The dermatology curriculum: Searching for balance

Arakali Lakshminarayana Shyam Prasad

 Department of Dermatology, M.S. Ramaiah Medical College, Bengaluru, Karnataka, India

Correspondence Address:
Arakali Lakshminarayana Shyam Prasad
Department of Dermatology, M.S. Ramaiah Medical College, Bengaluru - 560 054, Karnataka
India

I started my medical training in 1975 and finished it in 1984, armed with a post-graduate degree in Dermatology, Venereology and Leprology, from one of the more prestigious medical colleges and universities in India. During those days, we went through a senior housemanship after internship, which comprised 6 months each in a medical and surgical allied field. Dermatology was at the bottom end of the totem pole, along with radiology, and I remember my close friends being not just surprised, but rather shocked that I chose to do my first 6 months of housemanship in a “last choice subject.” They were even more surprised when I chose it over surgery for my post-graduation; surgeons then, as now, being the glamour boys/girls.

Cut to 2020. The specialty I chose has also become the glamorous one, competing with radiology, for being the most wanted among medical graduates to join for post-graduation. What a turnaround! Of course, the reason for this is a no-brainer. The explosion of esthetic dermatology and, to an extent, dermatologic surgery, has made the specialty a potentially lucrative one. Add to that, fixed hours and few emergencies and the attraction becomes obvious.

While I have no problems with dermatologists increasing their earning potential, I do feel that our chosen field has become further trivialized as far as the practice of medicine is concerned. Younger dermatologists no longer want to manage even the mildly serious dermatoses, leave alone conditions like pemphigus or systemic lupus erythematosus, partly because they feel diffident and partly because it's just not financially remunerative enough.

The bigger concern is that we are letting loose into the community a very large number of doctors, who are half-baked, especially as cosmetic dermatologists. The present curriculum is still heavily dependent on what is given in standard textbooks of dermatology. The evaluation, both theory and clinical, gives emphasis to the medical aspects. But what do we see when students get their MD degree? Due to the paucity of job opportunities in government institutions, most of them go into the private sector, where their core dermatology skills attenuate, and the lucrative nature of cosmetology makes them forget whatever they had learnt of the medical practice of dermatology. Even during their training period, those of us in medical colleges would testify that the average resident's interest in hardcore dermatology is tepid at best. Unfortunately, they learn only a little theory about the cosmetic aspects and have even less hands-on experience of various procedures, so when they start their practice, their labels of “cosmetic dermatologist” with a long list of procedures done, hardly carries any weight.

The Medical Council of India has recently formulated competency-based curricula, both for MBBS and for MD.^[1] The objective of this revamp is laudable—it is to ensure that no medical student gets his/her degree without achieving a minimum level of competency. When I went through this document, I found that the only new psychomotor skills listed in addition to those which I had learnt nearly four decades ago were chemical peels and acne surgery. I may add that there are nearly two pages devoted to listing different types of skills expected from a postgraduate in the specialty. As far as lasers are concerned, students need to “acquire knowledge of the basics of laser operation and precautions which needs to be taken;” no need for hands-on experience. The section on assessment, surely the bedrock of any learning, has hardly changed, with the same format being continued. Within this format, how is one to assess whether a resident is competent in a particular skill? The recommended reading list does not have a single textbook on cosmetic dermatology. Thus, one would expect the status quo to continue, with students being tested mainly in their competence in medical dermatology, but ending up practicing cosmetic dermatology, in which their skills would be open to question.

Our training module in the subject, thus, begs the question—what do we want our postgraduates to be? The system appears flawed the way it is designed at present. How do we get the right balance between “serious” and “frivolous” dermatology?

It appears, from hearsay evidence, that most of our residents join the MD course with the ultimate objective of opening up a practice which would enable them to earn well after completing the course, which, of course, would mean getting into a predominantly cosmetic-based practice. If that is indeed the case, why make them go through 3 years of rigorous academics, putting a strain on them, on the teaching faculty and on the system, when they are not going to put it to use? It is like some of our MBBS graduates going into business or joining the civil services—a real waste of time and money. Redesigning our curriculum to allow for an efficient utilization of human and material resources by reducing the quantum of cognitive knowledge and increasing psychomotor and affective skills, while also designing an effective assessment methodology, would be one way forward. This, however, would mean decreasing the emphasis on hardcore dermatology, surely not advisable when we are supposed to be producing fully trained specialists. If we want to preserve and improve our status among our fellow physicians, we need to be open to newer ideas and out of the box thinking in recognizing what constitutes an expert in esthetic dermatology. Whether this takes the form of specialized postgraduate courses in cosmetic dermatology after MBBS, or separating out leprosy and sexually transmitted diseases from the course by including them under infectious diseases and genitourinary medicine, respectively, or post MD courses recognized by the Medical Council Of India, or any other innovative suggestion, it should be a subject of introspection and debate within our community, as should the redesigning of our curriculum. In its present avatar, it neither trains students effectively nor does it help the community at large.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

1.	Available from: https://www.mciindia.org/CMS/wp-content/uploads/2019/09/MD-Dermatology.pdf. [Last accessed on 2020 Apr 17]. [Google Scholar]