Global trends in attendance in medical colleges and possible solutions

Attendance by proxy is just as important as oxygen for all students who study medicine. Even I am guilty of asking classmates to impersonate me and on more than one occasion have had two friends answer my roll call at the same time, much to the amusement of the professor and the class. When the lights go down in the lecture hall and the PowerPoint slides go up, the full-blown air-conditioned environment and the monotony of the lecture are perfect triggers for afternoon naps. The physiological phenomenon of postprandial somnolence is my defence to most people, who understand the phrase. In my state of drowsiness, I would conduct an impromptu survey of the people around me and most of the class would be in the same state as yours truly.

Section 5.8 of UGC regulations of 2003, which governs all colleges in India, states that a student is eligible to appear for an examination only if she has an attendance of more than 75%.^[1] Judges in the various cases in high courts have repeatedly stressed on the importance of attending classes, even going on to say that ‘No student can excel in her life unless she attends the classes of the courses which she undertakes’. In a landmark case in Delhi, where students of Jamia Millia Islamia pleaded that their attendance be waived on the basis of the medical certificates they produced, the high court said that it does sympathize with the students who will have to waste a year of their education but ‘indulging to such requests would lead to complete chaos and open up a pandora’s box’.^[2] In one case even relief was denied to an LLB student because of pregnancy.^[3]

Intuitively speaking it seems pretty straight forward; lectures have historically been the sole method of imparting knowledge to the masses. One can argue that if someone attends classes she is bound to score well in her examinations, there have been studies^[4] corroborating this finding that medical students who attend more classes had higher scores.

Although the importance of attending classes has been well established, yet there seems to be a rising trend of a marked decrease in attendance in medical schools in the USA and all over the world.^[5] Even prestigious institutes such as Harvard and Johns Hopkins have seen a drop in their classroom attendance to 30%–40%. Thus, raising the question of how important is the role of the teacher in attracting students to their classes because in these institutes even Nobel laureates have had to teach to empty seats. Availability of online video lectures from various sources (recorded by the institute, Kaplan, Pathoma, etc.) is an important factor contributing to this absenteeism.^[6] Students including me prefer to study the topics that we are weak at, during our leisure time and at the pace that is convenient to us (watching Dr Najeeb’s lecture videos sometimes at twice the normal speed has been a part of lot of students’ lives). Attitudes of medical students and professors regarding attendance can also be often contradictory. A survey in a medical school in St Louis, Missouri concluded that students believed that classrooms are a source of factual information, however the professors thought that classrooms were important in the professional socialization process; students thought that they should be allowed to regularly skip classes for research and social work and considered online lectures to be a valid substitute for classroom (which was a big no-no for professors). However, in the end both of them agreed that a shorter attendance did have a negative impact on students grades.^[7] Such a philosophical discordance between the students and professors also affects the attendance at that school.

In the USA, increased importance on United States Medical Licensure Examination (USMLE) Step 1 for residency placement has developed a sense of resentment among students for teachers, who do not teach material exactly tested on the Step 1 examination, which subsequently leads to fewer students attending classes.^[5] Such a system seems too familiar to the Indian system where the National Eligibility cum Entrance Test Postgraduate (NEET PG) is a do-or-die examination and everything that is not strictly covered in the syllabus is considered a distraction. Ethics and humanities—distraction; clinical and basic science research—distraction; innovation and public policy—distraction. The first line that a professor told us when he addressed our class was that college is different from our schools, in the way that we will not be spoon-fed in college anymore, we must learn ourselves whatever we want to learn and however we want to learn. It felt liberating to hear that finally after 2 years, our approach to studies would not strictly be examination-oriented. But as I finished my 2nd professional examinations, I came to know that more than half of my batch was joining one or the other PG-coaching institute. I followed suit and soon realized that this was an institute ready to spoonfeed me and I was extremely elated to spend a lot of money being passively fed. In a scenario where individual brilliance in select examinations is rewarded heavily, such a Nash equilibrium is bound to happen.

The world is facing a falling trend in attendance in medical schools. However, few schools have adopted innovative classroom management methods to address this problem. One such innovative idea is that of a ‘flipped classroom’ where students do the classwork at home and homework in class. The students are given reading material online and are supposed to discuss and solve questions in the class. The medical college in Michigan State University tried this approach and found that students were not only attending classes more often but were also retaining the study material better.^[8] Some experts have tried implementing strategies such as preparing learning contracts for students before the beginning of the semester, giving surprise quizzes, providing handouts in class but not online and collect contact information of students beforehand and periodically message and email them about their attendance,^[9] but enough evidence does not exist to objectively quantify their efficacy. Many institutes are slowly adopting a small group discussion approach compared to a didactic lecture because evidence suggests that the former improves the learning experience and final performance.^[10],[11] Policies of various institutes on attendance also differ in many colleges, but all have a core philosophy that ‘a student cannot be deemed to have taken a course unless he/she has had a certain minimum amount of classroom exposure’. Some institutes bar students from sitting for examinations if they fall short of attendance, whereas others reduce their final grades (e.g. if a student got A and has a short attendance, the grade might be changed to B or A^-). Some institutes assign marks or credits for attendance and some deduct marks from the final score. An extreme example of attendance policy in an Indian medical school is of Maleka Manipal Medical School, which increased compulsory attendance from 75% to 90% and found that this intervention led to an increase in the number of students passing and securing distinction.^[12]

Decreased attendance in medical colleges is a worldwide phenomenon. How different systems approach to solve this problem tells us about the institutions and what they want from their soon-to-be doctors. Some systems have tried to look at the problem from a bird’s-eye perspective and have employed innovative interventions. All these methods have a core philosophy, i.e. they are trying to recognize the problem and try to solve it in the best way possible. Presently, the Indian system of compulsory attendance in medical schools seems a little suffocating. Unlike other engineering or law colleges, medical schools give less than a month’s leave to their students as opposed to 2–3 months in the former, which harms their chances of pursuing research or community work outside the college. Besides, they are forced to attend an increasing number of lectures all-round the year. The compulsory attendance policy does have an important core concept but is a lazy policy decision as it does little to generate students’ interest in classes, it fails to improve the quality of classes and hampers the students’ overall educational experience.

I strongly believe that classrooms are an important means to disseminate knowledge and information. A place for teachers to get to know their students, their interests and passions, and for the students to understand their role in healthcare in particular and the universe in general. However, I have always attended the bare minimum number of classes needed to be eligible for the examination. I sincerely hope that students and professors develop similar attitudes and expectations when it comes to a classroom lecture and experiment and implement novel and innovative techniques to keep themselves and their students interested and wanting for more. The famous psychiatrist Carl Gustav Young has said: ‘One looks back with appreciation to the brilliant teachers, but with gratitude to those who touch our human feelings. Because curriculum is so much necessary raw material, but warmth is the vital element for the growing plant and the student’s soul.'

Conflicts of interest. None declared