The pioneer medial educationist talks to Medicos Next about his career and medical education in Nepal as he retires from his post at Nepal Medical College after over 24 years of service in July this year.
Dr. Shekhar Babu Rizyal, Former Director Medical Education Dept., Nepal Medical College, did his schooling at St. Augustine’s School, Kalimpong, India, and passed Senior Cambridge in 1962.He did his I. Sc. from Trichandra College, Kathmandu, and joined the MBBS program at Calcutta Medical College and passed out as a medical doctor in 1972. He acquired D.T.C.D. from University of Wales, U.K., in 1983, and MHP Ed. from University of New South Wales, Sydney, Australia, in 1990.
He joined the Auxilliary Health Worker’s School at Maharajgunj in November 1972 and taught AHW, as well as students of Certificate in Medicine: General Medicine, Health Laboratory, Pharmacy, and Radiology at the Maharajgunj campus of IOM. He took classes for Certificate in Nursing at Mahaboudha Nursing Campus, as well as for Certificate in Ayurved, related to modern medicine, at Nardevi Ayurrved Campus. Later, when MBBS program was started at IOM in 1978, he was assigned the responsibility of taking clinical and early clinical exposure classes, followed by theoretical classes for the MBBS program. He became a lecturer in 1976 and associate professor in 1999. After functioning of T.U.T.H in 1983, he also became directly involved with patient care.
He founded the Medical Education Support Unit at Institute of Medicine in 1986, and subsequently became involved in teacher training workshops and curriculum review workshops of IOM. The unit was upgraded to Medical Education Department subsequently, which at the moment has turned into National Centre for Health Professions Education at Maharajgunj under the Institute of Medicine. He served the Maharajgunj campus as Chief of Academic Unit, 1973-1975, Chief of Academic and Students Welfare Section from 1975-76, Asst. Dean (Academic and Examination) of Institute of Medicine, 1992-1976.
He represented the Institute of Medicine at the Field Directors Conference at Centre for Educational Development in Health, Harvard University, Boston, USA, in 1976; he was the Nepal representative at the Need Based Curriculum for Undergraduate Medical Education Program of the Medical Council of India, New Delhi, 1993; and the national representative at the Second World Summit Conference on Medical Education, organized by the World Federation for Medical Education, Edinburgh, in 1993. During the initial phase of establishing B. P. Koirala Institute of Health Sciences, he made contributions in designing its first version of the MBBS curriculum.
He resigned from the faculty position of Associate Professor in Medicine and Assistant Dean (Academic and Examinations) of the Institute of Medicine for the sole purpose of establishing Nepal Medical College as its founding principal, and Tribhuvan University approved the resignation letter in February 1997.
Please tell us about your association with Nepal Medical College.
Honestly speaking, when I was approached by the founding members of Nepal Medical College (NMC), I was overwhelmed with joy when such senior-most medical doctors of Nepal like the late Dr. Sachhe Kumar Pahari, approached me and sought my help in establishing NMC, run by Nepali medical doctors and other professionals. And, after discussing over the matter with my late better half for about a week, we decided that I resign from the Institute of Medicine and join Nepal Medical College. The provision for taking sabbatical leave or unpaid leave for certain period of time did exist then, and was an option for me, instead of resigning from my post. But, speaking frankly, I did not like to opt for that scheme, as I thought if I did, I would be working half-heartedly at an institution that required full time commitment for nurturing during its formative phase of development.
I was appointed the founding principal, and with the supportive help of all the founder members, faculty members, administrative staff, and well wishers, was involved in establishing our own 100-bed teaching hospital for Nepal Medical College in Atterkhel, Gokarneshower, in November 1997, fulfilling the pre-requisite of Nepal Medical Council for starting MBBS program. The MBBS program, with a batch of 75 students, after getting affiliation from Kathmandu University and recognition from Nepal Medical Council, was started on December 29, 1997 (Poush 14, 2054).
My portfolios with Nepal Medical College have been as follows: Founding Principal, 2053/10/7 to 2067/5/31; Deputy Director (Academic), 2067/6/1 – 2068/1/31; Principal cum Director Medical Education 1070/2/19 – 2073/4/31. I resigned from the post of Principal cum Director Medical Education from 2073/5/1 due to my requirement for staying outside Nepal,in order to taking medical care of my late better half. I was reappointed Director Medical Education from 2073/12/1 till 2077/4/1
During the 24 plus years of my association with Nepal Medical College, academic programs MBBS, BDS, and B. Sc Nursing, together with MD, MS, and DM in Nephrology have been running at the college, and its teaching hospital and the credit all goes to the founder members, faculty members, and staff of the college and hospital.
Review of different curricula, as well as assessment schemes; workshops on teacher training, problem-based learning, and conducting fortnightly CPD programs for faculty members, PG residents, and interns are some of the activities being looked after by the Medical Education Department. I was once a former member of Academic Council of B P Koirala Institute of Health Sciences, Dharan, Kathmandu University, Dhulikhel, and a member of Senate of Kathmandu University, and executive member of Nepal Medical Council.
Please tell us about your work and responsibilities as Medical Education Director at Nepal Medical College.
The Medical Education Department (MED) is primarily concerned with faculty development programs through different kinds of workshops. For all those faculty members joining Nepal Medical College for the first time, teacher training workshops are organized to sensitize them on the curricular design, writing-learning outcomes, identifying different teaching methods, designing assessment of students, and performing microteaching session for gaining self confidence in teaching. Through this, one gets to know some amount of pedagogy and educational technology, which helps to build some degree of confidence in helping students learn out of one’s teaching sessions.
At times, MED holds other workshops pertaining to looking into teaching strategy of problem-based learning, or focuses on certain aspects of teaching /learning activities or assessment of students. Since the last two years, MED has been holding fortnightly continuing professional development (CPD) programs for the faculty members, postgraduate resident doctors, and interns on different themes with the involvement of faculty members of all departments.
MED is also involved in orientation programs of first year students of all undergraduate programs, and is also involved in sensitizing first year MBBS students to the health profession, medical ethics, societal expectations of medical profession, and some aspects of introduction to clinical medicine.
You were also coordinator of the college’s Institutional Review Committee (NMC – IRC). Can you tell us something about what it is responsible for?
Nepal Health Research Council, which is the apex body for looking after health research in Nepal, under the Ministry of Health and Population, has given directives to all medical colleges / health institutions to form an Institutional Review Committee, which in case of Nepal Medical College is named as NMC-IRC. This committee is formed by the principal of the college and constitutes faculty members, along with a legal advocate from outside. This committee gets research proposals from faculty members who want to undertake research at NMC/ NMCTH, following which, its members go through the research proposals and scrutinize the proposal and invite the investigator to make presentation before the NMC-IRC.
NMC-IRC members ask questions related to that particular proposal, and the presenter is required to give answers, or in case something is missing, to add, or in case something needs to be corrected, make the required corrections. Depending on the nature of corrections, the investigator is either asked to rewrite the proposal and make representation, or make certain charges before getting approval of NMC-IRC for undertaking the research at Nepal Medical College/ Nepal Medical College Teaching Hospital. The college has been allocating annual fund for undertaking research by its faculty members. NMC-IRC assesses research proposals of faculty members and approves annual budget allocations to those who apply for research fund.
For all the first year postgraduate residents, NMC-IRC conducts a workshop on writing thesis protocols, which is an integral part of the PG program. After this, it holds another workshop to help the PG residents write their thesis proposals to be sent to the university for approval. After getting approval from the university, it holds a third workshop to help the residents collect data findings for their proposal, and finally, during the third year, it again holds a workshop to see how the residents have collected data, analyzed them, and done their writing, before submitting their thesis to the university.
The NMC-IRC also holds national conferences on research, conducted by NMC faculty at the institutional level, and the first of its kind was held last year. The annual meeting of NHRC is attended by NMC-IRC, and the member secretary (research director) presents its annual report and briefs on its activities.
Your early career was at IOM, Maharajgunj, and you are among the first doctors to be involved with medical education in Nepal. Can you tell us something about the beginnings of medical education as you experienced it?
When I joined A. H.W. School at Maharajgunj in November 1972, the IOM had just been established as one of the 10 institutes belonging to different faculties under Tribhuvan University, which was in keeping with the new education system of Nepal promulgated in 1972, (2029 BS). As a result, the AHW program, running at Maharajgunj, the nursing program, running at Mahaboudha next to Bir Hospital, and Ayurved program, running at Naradevi under the Ministry of Health were taken over by the Ministry of Education to becoming academic programs of Tribhuvan University.
Later on, as the demand for mid-level manpower to provide health services in health posts in Nepal grew, the following programs were started—Certificate in Medicine, General Medicine (for the role of health post in-charge); Health Laboratory Technology (perform different laboratory tests at hospitals); Pharmacy (for hospital pharmacies), and Radiography (to take x-rays in radiology department of hospitals). These categories of human resource in health served the country by taking role at different settings and get the credit for providing healthcare service over the mountains, hills, and plains of Nepal.
As the long-term national health plan projected requirement of a large number of medical officers to serve at district, zonal, and regional hospitals, IOM took a bold decision to start MBBS program by taking the Valley group of hospitals—Bir Hospital, Prashutigriha, Kanti Hospital, and Tripureshowar Eye Hospital—for the clinical exposure of the MBBS students, while most of the theoretical classes took place at the Maharajgunj campus and Bir Hospital. With very kind donation of people of a very friendly country, Japan, the Tribhuvan University Teaching Hospital was constructed through JICA, on the request made by the late Dr. Moin Shah, the founding dean of IOM, to the late King Birendra Bikram Shah during his visit to the Maharajgunj campus and the Institute of Medicine in the mid-70s. During his state visit to Japan later, he put forward his desire to the Emperor of Japan to have Tribhuvan University Teaching Hospital built at Maharajgunj on land that belonged to Nepal Army. Subsequently, T.U.T.H. was built by JICA and handed over to Tribhuvan University Institute of Medicine in 1983. And, it stands tall today as a symbol of love of the Japanese people for the people of Nepal.
The MBBS curriculum was developed on the basis of the health needs of the country, based on the research study carried out in four districts of Nepal by a team headed by Prof. Dr. Mathura Prasad Shrestha of Community Medicine Dept, IOM. The integrated organ system of preclinical subjects, together with early clinical exposure, community-based learning, and problem-based learning found their places in the MBBS curriculum. The students who were eligible to the program were those who had passed the certificate in medicine, health lab, radiology, pharmacy, nursing, and Ayurved programs of IOM. Later on, 50% of the students were admitted from I.Sc., which after certain number of years gave way to 100% entry from I.Sc. / 10+2 / equivalent program in keeping with the government policy then.
Diploma programs were started in different subjects to meet the need for specialists in Nepal. Later on, the MDGP program was started with the help of University of Calgary, Canada. In an attempt to start MD/ MS programs, the Postgraduate Medical Education Committee (PGMEC) was constituted by Tribhuvan University, in which the dean of IOM was chairman, and the member secretary was from Bir Hospital, with senior/other faculty members identified at the Valley group of hospitals and the faculty members of IOM being members. Initially, MD/ MS programs were governed by PGMEC and certification by T.U.
IOM is one of the premier institutes of medicine; are you happy with the way it is running today? If not, why? And, what are your suggestions for its better functioning?
Let me clarify that the Institute of Medicine is the premier institute, which started from a very humble beginning in 1972. With limited physical infrastructure of its own and taking support of Kathmandu Valley group of hospitals, it launched academic programs in creating human resources in health within the country. Over the years, with the foresightedness of the deans, campus chiefs of Maharajgunj Medicine Campus, hospital directors of TUTH, and program coordinators, head of departments, and all the faculty and administration and teaching staff, it has attained the height of running the DM/ MCH/ Ph.D programs, in addition to MD/ MS/ M.Sc. Nursing/ MS/ MPH programs and other professional academic programs through its constituent campuses and affiliated colleges.
I am very happy to see the academic programs of T.U. Institute of Medicine educating different levels of human resources in health, both for the country as well as for other SAARC nations. However, I am not at all happy to see the Institute of Medicine still being under Tribhuvan University and not given the status of institute/ university, with full autonomy of administration, finance, academics, and examinations, which is the need of the time for further growth and development of health professions education and delivery of quality healthcare services and undertaking of quality research activities.
The recent kidney transplant on Rt ’Hon’ble Prime Minister at IOM /TUTH speaks very clearly and loudly about the quality and state-of-the-art healthcare it delivers, for which all my colleagues at IOM /TUTH deserve heartfelt congratulation for making Nepal very proud.
What have been your notable achievements as the president of AHPEN?
The Association of Health Professions Educationists of Nepal (AHPEN) was established in 2016 and the first national conference was held at Nepalese Army Institute of Health Science on 2-3 December, 2017, and the first souvenir, “Health Professions Education: Changes and Opportunities”, was published on the occasion. It was participated in by national health profession educationists as well as those from Bangladesh, Srilanka, Bhutan, and Thailand. It has developed link with South Asia Regional Association of Medical Educationists and will participate in its conference to be held in Dhaka, Bangladesh, on 16-17 October, this year.
As all its members, including executive committee members, are attached with health profession institutions in the capacity of faculty members, it may not be required to stress further the roles they all play in their own fields of specialty. Continuing professional development (CPD) programs are being held at different institutions. Efforts for driving membership from all the medical colleges/ campuses is ongoing. With time, I am confident that it will diversify its activities and contribute to the cause of health profession education not only in Nepal, but also in the South Asian region.
As a medical educationist with a critical role in policy making, are you satisfied with the programs of the medical education sector in the country?
Let me be very honest and sincere that the dual system of Ministry of Education, Science & Technology, together with Tribhuvan University and Kathmandu University, with the Institute of Medicine of T.U. and School of Medical Sciences, together with their affiliated medical/ dental/ nursing/ Ayurved/ pharmacy colleges being on the one side, and the Ministry of Health and Population, together with B P Koirala Institute of Health Science, National Academy of Health Science, Patan Academy of Health Science, Karnali Institute of Health Science, Rapti Institute of Health Science, Western Institute of Health Sciences, and some more in future being on the other, two ministers of respective ministries holding the post of pro-chancellors of universities/institutes are involved for the same purpose of generating human resources in health. This is sheer wastage of energy and resources of two ministries, and I suggest they sit together and decide to hand over from two ministries to a single ministry. At the moment, for meeting the single objective of producing human resources in health, there are two ministries for meeting the same target. This is wrong. Best would be to hand over all high technical education in health to the Ministry of Health and Population, which must be responsible for planning the required numbers of human resources in health, what category and level of human resources are to be trained and deployed at which category of health institutions, which institutions should be prioritized for what level of human resources, and so on and so forth should be discussed thoroughly by the Ministry of Health and Population at the national level, and decisions taken care of.
From my point of view, everything related to health, may that be educational aspect, or health care delivery aspect, or research related to health, must solely lie under the jurisdiction of the Ministry of Health and Population for all practical purposes.
Whole of Nepal needs to be looked from the sane binoculars for identifying the health related matters, and planning, training, and deploying of human resources in health must be done by of the Ministry of Health and Population. Only then, good health care system can flourish throughout Nepal.
Do you agree that medical education is only meant for the rich and out of the reach of many deserving, but poor, students? If so, what is your suggestion to rectify the situation?
Without being drifted by the wind of mass media, which picks up public sentiments on issuers of these kinds, while making one’s fair judgment on the question of who should pursue medical education (in a larger context, health professions education) it is neither the rich nor the poor, but someone who is meritorious and deserving, who is motivated to learn, wants to dedicate whole life in service to humanity, in all sincerity, honesty, and whole-heartedly, such a candidate deserves the right to entry.
As regards what can be done to enable the marginalized group, different ethnic groups, under-privileged section of society, or those handicapped, who meet the eligibility criteria to pursue health professions education, but are unable to pay for the studies, in such cases, as the system is already in existence, they need to be admitted through the free scholarships quota system that the government is already implementing.
However, in order to provide opportunity for getting admission into the academic programs by these candidates, such candidates must be identified and nominated by each of 753 municipalities that Nepal is constituted of, and after having completing the course of study, must return to own municipality to serve own local society for a certain number of years of service as per a bond signed with the town municipality that nominated him/her for the study. In case the government quota may not suffice the number required for all the 753 municipalities of Nepal, to nominate a candidate by each municipality each year, provision must be made by the federal government through the provincial governments to allocate budget for providing scholarships to each and every municipality for a candidate for getting admission into health professions education programs, if free scholarship or quota is unavailable. Whether through free scholarship, or through allocation of budget by the government for getting a seat reserved on payment, if we can implement this system of developing own human resources in health by each and every municipality, the day will not be very far to see good healthcare system prevail fully throughout Nepal. If this system is adopted, then, over one to two decades, all the 753 municipalities will develop a good system of dispending healthcare to all the citizens residing over the mountains, hills, and plains of Nepal.
You are now a member of the Medical Education Commission. How do your visualize your role in the capacity and what do you anticipate to achieve?
The president of the Association of Health Professions Education of Nepal (AHPEN) had been included a member of Medical Education Commission (MEC) when it was first constituted under the previous government in 2074. As the president of AHPEN, I had received appointment letter then, but no meeting of MEC was convened then.
However, reappointment letter of the president of AHPEN as a member of MEC is yet to be received, though the first meeting of the newly-formed MEC has already been convened in February. No further comment can be made, under the present context, except that I very much appreciate for the interview and thank MEDICOS Next for giving me an opportunity.