In this posting, Nepalese medical educator and MH Editorial Advisory Board Member, Ravi Shankar, describes the educational background of students entering medical school in South Asia.

South Asia is a densely populated region and contains within its boundaries a large proportion of the world’s population and also a large proportion of the world’s poor. These countries share a set of common cultural and social values. These include respect for authority, regard and respect for elders, strong family ties, the predominance of family and society in decision making, and restrictions on individual freedom.

In South Asia students enter medical school after twelve years of schooling. In the last two years of schooling, the subjects of Physics, Chemistry and Biology (collectively termed Science) are mandatory. During their school years, the students learn various subjects like languages, science, social studies, mathematics, physical education, drawing and the ‘crafts’. These days, English medium schools are becoming popular. In these schools the various subjects are taught in English. The national language, and the mother tongue of students, are taught as second and third languages respectively. In vernacular medium schools, the subjects are taught in the native languages and English is the third language.

Although drawing, arts and crafts exist in the curriculum, it is my experience that little attention or emphasis is given to these subjects. The same may also be true of physical training. Drawing and crafts teachers are usually not well trained and well paid. The academic requirements for these teachers are less stringent than for other subjects. Also these teachers often lack knowledge of recent developments in the subject and how to inculcate a love of the arts in their students. Modern learning methodologies are not commonly used. The students just draw and paint pictures or create craft objects without necessarily knowing why they are making these or the significance of the exercise. Often, the students find it difficult to make complex designs and get their parents and other elders in the house to help out. Training in art appreciation and appreciating movies and other performing arts are lacking. Certain individuals pick up these skills on their own without much help from the formal school system. Most of the bright students opt for medicine or engineering or commerce and management and subjects like physics, chemistry, mathematics and biology receive greater emphasis.

A major problem is that teaching in most schools is didactic, memory-based and directed towards doing well in the examinations. The examinations emphasize memory and recall and this emphasis drives the school education system. The languages are also often taught in a similar manner with emphasis on the examinations. The romance and beauty of the subject is often missed. It has been up to a few excellent, dedicated and motivated teachers to inculcate in their students a love of languages.

To enable students to score well in examinations during their school years and to coach them in writing model answers for questions a number of coaching institutes and private tuition centres have sprung up. Guide books which give model answers to most likely questions are also available in the market. The system does allow a certain amount of leeway for teachers to teach their subjects differently as long as their students do well in the examinations especially in the lower and less important standards. A problem with this approach is that appreciation of short stories, novels, essays and poetry is not a common feature among the educated elite. A large proportion of the population is illiterate or inadequately educated and is unable to appreciate the written word.

After ten standard, the students have to choose one among the three streams of study – arts (humanities), commerce or science. Vocational streams are also offered in certain institutions. The choice of a stream is dependent on the marks obtained and the reputation of the college in which you want to enroll. Certain well established and reputed colleges have higher cutoff marks. Previously the highest rankers used to opt for science, the middle ones for commerce and the students who obtained lower marks used to opt for the arts and the humanities. These days with more opportunities in arts, advertising, movies and television the scenario is slowly changing. Many of the more innovative institutions have started dynamic and flexible courses which aim to meet the demands of the job market.

Students are selected to medical school either on the basis of their twelfth standard marks or on their performance in entrance examinations conducted by various bodies. Certain colleges select self-financing students primarily based on their marks and their ability to pay the high tuition and academic fees. Management quotas where the fees are very high exist in many institutions. In many countries seats are also reserved for various disadvantaged sections of society. Many schools conduct an interview before admission but this does not usually carry any weightage in selection.

The end result is that the student is well attuned to rote learning, memorizing facts and reproducing the same in the examination. The faculties of critical thinking, rational analysis and problem solving are not well developed. However, there are exceptions both with regard to individuals and institutions. These days, ‘alternative schools’ are being started but they remain an exception.

Also students who get into medical school are among the top performers in the academic system. The humanities as already said gets students who did not do so well in the examinations. The medical graduates thus develop the feeling of being a ‘privileged elite’ and a cut above graduates of other disciplines. Also most medical schools in South Asia are isolated institutions and unlike in the west are not part of a university with students of other disciplines studying in the same campus. Thus opportunities for interaction among graduates of various disciplines are minimal. The educational system is not very much in favor of mixed curricula and student-designed courses of study depending on their interest and aptitude.

Medical schools follow a rigorous curriculum and the emphasis is again mainly on rote learning and memorization of facts. The exams mainly test didactic knowledge and the ability to reproduce memorized information. Attempts to change this are underway in selected institutions and by selected teachers. The teachers, the students, the other staff are all from a science background and science is the language of medicine. The schools offer no opportunities for students to learn the arts and the humanities. Certain interested students learn to paint, make sculpture or play a musical instrument from institutions and individuals outside. Due to the rigorous curriculum and academic demands many however have to sacrifice their artistic pursuits.

The concept of a core curriculum and electives is not common and all students study basically the same curriculum and there are no special study modules (SSMs). I have conducted a voluntary medical humanities module at the Manipal College of Medical Sciences, Pokhara, Nepal and enjoyed the experience. I used literature and art, case scenarios and role-plays to explore various aspects of the humanities as related to medicine. Being voluntary, the students self-selected themselves and only interested students participated. Nevertheless, students had difficulties in reading and appreciating certain of the literature excerpts which were written in English, for them, a foreign language. However, English is the working language of medical education and, given the multiplicity of languages spoken by students, finding an alternative common language is difficult.

I have also conducted literature and art based sessions at KIST Medical College in Lalitpur, Nepal and, again, found that the participants had difficulty understanding and appreciating the literature excerpts. There was no formal training on literature appreciation during the school years and the participants found the scenarios and the language difficult to comprehend. Student found the paintings easier to understand but appreciation of the painting and its relevance to the subject of discussion was often done at a superficial level. Formal art appreciation is not a common phenomenon in South Asia although there are signs of change.

Thus arts and the humanities have a low status in South Asian both in general education and, consequently, in medical education. The technical aspects of medicine are of course important, but the arts are equally important to produce a well rounded and humane doctor. This may also be true for other professions. Greater emphasis on the arts is required to ensure that society does not neglect its more creative side and that people learn to lead richer, fuller and more satisfying lives.

Dr. P. Ravi Shankar

KIST Medical College

P.O. Box 14142

Kathmandu

Nepal

Phone: 977-1-5201680

Fax: 977-1-5201496

E-mail: ravi.dr.shankar@gmail.com