Mixed Messages: the ‘hidden curriculum’ and the consequences of ‘excellence’ at India’s most prestigious medical school
By Anna Ruddock, member of the Social Science Approaches for Research and Engagement in Health Policy and Systems TWG
It’s that time of year again. When tens of thousands of aspiring young Indian doctors dream about winning a place at the country’s most prestigious medical college – the All India Institute of Medical Sciences (AIIMS) in Delhi.
Opened in 1956, AIIMS is an enormous government-funded hospital, anomalous in the public healthcare landscape for employing many of India’s most respected doctors, who consistently provide a high standard of free or low-cost care to patients of low socioeconomic status. It also occupies an unassailable position atop the hierarchy of Indian medical education. It is, we are regularly informed by the media and the medical establishment, ‘the best’.
In May, around 90,000candidates will compete over 72 MBBS seats at the college, which makes for an acceptance rate of less than 0.01%. The tiny minority of successful students are catapulted into an exclusive club, with their achievement celebrated in the national press.
What does it mean for AIIMS and its students to be the best? And what are the consequences for Indian public health, when perceptions of medical excellence are largely confined to urban, ‘super-specialised’ practice? Such questions fuelled my PhD thesis. As I continue to think about them, I become more convinced of the importance of paying close attention to the systems and circumstances of health professionals’ training across contexts and the implications they have for the politics and practice of health and medicine.
I am hardly the first to suggest this. US-based anthropologists in particular have undertaken detailed studies of how the personal and professional identities of doctors are moulded by medical schools (Adams & Kaufmann 2011; Good & Good 1989; Holmes, Jenks & Stonnington 2011). However, with notable exceptions (see Claire Wendland’s 2010 study of a Malawian medical college in particular), less attention has been paid to medical training in LMICs. And yet I would argue that such analysis is crucial in order to further our understanding of a wide range of interrelated themes, including attitudes towards patients and their behaviours; affliction and disease; power and social norms; and aspiration and ambition.
This became central to my research with students at AIIMS, who overwhelmingly aspire to be ‘super-specialists’ working in well-equipped urban environments. It was not surprising that students of India’s most prestigious medical college wanted to pursue the most prestigious type of career. What did prove interesting, however, was how this idea of prestige was framed and internalised by students.
A postcolonial institution (albeit conceived pre-independence), AIIMS was established as part of the effort to stimulate national development through science and technology. It was intended as a specialised tertiary hospital, but the absence of an adequate supporting health system meant that it quickly began to treat patients who required primary or secondary care. Patient numbers have increased dramatically over the years, to the point that the AIIMS outpatient department currently sees an average of 7,400 people a day. Many of these patients travel from beyond Delhi, incurring significant expense, for the competent and affordable treatment that they cannot find at home. Students are therefore exposed to a huge spectrum of medical conditions – a situation they acknowledge as a unique educational asset. They are also confronted with the structural conditions of poverty and marginalisation that continue to afflict vast swathes of the Indian population.
Simultaneously, however, students are encouraged to pursue (super-) specialised practice. One senior faculty member told me that the AIIMS administration took more pride in students who went to the US for postgraduate study than those who went to work in Indian primary health centres. A fourth-year student, Anjali1, said that even if she were interested in family medicine, she wouldn’t know, because it isn’t taught at AIIMS. While another student, Azam, said that there was a certain level of achievement expected of an AIIMS graduate, and failing to live up to it would invite stigma. A former director of AIIMS summarised the devaluation of general medicine in more dramatic terms by concluding that ‘AIIMS killed the GP.’
There is of course more to it than this. Practising medicine in the public sector is generally unappealing, particularly in rural areas, given inadequate medical facilities, low pay, and a lack of infrastructure to support the minimum quality of life that graduates expect. Among many AIIMS students, however, there is also a perception that practising medicine beyond the city is insufficiently challenging for graduates of their calibre. This perception goes largely unchallenged at the Institute.
The ‘hidden curriculum’ (Taylor & Wendland 2014) also influences future doctors and demands close scrutiny. For example, communication skills are not taught as part of the AIIMS curriculum. Lessons are generally learned via observation, and occasionally through the direct instruction of particular faculty members, or through poorly-attended voluntary workshops. Understandings of what it is to be a ‘good’ doctor and a ‘good’ (read: ‘responsible’) patient are therefore rarely interrogated as part of an AIIMS medical education, but are likely to be reproduced through mimesis in students’ future practice.
My research led me to challenge a simplistic understanding of what it means for AIIMS to be ‘the best’, and to ask who truly benefits from ‘excellence’ in Indian medical education. However, my broader concern applies across contexts and to all health systems. That is to urge closer academic attention to processes of medical training, and to their influence and impact on the politics and power dynamics of national healthcare landscapes.
1. All research participants’ names have been changed to protect anonymity.
Image credit: © Anna Ruddock