A patient walks into a Primary Health Centre in Tamil Nadu at midnight with chest pain. Another is brought after a road traffic accident. Will the young MBBS doctor on duty be confident and competent to manage these emergencies safely? This question at the heart of the debate on medical education reforms in India today.
Tamil Nadu’s public health system is well recognised, with low maternal and infant mortality, extensive primary care, and a functioning referral network. Medical education in Tamil Nadu has long aligned with this vision, producing doctors for government facilities. Yet, current national reforms raise concerns that this alignment is being eroded.
Two policies have reshaped medical education over the last decade: The introduction of Competency Based Medical Education (CBME) in 2019 and the centralised National Eligibility-cum-Entrance Test (NEET) for undergraduate and postgraduate admissions.
These have been introduced to improve quality and transparency, but their unintended consequences challenge Tamil Nadu’s focus on social accountability.
Indian medical education, guided by the Bhore Committee’s vision of a ‘basic doctor’ who can address community health needs, has aligned closely with Tamil Nadu’s vision of equitable health care.
CBME has, however, shifted focus to producing market-oriented ‘world-class’ doctors. While intended to ensure minimum competence, the numerous and prescriptive competencies, documentation, and reporting requirements have fragmented teaching and assessment, rather than strengthening clinical training.
Faculty spend an increasing amount of time to complete paperwork instead of bedside teaching. The autonomy of teachers and institutions to prioritise local health needs has diminished, and the focus on clinical training and community exposure has reduced. As a result, the “hidden curriculum” of mentoring, role-modelling, instilling ethics, and promoting good clinical practice has weakened.
Students report rising stress, declining engagement with clinical learning, and a growing perception that undergraduate education is no longer oriented towards a functional basic doctor. Faculty surveys echo these concerns, highlighting excessive checklists, assessment burdens, and declining clinical preparedness of graduating interns.
Reports from internship postings are particularly worrying. Many interns lack confidence in handling basic emergencies or performing common procedures such as intravenous cannulation, catheterisation, wound suturing, or initial resuscitation. These gaps will directly affect patient safety, especially in peripheral health facilities where young doctors are the first point of care.
The introduction of NEET has further distorted educational priorities. It has fuelled a massive coaching industry, with many MBBS students enrolling for postgraduate NEET coaching from their first year itself, devoting substantial time to training in MCQs rather than focusing on clinical experience and developing clinical skills.
This undermines their clinical preparedness for independent practice and discourages graduates from working in the health system after their MBBS training.
These developments have serious implications for public health in Tamil Nadu, which relies on MBBS graduates to ensure staffing in the system.
It is imperative to recapture the original spirit of the CBME and align it with the health needs of Tamil Nadu and across India. Towards to this, we suggest the following steps:
First, competence must be made practical and meaningful. Rather than ticking off numerous competencies, every graduate should be able to perform a clearly defined set of observable tasks aligned to the common health problems, such as fever, breathlessness, and chest pain; initiating basic resuscitation; performing common procedures; prescribing safely; and communicating with patients.
Second, clinical training must be strengthened. Adequate bedside exposure, participation in patient care, mentoring by senior clinicians and assessment in clinical settings should be ensured. Community-based training in primary and secondary care settings should be an essential requirement.
Third, the internship should be restored as a true supervised pre-licensure year. Uniform rotations, involvement in clinical care and graded responsibility, structured feedback, assessment of important skills, and validated logbooks can ensure that the internship fulfils its role.
Fourthly, greater weightage should be given to structured assessments in the workplace during clinical training. NEET and NExT should give importance to clinical skills and work-based performance during internship.
Fifth, CBME should serve as a guiding framework, rather than a rigid set of rules. Teachers should be encouraged to develop innovative education to meet the needs of students, patients and local communities. Colleges with strong track records of innovation should be allowed flexibility to tailor their education in line with their social mission and local health needs.
Finally, the impact of CBME and NEET must be systematically studied. Colleges should be encouraged to identify the difficulties that students and teachers face and evolve mechanisms to address these.
Medical education in Tamil Nadu stands at a crossroads. As it risks losing its clinical emphasis, the State has the opportunity to lead a way forward by reaffirming a vital principle: Medical education must serve the health of the community. By encouraging colleges and teachers to strengthen the clinical training, community exposures and preparing students for independent practice, we can develop a contextual education relevant to the health of the community.
To rebuild the credibility of the MBBS course, medical education must return to its core purpose of serving the health of the people by focusing on training physicians who are competent, ethical, and compassionate, and can deliver safe care from the day they complete their undergraduate training.
(Dr George Mathew is former Professor of Surgery and Principal CMC, Vellore; Dr Anand Zachariah is Senior Professor of Medicine, CMC, Vellore. The views expressed in this article are personal opinions of the authors and does not reflect the opinion of any institution or organisation)