INTRODUCTION

India is a multilingual country with no national language; however, Hindi and English are the official languages. The languages are predominantly of Indo-Aryan lineage, followed by Dravidian, Tibeto-Burman, and Austro-Asiatic origin.1 Medical education in India is dominated by modern medicine, followed by several traditional medicine streams called AYUSH, which stands for a combination of Ayurveda, Yoga, Naturopathy, Unani, Siddha, and Sowa Rigpa, as well as Homoeopathy.2 Although some courses in alternative medicine systems are taught in Sanskrit and other regional languages,3 the language of teaching and learning in modern medicine is exclusively English.

A student has the liberty to choose the instructional medium up to the higher secondary level, as there is a cafeteria choice of regional languages, including Hindi and English. However, when they join modern medicine, they have no option but to study in English. Students who continue their education in a regional language or Hindi may face a dual burden of learning medical science and the language.4 Several countries such as China, Japan, Mexico, and Russia offer medical science in their local languages. However, to date, in India, there is no alternative language for learning modern medicine.

In 2019, the Indian Medical Council was replaced by the National Medical Commission (NMC) which is the regulator of medical education in India.5 About 2 years ago the education minister of the state of Madhya Pradesh declared the formation of a committee to plan the introduction of medical and paramedical courses in Hindi. Another Indian state, Uttar Pradesh, was also evaluating a proposal to start medical courses in Hindi. However, NMC previously clarified that it would not recognize the MBBS (undergraduate medical course) in Hindi.6 Some experts opine that introducing medical education in Indian regional languages would reduce the burden on students who are suddenly exposed to a vast medical curriculum after studying science in a vernacular language in high school.4 Some others do not support the view and think it would be an experiment with an uncertain outcome that may create a dent in the medical education system.6 However, the introduction of at least one medical institution in each state that offers medical education in the regional language of that particular state is being planned.7 At an NMC meeting, it was suggested that subjects taught in MBBS can be bilingual or trilingual.8 We presume that trilingual may comprise English, Hindi, and the regional language of the state (e.g. Bengali in West Bengal).9

In this context, we did a qualitative survey to observe the perceptions of Indian first-year medical students regarding teaching and learning in the vernacular language. The result would help gain a glimpse of students’ opinions and may be considered by policymakers for further planning of medical education in the vernacular language. The finding may also aid in the formulation of a questionnaire for quantitative data collection in a nationwide survey.

METHODS Ethics

This study involved collecting qualitative data through telephone interviews with medical students. The conversation began with an overview of the study’s aim and description, with an emphasis on the publication of anonymous data. The respondents, who verbally confirmed their voluntary participation, were interviewed. As the interview was conducted over the telephone, it was not possible to obtain written consent. For any participant under 18 years of age, consent was obtained from their parents, and assent was obtained from the participant. The participants were also informed that their recorded voice calls would be permanently deleted after transcription of the audio into text, without any identification marks. Following the World Medical Association’s Declaration of Helsinki, updated in 2013, this study was done after approval by the institutional ethics committee.

Type and setting

This cross-sectional, observational study involved a qualitative, in-depth interview over the telephone using a convenience sample from all over India from July to December 2021.

Interview guide

Two interview guides were prepared individually by the first and second authors and a consensus draft was prepared. This draft was reviewed by four additional experts, including one medical education expert, one public health expert with previous experience in qualitative surveys, one English language expert unrelated to medical education, and one clinical psychologist. They reviewed the informed consent, openness of the questions, appropriateness of probes, potential cultural barriers, gender issues, linguistic difficulties, and feasibility of using the guide for undergraduate medical students. After inputs, the guide was amended and the final version prepared (Table 1).

TABLE 1. In-depth telephonic interview guide for this study

Domain Open question Probe Books What is your opinion about the fact that all your books are written in English and you have to read in only English? Any identifiable advantages or disadvantages; if it is taking more time to read; if you face any difficulty in understanding in English; if you need to translate the sentences and understand in vernacular language; any difficulty in making notes from books; if the book were written in vernacular language, any perceived advantage or disadvantage about – time to read and understand, remembering, summarizing or making notes Classes The lectures and tutorials are conducted in English. What is your opinion on learning from these classes? Any advantage or disadvantage in understanding terms in English; understanding English sentences; needing to translate in vernacular language to understand; any issues in taking notes; level of interest; if the classes are conducted in vernacular language, any perceived advantage or disadvantage about - understanding, remembering, summarizing, taking notes or interest Questions We would like to know your level of comfort when you are asked questions in English during class. Any necessity to translate into vernacular language first; time to understand the question; any hesitation to ask for the question to be repeated; level of comfort if questions were in vernacular language Expression What is your opinion about the language you would feel comfortable answering a question in a class? Any difficulty in speaking the language, remembering terms, formation of sentences, hesitation in answering in the wrong sentence, and answering in vernacular language Written
examination We would like to know about your understanding of printed English questions and writing answers in English. Any ease or difficulty in understanding; required time to understand; any issue in constructing sentences in English; required speed in writing examination; opinion about vernacular language – understanding and writing Viva What is your opinion about your viva or oral examination in English Understanding the question; hesitation to ask for the question to be repeated; needs to translate to understand; if questions asked in vernacular; allowed to answer in vernacular Open Could you please share something more regarding studying in vernacular language? No probe was designed for open comment Sampling technique

We used a convenience sample for this study. A contact list of 108 medical students across India was compiled after gathering input from personal contacts. India was divided into six zones (Fig. 1). We required a minimum of 12 subjects to achieve thematic saturation for this study.10 However, with the aim of achieving equal participation from each zone and a saleable sample size, we aimed to recruit at least 12 participants from each zone. Due to a high dropout rate or probable non-reachability, we increased the number of respondents by 50% to achieve a total of 18 participants from each zone.

FIG 1. Number and percentage of survey participants according to different zones in India (p=0.55)

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Interview technique

A phone call was made to the selected participants, and they were introduced to the surveyor, who described the aim, method of data collection, and their privacy. All the phone calls were recorded after getting verbal consent from the participants. The survey was conducted in English. However, participants were also offered Hindi, Bangla and Odia as alternative languages. We were unable to offer other regional languages due to a lack of language expertise. The in-depth interview was conducted using open-ended questions, following the guidelines presented in Table 1. Recorded phone calls were saved for transcription and further analysis.

Data handling and analysis

Audio calls were transcribed into text by the second author ensuring anonymity. However, the age, sex, region, college category (government/private) and prior language of study were included. We used a 6-step thematic analysis method, as suggested by Braun and Clarke in 2006, to identify themes from the transcripts. Two authors analyzed the data individually and reached a consensus for the final result (Fig. 2).11 In addition, texts were analyzed in QDA Miner Lite v.2.0.8 (Provalis Research: Montreal, Canada).

FIG 2. Methods of thematic analysis used in this study (the grey arrow indicates that a researchers may go back to a previous step for a revision)

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For citing the quoted text, we used the following format: age in number+sex (M male, F female)+Region (C central, E eastern, N northern, Ne north eastern, S southern, W western)+college (G government-run, P private)+Language medium in high school (E English, V vernacular). For example, a code ‘19MSGV’ indicates a 19-year-old male from the southern zone who is studying in a government medical college and whose medium of instruction in high school was the vernacular language.

RESULTS

Eighty first-year medical students of modern medicine participated in this survey. There were 53 (66.3%) males; 61 (76.3%) were from government medical colleges and 19 (23.8%) from private medical colleges; 47 (58.8%) had a vernacular language medium and 33 (41.3%) had an English language medium in high school. The majority of students were in the 17–18 years age group (Table 2). A summary of themes, codes, and their frequencies within each theme is presented in Table 3. Quoted statements and qualitative analysis output are also presented.

TABLE 2. Research participants’ characteristics

Variable Category n(%) p value Age (completed years) 17–18 41 (51.25) <0.0001* 19–20 33 (41.25) 21–22 6 (7.5) Sex Male 53 (66.25) 0.005† Female 27 (33.75) College Government 61 (76.25) <0.0001† Private 19 (23.75) Medium of study in high school Vernacular 47 (58.75) 0.15 English 33 (41.25)

TABLE 3. Theme and major finding under the theme with their occurrences

Organizing theme Basic theme Codes Frequency (% of codes) Educational material Books Understanding 77 (28.73) Remembering 64 (23.88) Time 55 (20.52) Quality books 43 (16.04) Notes 29 (10.82) Media access Online learning text 27 (40.91) Videos 24 (36.36) Ebook access, electronic journals 15 (22.73) Classroom learning Understanding Ease following 66 (24) Residuals 63 (22.91) Interest 63 (22.91) Discordant books 57 (20.73) Migration 26 (9.45) Questioning Understanding 58 (59.79) Confidence 39 (40.21) Answering Easy sentence formation 61 (42.36) Ease of expression 52 (36.11) No hesitation 31 (21.53) Examination Written Confidence in expression 56 (42.11) Terms in vernacular 44 (33.08) Less time required 33 (24.81) Viva Easy understanding 54 (43.2) Confidence in answering 43 (34.4) Hesitation in answering 28 (22.4) Career progression Foreign degree acquisition 27 (31.4) Working abroad 21 (24.42) Inter-state migration 20 (23.26) Taking all India coaching 18 (20.93) Informed choice Freedom of medium Concordance with plus two medium 47 (52.81) Optional nature 42 (47.19) Books in vernacular language

Books written in the vernacular language would help in a better understanding of the topic. In addition, it would be easier to remember the topic of concern if it were read in the vernacular. However, a hybrid model may also be a good option where books are available in English and the same book is available in other languages. It would facilitate students’ ability to read in English and understand it in their vernacular language. However, many students opined that they were in an English medium and that studying in other medium would be an extra burden. In contrast, many students opined that a sudden change of medium would be an extra burden. However, as there is no availability of quality books in the vernacular language, it would be premature to shift the medium.

‘It would definitely be easy for us to understand the complex topic if read in the mother tongue and I remember better if I read a book in my language’ – 20MEGV

‘I could read, understand and learn better if it was my mother tongue. But where are the books in other languages? It will take time to shift from English to other mediums. But, so many languages…’ – 19FCGV

‘If we can get the same book in English and ditto in my mother tongue, it will help to keep both books side by side and I can understand better…I face difficulty in taking notes in English’ – 17MEPV

‘It will not be better for me. I was in the English medium from my childhood. I will face difficulty reading books in another language’ – 19FNPE

Classes in vernacular language

Classes in medical colleges, including 1-hour lectures, demonstrations, and tutorials, may be conducted in regional language to facilitate understanding of complex topics. It would increase the students’ interest when taught in a language of their comfort. However, the language should be understood by the entire class. English is the language that every student can understand to some extent. It would not be easy if a class is taught in a language of the state and students from other mediums are present. It would limit the inter-state migration of students.

‘If teachers teach in my mother tongue, it will help in understanding a complex topic easily’ – 18FNeGV

‘I am from [regional language] medium. If classes are taken in [regional language], it will increase my attention and interest and also I can write the notes easily’ – 20MWGV

‘I will understand easily… But it can cause problem to students who do not know [regional language]’ – 19FEGV

‘I read in [regional language of native state], but now am in a different state, I will not understand anything if taught in [regional language of current state]’ – 18MWGV

Classroom communication: Questioning

Lectures are often accompanied by question-and-answer sessions. Practical classes, demonstrations, and small-group teaching requires even more effective communication. Students perceive that they understand the questions asked in vernacular better. When questions are asked in English, the difficulty in understanding sometimes inhibits them from answering. If it is asked in an unknown regional language it is not understood and the students remain non-responsive. Asking questions in English also creates a sense of hesitation among students who are from vernacular language mediums. However, asking questions in the medium of higher secondary poses no such hesitations. For example, a student from an English medium has no problem asking a question in English.

‘If the questions are asked in my mother tongue, I can understand it easily’ – 19MCPV

‘I frequently need to stress to understand what teachers are asking. Many a time, I can’t understand the question’ – 20FWGV

‘I feel shy to ask a question in English as I am weak in English’ – 20MEGV

‘I have no issue in English, and I am comfortable in both Hindi and English, either in understanding or asking questions’ – 18FCPE

Classroom communication: Answering

In classroom communication with teachers, if students have the option to answer in their vernacular language, they may gain confidence to state their answers clearly. When any question is answered in English, students from the vernacular medium need to form the sentences and then convey the answer. Hence, many a time, although they know the answer, it becomes difficult to convey it in English. Students who have freedom in the choice of language help in removing hesitation in communication with the teacher.

‘It’s really tough for me to answer in English as I can write it but can’t speak fluently’ – 19MNeGV

‘It’s taking more time to answer in English; I think I could answer better in [vernacular language]’ - 20MNGV

‘Yes, I can understand the English question, but sometimes I am lost in forming the sentence and feel that if I could answer in [vernacular language]’ – 18FEGV

‘Initially, I faced difficulty in answering in English, but I am improving’ – 19MEPV

Written examination in vernacular language

Evaluation of students, either formative or summative, by written examination, is now conducted exclusively in English. Some students perceive that they could write the examination with confidence if it were in the vernacular. Some students opined that they need to continually think about the answers in vernacular and then translate them into English. However, this is exclusively for those whose medium of instruction was a vernacular language at the higher secondary level. As they need to be subconsciously alert to the translation, it takes more time to answer. However, students also noted that it may be challenging to learn some of the terminology in the vernacular language. Hence, the freedom to express oneself in a hybrid language may be beneficial when students have the choice to write in their vernacular language and use some English terminology.

‘Written examination in my language would surely be easier for me to express my answers’ – 19MNGV

‘My answers in English take more time, I think in [vernacular language], then, I write in English’ – 20MNPV

‘It would be a good choice if we write in vernacular language, I am from [vernacular language] medium, and I am in [state with another vernacular language]. So, I need the freedom to write in my language’ – 19FWGV

‘If we can write in vernacular and complex terminologies in English, it would be better. As we have done in our higher secondary biology’ – 18FEGV

Viva voce

Formative and summative assessments are commonly conducted through written, practical, and viva voce methods. Students expressed that it would be easier if the examiner could understand their spoken language. Although they may try to answer in English, at times, if they are given the freedom to shift to their mother tongue, it would be beneficial. They can express complex matters easily in their mother tongue. They would feel comfortable if the examiner asked them questions in their vernacular language or at least permitted them to answer in their vernacular language. In the current system, students hesitate to ask if they can answer in vernacular. However, if it is known that they can choose any language or a combination, it would help convey the answer more effectively to the examiner. In contrast, some students opined that it would be difficult to implement, as there are no books in vernacular languages and a lack of experienced teachers in these languages.

‘Sometimes, I become stuck in a maze! I cannot proceed further in English…it would be good if I get a chance to shift from English to my mother tongue’ – 17MNeGV

‘English and [vernacular] may be made optional, and I can choose any one of them’ – 20FCPE

‘Once, I was in viva and I forgot the English term of the ureter and I could remember the [vernacular term] and I was shy to state that…if I could express the term in [vernacular term], I could complete the answer…thought block happens more with English for me’ – 18MEGV

‘I find no difficulty… and I think combining regional language and English would make a hotchpotch…where are the books, teachers, and culture to adapt it…they [teachers] read everything in English’ – 19FSPE

Career progression

The vernacular medium in undergraduate should be further extended to postgraduate studies. If a student studies in one of the Indian regional languages, that medium should also be available in the postgraduate programme. Students commented that this may cause chaos in medical education. Many students are also concerned about the National Exit Test, an examination that Indian medical graduates must pass to obtain their MBBS degree (not yet started). Furthermore, the acquisition of foreign degrees and migration to other countries would be limited. The doctors would face challenges in working in an environment where other languages are used by their colleagues. Interstate migrations of doctors in India may also pose a problem. Furthermore, students opined that uniform language should only be practical for coaching for the graduation entrance examinations.

‘If I get a chance to study MBBS in [vernacular language], the PG should also be in [vernacular language]. Else, I will face the same language transformation problem I am currently facing to adopt English’ – 21MCGV

‘It will be a big trouble for those who want to travel across states of India or want to go foreign countries…What about NEXT, will it be available in a regional language like NEET-UG? If yes, then it’s okay’ – 19FSPE

‘MBBS in vernacular language will stop our path to get a foreign degree’ – 20FEGE

‘Many students start preparing a little bit for NEET PG from even 1st year; it will be a problem if I study MBBS in another language and attend all India coaching in English’ – 19MWGV

Informed choice

The choice of a medium other than English may be made optional. The choice is also available in various states in higher secondary education. This could be continued in medical education. The students can continue their education on the same medium in undergraduate medical courses. Currently, books are written in English, and teachers are trained to teach in English. Hence, students may be reluctant to take a course in a vernacular medium.

‘It would be great if I get the option to study in the same medium I studied higher secondary, no more medium change’ – 18FNGV

‘I would be trying USMLE (United States Medical Licensure Examination) in the future; it will be difficult for me if there is no option to study in English’ – 20FCPE

‘If the vernacular medium starts, we should get an option to choose between the English or vernacular language. Compulsory vernacular medium would not be a good’ – 20FEGE

‘Everything is now in English, how can it be implemented, I wonder…so, I do not want to switch to vernacular medium’ ––18MNeGE

Media and journal access

Supplementary study materials, including written notes, graphical explanations, visual mnemonics, eBook access with the textbook, and instructional videos, are available in English. If students start learning an exclusively vernacular language, its usage would be limited. Hence, along with textbooks, other media must also be prepared in regional languages for full implementation. Additionally, medical journals often take decades to become available online in vernacular languages.

‘I watch YouTube videos and access a visual mnemonics book; it is in English like our textbook’ - 19MSPE

‘I think the vernacular language books should also have complimentary video instructions and ebook in that language’ – 18FSPV

‘Vernacular language would limit us using foreign videos, images, and other materials in English’ – 18MCGE

‘I heard about STS (Short term studentship) project by ICMR (Indian Council of Medical Research), I was reading some journal articles online, all in English, no medical journal is available online in vernacular language’ – 18FEGE

DISCUSSION

With the aim of observing the perception of Indian medical students towards learning modern medicine in vernacular language, we identified several issues that concern students regarding the introduction of the curriculum in vernacular languages. India is a country where students have the opportunity to choose their vernacular language in higher secondary education. However, in professional courses and higher education, the option of using a regional language as the medium is limited. Undergraduate medical education in India is currently exclusively available in English. The apex medical education regulator has suggested a plan for trilingual medical education.

We identified 9 principal themes from the analysis of qualitative data obtained from the in-depth interviews. Students perceive that the introduction of the vernacular medium in medical education, which is similar to their higher secondary education medium, would help them overcome the language barrier. They face a sudden shift from vernacular to English, and proficiency in the language of the medium is an important determinant of academic performance.12,13 Vernacular books are available in many parts of the world and can facilitate learning among students who have difficulty understanding a foreign language.14,15 Teaching and learning in the vernacular may also help ease communication between teachers and students. However, in India, students in a medical college may come from different parts of the country with varying language backgrounds. Hence, a uniform language is required to cater to all students simultaneously. Currently, English is the language of choice. The next common language that may be considered widely acceptable is Hindi. However, in many parts of India, the vernacular language medium is used, and Hindi is not taught; instead, English is the second language, with the vernacular being the first language. Hence, a compulsory shift from English to Hindi also may face difficulty in implementation.

During the written and oral examinations, answering questions in the vernacular language helps facilitate better communication and expression with minimal hesitation. However, studies in vernacular languages also make students less prepared for migration to other states or foreign countries for higher education or employment. In contrast, learning the local language would help students communicate with patients.16 In all medical colleges, a certain number of seats are reserved for candidates from other states. They would face difficulty if the classes were conducted in a regional language. Hence, it may be considered optional so that students have the choice to study in either English or their vernacular. This also creates a discordant academic environment where teachers with bilingual expertise will be in high demand. Hence, the preparation of resources, including textbooks and other media (e.g. eBooks, study materials, and videos), and the training of the workforce are major aspects to consider for the implementation of medical education in vernacular languages.

Arabian medical students believe that learning in English will not impact their performance. Additionally, approximately one-third of the sample would accept both Arabic and English as languages for learning medicine.17 However, in another study, it was found that nearly 45% of students need to translate English terms into Arabic for better understanding.18 Hence, a hybrid model is suggested to overcome the language barrier.19 In India, the medical entrance examination offers questions in 11 regional languages as well as English. A similar offer of regional languages along with English in the medical curriculum may help overcome the language barrier.20 This concept is also supported by the finding that students opined there must be an informed choice for the medium. However, this evolution would take time for implementation.

Limitations

Although this is the first study on this topic in India, it has several limitations and the study results should be interpreted with caution. This study was conducted with a convenience sample. Although this was the only possible method and we recruited students from different zones of India, the biases inherent in a non-probability sample may still be present. In addition, any social desirability bias was beyond our control.21 The in-depth interview was conducted over the telephone. A good rapport and confidence in the interview are better established with a face-to-face in-depth interview. Furthermore, we could not offer language options for the interview other than English, Hindi, Bengali, and Odia due to the interviewer’s lack of expertise in other regional languages. This is a major limitation of the study, as students might respond in more detail in their native language. We were unable to obtain written consent due to our limited logistics and considered verbal consent over the telephone as a surrogate. Although the distribution of the sample in the zones was not statistically significantly different, the aimed number of participants could not be recruited from the western and north-eastern zones.

Conclusion

The introduction of medical education in vernacular languages in India should be considered after analyzing the factors that determine its potential advantages and disadvantages. A multilingual country such as India needs a common language to maintain a uniform educational environment. Although regional language medium would facilitate learning among students, uniformity would be affected. This may limit interstate migration and further education or practice in other countries. Creating authentic textbooks and other educational resources in a regional language, as well as training a workforce in a new language, are key factors to consider. The students may be given an informed choice to study either in the current English medium or their vernacular language after implementation.