National Medical Commission Regulations on Entrance Examination Cut-off

Some of us are perturbed over the recent stipulation by the National Medical Commission (NMC) on relaxations in cut-off marks for medical entrance examinations in the country. This would allow pupils who score the minimum qualifying marks, which is now the nominal fifth percentile, in the National Eligibility and Entrance Test (NEET) to be considered for admission to medical colleges. This has come as a cultural shock for academic Puritans, and conservative thinkers who consider that lowering the ‘merit’ yardstick would jeopardise the very sanctity of medical education in the country. This could hamper the delivery of medical care in the nation, placing the lives of Indian citizens at risk through the certification of professionals with suboptimal capabilities. Medicine, it is largely thought, demands the exercise of the highest levels of intellectual pursuits, and only the sharpest as well as brightest pupils should have access to medical education. The tampering of quality that they think would ensue may retard the pace of intellectual growth in the country, otherwise poised for rapid development, as a longer-term strategy. On the contrary, the planners of the move, as well as many others, feel differently. They argue that the objectives of medical education should accommodate a balance between the needs of the country and the number of professionals produced at a given point, and it should maintain professional education quality through proactive vigilance in the art of imparting it in the same breadth. This is like an ever-recurring debate in education, between achieving perfection and sanctity of content on the one hand and the potential risks–benefits of expanding access through horizontal spread on the other. We need to dissect the matter from a pragmatic, dynamic, social viewpoint of expanding access rather than an orthodox and obsessive matrix of merit in medical education that guards the quality concern but fails to address the needs of service as it appears at this point. The issue has more than pure logic in it. It is fairly culturally sensitive and impregnated with insecurity and fear of losing a paradise of excellence. The question of choosing the most efficient and just method for selecting the ‘fortunate few’ who would enjoy the privilege of getting christened to divinity, as studying medicine in India is considered to be, has all along evoked significant social ripples in India, both in professional circles and among lay people. It had all landed up in judicial forums almost regularly for the resolution of controversies and providing methodical solutions for obedience. No other stream of education bears that many legal imprints in framing statutory regulations as medical education does in India. What intrigues, in the face of such enthusiasm around the gateway to the paradise, is the fact that that the same social excitement or even a fraction of that is virtually absent when issues such as maintenance of standards of training and the quality of medical education provided in the mushrooming edifices called medical colleges is perceived to be slipping down the ladder very fast. As the concern grips circles and voices are raised, the caretakers act through new and newer changes to tide them over the difficulty, albeit with very short-term outcomes. As a result, fairly dynamic changes in criteria for entrance keep on happening here, and the latest one is a prescription by the NMC for lowering the cut-off marks obtained in NEET as eligibility for consideration of admission to medical colleges. NMC, reportedly, have resorted to this strategy to expand access to medical education in the country, when the country needs to churn out more qualified medical professionals than what exists at a rapid pace. Understandably, this round of modifications has been done to protect the private medical colleges from losing seats for encashment. A large number of seats remained vacant, caught up in the cut-off dragnet, and that was challenging the financial health of the medical education industry, which the country is abuzz with vibrancy. The fallout could be that the latest round of modifications virtually enables the so-called ‘poor’ performers in NEET to potentially enter medical colleges. This possibility has raised eyebrows and has sent shock waves to many who argue that this amount of democratic widening in the medical professional space may threaten the very premises of medicine by undermining the quality question at the doorstep itself. It is argued that resorting to this strategy may produce a subset of ‘quacks with degrees’. Given that mutant viruses always have the replication advantage and outwit the wild ones fast, the fear is that the cultural and capability attributes of the profession might fall rapidly. Medicine is a science and often demands the highest amount of utilisation of intellectual faculty and analytical capabilities. The crevices of the question need to be dissected from a number of angles and conclusions reached. To have a rational approach to the evolving landscape of medical education arising out of a relaxation of the percentile cut-off at entry, we need to understand the context of the country in a dynamic, contemporary frame and, most importantly, be courageous as well as flexible enough in accommodating the grounds needs. First, and foremost, the ‘permissive tolerance’ and ‘accommodation’ of the so-called lesser meritorious pupils by NMC should be viewed as a social necessity and a judged response to the existing context in India. While quality is an important consideration, the country needs to have a rapid reversal of its current highly perverse doctor–population ratio. While stringency in entry criteria is a safeguard for quality, the exclusivity that it imparts is an impediment to a rapid increase in the number of trained medical personnel in the country, as is needed. We are in a transitional phase of development in this country, walking past the Hillary steps towards the peak, while the relics of past underdevelopment still have their imprint on the social body. Doctors are the pivots of the health care human resources team and form the vanguards of the health systems. The paucity of an adequate number of basic doctors makes the system limp at the doorstep. In tandem, it shines in the most modern tertiary care hospitals where world-class facilities are available that foster medical tourism but deny access to a large populace of the country. It is like the Tantalus myth and is not the coveted system for the country. We should be producing specialists of the highest calibre while not forgetting the need for primary care provisions. It seems likely that relaxing the entry point cut-offs will be helpful in reversing this skewed pattern in the need availability scenario. In fact, it may so happen that once the country has met its’ crucial targets in numbers through such policy, in the next couple of years, it may relook at the strategy under discussion, raising the thresholds for entry again and swinging the balance to a ‘pursuit for quality’ only, as many puritans and less flexible conservatives would feel happy with. This dynamicity of approach, flexibility to social needs and balanced maintenance of quality are going to shape the health system with the right design and capability of human resources that it needs. Let us shape the system like an infantry with border guards and sentries at the remotest points in large numbers and the lieutenants as well as generals in strategic locations to lead them. Currently, it is too skewed to be a top-heavy view only. The NMC prescription of a wider entry gate is likely to provide the health system a broader pedestal that it needs to build a robust tower over it. Secondly, the current prescription of NMC effectively challenges the strength of the present yardstick of measuring merit. While not challenging the need for having the ablest pupils, the methods for selection of the ‘most intelligent ones’, as needed, have never been uniformly agreed upon over time and across societies. It has veered from the pure subjectivity of ancient and medieval society, to progressively increasing objectivity as mathematics, statistics and finally, computers have come to dominate our means of picking the right kind of apple as well as the elimination of bias. Even if we do not disagree with the central dogma of the need to have intelligent pupils in medicine, it can be widely argued that the method that we adopt currently is not the one to do that. NEET, in its current form is a test of swiftness, agility and tactfulness rather than comprehensive knowledge of the person. Even more deeply fallacious are its core values. It is primarily a method of elimination rather than selection. The current practice of a single-day performance over a couple of hours is unlikely to do justice to the assessment of his/her intelligence, which, in its truest form, is an all-around phenomenon. In real life, too, it is more than usual to see people with so-called average intelligence turning out to be doctors loved by people. Medicine is an excellent paradigm of knowledge and practice where cognition and affect need perfect blending. Hence, showing up not well in a 1-day entrance examination, designed to measure the ability to hit the bull’s eye with precision, is not a perfect way to measure somebody’s ability to serve in the medical profession. Hence, allowing the lower-end performers in the designed entrance is unlikely to do injustice to the basic objective of medical education and training. It should not, of course, perforate the rightful primacy of the good performers in entrance. Finally, and as a potential changer of the paradigm, it has challenged the dogma that centres around the supremacy of the cognitive elites as the only torchbearers of the profession. Medicine is undoubtedly a densely scientific cult, but its nature varies from the other science disciplines that deal with inanimate objects. Affective pursuits form an integral component of medical practice, and no merit list or biomarker can ensure that with predictive power. It is interesting to note that there is generally a disagreement and non-coexistence of cognitive power and affective elements of an individual. It is not easy to see many who solve puzzles in science and play the violin with equal ability as well as passion. While this is an extreme example, good medical practice demands a fair blend of both. The means of picking up the right people to groom as doctors could accommodate this, too. And that’s not possible with a numerical yardstick. Overall, we may dress our thoughts afresh with a new leash of ideas. There is no all perfect method for selecting the appropriate candidates to be future medical professionals in India. The current numerical merit-based approach, the 3 h bullfight examination, and a high bar for consideration may not be sufficiently sensitive to be considered as full-proof methods that rise up to the needs of the context in this country. We could be more permissive to accommodate the new regulations of NMC for lowered cut-offs in the selection test and be flexible enough as well as have the readiness to change this one too if it proves to be not useful. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.