoeopathic Medical Education at the undergraduate level and had commenced a pilot project at Father Muller’s Homoeopathic Medical College, Mangalore.^[19] This project remained partially implemented as a result of his premature demise.

Years later, some of his ideas have been implemented at Dr. M. L. Dhawale Memorial Homoeopathic Institute, Palghar (postgraduate) (2002–2018) and Malini Kishor Sanghvi Homoeopathic Medical College, Karjan (undergraduate) (2008–2018) and have been presented at the CCH Workshops in Excellence in Education and in the International Conference in Homoeopathy, Kolkata, in 2010.^[20] The opportunity was utilized for framing a competence-based syllabus for a new subject: Advanced Teaching of the Practice of Fundamentals of Homoeopathy, which was then adopted by the MUHS, Nashik.^[21] In future, it is possible to consolidate this work and evolve new perspectives. One will have to ponder over the considerable thought that has gone into the working out the operational guidelines as well.

However, the prime question is: What do we train the doctors for? We need to accurately identify the health care needs of our country, which we know are changing with the passage of time. We need to gauge the extent of these changes.

CHANGING HEALTH-CARE NEEDS OF THE COUNTRY

In 2016, the Lancet published an interesting study that identified the significant changes that had occurred in the diseases prevalent in India between 1990 and 2016.^[22] The results are striking. The five leading individual causes of disability-adjusted life years (DALYs) in India in 2016 were ischemic heart disease, chronic obstructive pulmonary disease, diarrheal diseases, lower respiratory infections, and cerebrovascular disease; the five leading risk factors for DALYs in 2016 were child and maternal malnutrition, air pollution, dietary risks, high systolic blood pressure, and high fasting plasma glucose.

Another finding was significant differences in the spread of illnesses among the states, with different per capita incomes leading the study to title it “nations within a nation.” Thus, it seems that a medical student studying in Jharkhand or Orissa, states with low capita incomes, and one studying in Kerala or Tamil Nadu with better economic standing, would need to study a different curriculum, since they are likely to be confronting different clinical realities when they get into practice.

Around the same time, another study reported in Lancet Psychiatry on the prevalence of mental illnesses in the Indian population concluded that almost 1 in 7 individuals in India were in need of some sort of mental health intervention.^[23] This is a large number, considering that all our undergraduates are exposed to are a few desultory lectures on psychiatric disorders and virtually no exposure to these conditions in the outpatient departments. Moreover, it is likely that approximately 15% of their patients will require them to have much greater familiarity with the concept and treatment of various mental illnesses.

What is significant is that neither has our curriculum been designed with this changing disease burden overtime and over locations within the country, nor has it altered over the last 30-odd years by incorporating the advances in Medical Education technology. The changes in the environmental factors related to pollution/climate change/globalization and their impact on health need to be considered, the ongoing COVID-19 pandemic being an example of the impact. The current scenario calls for bracing for the medium- and long-term impact as well as the consequences of changing lifestyles.^[24] These events have once again emphasized the grave importance of public health, community mobilization, and the best preventive health practices to deal with the multiple issues we are likely to encounter in the future.

CHARTING AN APPROACH TO REVITALIZING HOMOEOPATHIC EDUCATION

A close study of the above will point out a need to review a lot that we are doing in our field. An attempt has been made below to correlate developments in the world of modern medical education with the classical Homoeopathic perspective. It will help to understand the pressing need to transform our thinking and action to keep pace with these new initiatives [Table 2].

A cursory glance at the above will tell us of the need to bring about some fundamental changes in our current practices. Some definitive guidelines are available for commencing this work.

The inevitable question: Who will bring about these far-reaching changes in our Institutions?

HARBINGERS OF CHANGE: TRAINED TEACHERS AS LEADERS

It had been a long-standing belief amongst the medical profession that the ability to treat is tantamount to the ability to teach. The fallacy has been recognized early enough all over the Western world and the effects of this have percolated into our country.^[25] In the light of the proposal by Singh et al., the erstwhile Medical Council of India had constructed an elaborate system of training for teachers in Medical colleges by recognizing the Nodal and Regional Centers of Medical Education and insisting that all teachers be exposed to Basic and Advanced Courses in Medical education. Establishment of a functional Medical Education Unit in each college became a necessity. Some Health Science Universities have taken up this in right earnest and have instituted sensitization and training programs in Medical Education and technology. Yet, the ethos of teacher training has not percolated deep enough in the mind set of Homoeopathic academicians. A formal training program that will help in setting up Medical Education Units in all Colleges should address this deficiency and help to internalize reforms as suggested in the above-mentioned paper.

Conventionally, the teacher in the Indian ethos fulfills many more roles than that of an instructor. They function as philosopher, friend, and guide. As homoeopaths, we have always given that status to our Master – revered him and attempted to follow in his footsteps – albeit sometimes to an extent that is not entirely desirable, taking leave of our own independence of thought. Yet, the importance of the teacher being a role model in the form of a missionary (Aphorism 1) cannot be minimized. For it would be on the shoulders of the teacher that the burden of bringing about the changes would rest. Hence, a leader ought to transform into a leader and Faculty Development Programs should be accordingly structured.

THE NEP 2020 AND ITS IMPACT ON HOMOEOPATHIC EDUCATION

We are fortunate that the NEP 2020^[26] has given the highest importance to the role of the teacher and the nature of the relationship between the teachers and the student in bringing about the transformation of education in the country. It is a document that is bold and breaks new ground as it is rooted in the Indian ethos. The demands it makes on educationists and academicians are huge.

Not only has it mentioned much of what we have already indicated above but also it has emphasized the need for sensitizing young health professionals to the reality of the demand of pluralistic health care in our society. All approaches to health care in this vast country are to be respected and it boldly calls for instituting an integrated approach at the undergraduate level so that all health-care providers are able to value the contribution of each approach in preserving and promoting health of the community.

Most important, it proposes a welcome ‘light but tight’ regulatory framework to substitute for the current inspection/ inspector dominated system. Audit and public disclosure while encouraging innovation are far more preferable to a strait jacket system that drains it of vibrancy, autonomy, good governance, and empowerment.

A ROAD MAP FOR REVITALIZING HOMOEOPATHIC EDUCATION

Looking at the developments that have been briefly summarized above, our final approach would be a fine integration of the steps that we have taken, namely, Hahnemannian philosophy, integrated with developments in Medical Education and on the bedrock of the NEP. We will need to bring about changes in the following areas of Homoeopathic Education.

1. Alignment of Objectives of Homoeopathic education with the national health-care needs of today and the ensuing decade

2. Defining the outcomes and competencies which a Homoeopathic physician should acquire to fulfill the above – at the undergraduate and postgraduate levels

3. Structuring the outline of the undergraduate and postgraduate courses, which will progressively result in the student developing the competencies defined above

4. Identifying the educational methodologies in tune with evolving competencies in different areas

5. Redefine the nature of the clinical exposure so that the student gets adequate experience of patients and their suffering as available in the community as well as in the hospitals

6. Inculcation of critical, evidence, and value-based thinking and communication skills which will eventually result in the wholesome development of the professional and a holistic integration of education and research

7. Devising reliable assessment methods that will enable the student to evolve these competencies at a pace suitable to his/her capacities

8. Designing a teacher training program which will enable the generation of human resources who will help in the creation of professionally competent homoeopathic physicians committed to the delivery of care to all sections of society, bringing innovation in conducting research while remaining lifelong learners

9. Carry through Institutional Reform by redefining the Standards of Educational infrastructure and requirements in the light of the above to build Global Institutions with modern facilities (to align with a post-COVID-19 scenario)

10. Ensure that the accreditation process of educational institutions and hospitals be carried out by independent agencies aligned to the Quality Council of India.

CONCLUSION

We have taken the opportunity afforded by the phenomenal changes in the socioeconomic-health scenario occurring all over the world in the light of the ongoing pandemic and in India to propose a bold departure from the current practice of Homoeopathic education. These proposals are deeply rooted in the principles of Homoeopathy enunciated by the Founder and the well tested practices of Medical Education evolving over the past century. The formulation of the NEP 2020 and the passing of the National Homoeopathy Commission Act by Parliament have raised new possibilities of breaking decisively from the past and to chart a new future that will respond creatively to the demands of our people. The role of the Homoeopathic profession is crucial and the pace at which we need to move has to be quick. Dr. Hahnemann would have appreciated such a wholesome action as that would give a new lease of life for this great science with immense possibilities to do good for all.