These past couple of days, the medical student community of Delhi (and by extension, India) has been seething with discontent over a piece of legislation that has been reverted after intense pressure from junior doctors at all levels. I have been very vocal on twitter and social media about the unfairness of this sudden imposition of a policy, to the level that I managed to alienate a dear friend who differed with me on this issue. So, I resolved I would write a couple of posts trying to highlight the pros and cons of this decision. In this post I shall present the popular view: that the imposition of the rural posting was an unethical one and needed to be reverted.
One has to face so many troughs and peaks in the roller coaster of a ride of a career in medicine, that sometimes, weariness creeps in; and sometimes, when that happens to me, Sir William Osler comes to my rescue. So, I would like to begin this post that stinks of weariness (and some shall label it saturated with selfishness as well) with these words that have sustained me through times lean and mean in a short career which has seen dizzying highs and depressing lows:
Before I begin to dissect the issue, a little background about how the Indian medical education system works for my non-Indian readers who may not be acquainted with the uniquely weird system that we are accustomed to.
India has a two-level medical education system. The first level commences right after high school after one qualifies a gruelling entrance examination. This consists of 4.5 years of didactic training in four different slots, teaching 14 major subjects. This is followed by 1 year of hands on “internship” where one is supposed to learn the ins and outs of the business of being a doctor. Following this 5.5 year ride, one gets the degree of MBBS, which is the primary medical degree in India. An MBBS doctor is the primary care giver in India, but owing primarily to the better employment opportunity afforded by specialisation, through obtaining of an MD/MS degree, the MBBS degree has slowly lost its sheen. It used to be a matter of great pride to be an MBBS doctor even till our parents’ generation; and within ONE generation, it has become redundant. In fact, it has been quite a while since I wrote about my views on the MBBS being a vestigial degree (and received a lot of mixed reactions for it!). The truth remains that this MD/MS degree, which is a 3-year course and can be done after one clears another entrance exam (the eligibility for which is the MBBS degree), has changed the landscape of medical education. Without going into the specifics, let me just say that one’s medical career is considered worthless if one does not obtain an MD/MS specialisation. Truth be told, the better employment opportunities, combined with the fact that Indian society is still a hubris-fuelled, intellectual feudal system, has elevated the status of MD/MS to an astronomical level. Students nowadays commit suicide if they do not get into a “good field” at the MD level. I know people who are worried about getting married because they think that their lack of an MD degree renders them poor “marriage material”. However, one fact that makes it even worse is that the whole postgraudation system is super-skewed. For about 45,000 MBBS graduates every year, there are 7,000 MD/MD/Diploma seats (give or take some) every year. Given the large “waiting list”, the ratio of applicants per seat sometimes exceeds 12-13. With such infinitesimal chances, and such a huge premium placed on the value of an MD degree, I guess you can imagine what must be going through the minds of a medical graduate who is fighting for an MD seat…
The point in making this long-winding introduction was to state the gargantuan importance of the post graduation degree in our lives.
In this scenario, the health ministry comes up, quite unilaterally, with the demand that the 5.5 year MBBS course be extended by a year, by adding one more year to the internship (making it a 2-year internship) and then add another optional year of rural service in order to make the MBBS graduate eligible for taking MD-entrance examinations. Here is a screenshot of the notice that makes these propositions:
Understandably, the medic students and interns, who were facing the butt of these new regulations were infuriated. Many viewed these unilaterally taken decisions to be driven not by altruism and a good will to develop the healthcare system, but as a populist agenda, with an eye on the vote-bank politics. The fact that the legislation was put into effect with the myopic, one-shot solution of sending doctors, without having anything to say about infrastructure development, provision of drugs, para-medical and nursing staff, did not help either. Also, given the disequilibrium in the number of PG seats when compared to MBBS seats, it would mean that a greater fraction of the graduates would be doing this rural posting without eventually getting to do an MD/MS. This sounds like an unfair deal to me, especially since the understanding was, when these students joined the MBBS course, that it would be a 5.5 year ordeal.
On a personal level, I find it morally repugnant that the MBBS student is being arm-wrenched and coerced to go to a rural posting with the gun of being ineligible for PG being held to their heads. The truth is that given an option most MBBS graduates would rather stay in the cities, and turn their back on the rural side. One may argue that it is a major reason why, despite increasing the MBBS seats, there remains (and shall also remain in the future), a dearth of physicians in the rural India.
However, sending a fresh pass-out to fend for himself or herself in the trenches of rural medicine seems a little cruel and misdirected. It seems, in the garb of providing healthcare, a veiled assertion that the rural Indian deserves this. The very logic that “this is better than no care” also stinks of populist agenda. So, we get to keep the MDs and specialists in the cities and send in the rookie, newly drafted physicians to the rural hinterlands to find their way via trial and error; without oversight, without supervision and without the infrastructure to deal with the issues being handed to them. While one may argue that there is no point sending a radiologist or plastic surgeon to the rural primary healthcare centre where there no facilities to utilise their skills, the question is, why not? While one may not expect an MRI or CT scanner, a USG or an X-Ray machine should be present to aid diagnostics. Otherwise the over reliance on quacks, private practitioners and abuse of the referral system within the traditional chain of primary>secondary>tertiary care system will continue unabated. This is where the demand for infrastructure development comes in. Each PHC, ideally, should serve the basic needs of the patient. When I was an intern, not too long ago, I was left aghast to see cases of malaria, diarrhoea and typhoid, to name a few, (which are all very common diseases in rural India), being referred through the entire primary>secondary>tertiary care framework. Eventually, a simple case of dehydration caused by diarrhoea would end in disaster because by the time the patient was brought in to the tertiary care centre, he was in shock, his kidneys had shut down and things were spiralling down faster than one could manage.
Sending an inexperience, unsupervised MBBS graduate to an ill-equipped rural PHC might look great on paper, but in reality, will solve nothing, as practically they shall be recruiting one pair of extra hands to send patients up the referral chain.
At the same time, I find myself disgusted to say that post-internship MBBS students are really poorly equipped to deal with patients on their own. I find students who have not undertaken normal vaginal deliveries or repaired episiotomies in their entire internship tenures. While some contend a two-year internship would be a good way to improve the lacking skills, I seriously doubt it. If one year in this particular system has not helped them to develop the skills, where is the logic in saying that double the time shall? One good way to ensure that their skills, theoretically and practically, could be tested was the common exit test (which came with its own retinue of issues). However, that seems like a distant nightmare now, and the medical education system, by taking these poorly designed, tentative steps is pushing development backwards instead of taking it forwards. Now all change in policy will be viewed with suspicion and anger.
So, MBBS graduates are too selfish to attend to the rural Indian? I am sure if given a proper set-up to work with, and properly incentivised, a large fragment would still go for this rural stint. One way I see this can work, at multiple levels, is if one is sent off for a year of rural posting immediately after qualifying for MD. In that case, another major issue, that of accommodating 45,000-50,000 (and growing) MBBS students into a fixed number of jobs (with a good pay as well) could be dealt with. These doctors, who have just crossed the threshold of the MD-entrance examination are still MBBS and are not yet specialists, so one cannot argue that their skills shall be wasted in a bare bones PHC. While there is some merit to the argument that the MD course is meant for specialisation and not for working as general practitioners, this could be taken as an eligibility criterion to sit for the MD exams. This could be somewhat like the thesis or dissertation that one has to submit in order to obtain eligibility for sitting the MD final examination. Indeed many students undertake an MD course with the view of becoming a clinician and not a researcher; so if they can be “forced” to do a thesis, why not “force” them to do a year in a rural PHC?
These rural PHCs could be tied in with a mother tertiary care centre. This would ensure that there is a better communication between the members of the referral chain and would actually bring more teeth to the curriculum of Community Medicine and Public Health that caters to this particular branch of healthcare management. Another irksome problem could be solved by enacting that one cannot quit the course during the rural stint year: that of PG seat wastage. These days, a growing trend is to take up one subject in MD/MS, work and study for a year, get a better rank in the entrance exam next year, quit and take up something else. If the rural stint was associated with the eligibility to write the MD final exam and one was not allowed to quit during this year, it would mean that quitters would have to do two years in rural service instead of one. This would dissuade casual candidates from taking up and blocking or wasting seats.
Of course, there is no saying that the skills of these MD first year students will be any better than post-internship students; probably they shall not be any better, but at least they shall not be coerced into going as the MBBS students are being now. And for those who do not end up doing an MD/MS specialisation, which is a significantly large number, one year would not be wasted in the wilderness doing rural service. They could explore alternate routes to further their careers.
Some have also claimed a different solution. A significant number of students come from rural backgrounds. Like the US Military (or even the Indian AFMC grads) scholarships, could we incentivise their training in exchange for ensuring that they serve a certain period following graduation in a rural setup? Could we, maybe, reverse the trend of caste-based reservations, for reservations based on economic considerations and then use this corpus to build up a force of empowered, dedicated rural physicians who shall be working in a system that they have grown up in (rather than sending in city slicks who shall need time to acclimatise)? I know this is too radical to happen in the next two decades, and given the proclivity of Indian politics to entertain populist vote bank agenda (and the strong caste-based system entrenched in the system), in forever, but this would solve several problems in one fell stroke.
I know that the issue of being a doctor and protesting against a rural stint seems antithetical. It is almost as if I am betraying the Hippocrates’ oath, but the truth could not be further from it. If the ministry enacts a law asking MD students to do a year of rural service, I would be the first one to sign up. And I think so would most others. because despite what society thinks of doctors in general, we still have those dreams in our eyes where we are making a contribution to the segment of society that needs us the most. In exchange, all we ask, is that we are given the infrastructure and the system for us to execute our skill set and some safety, and incentives. Is that too unreasonable a demand? I believe not.
It is not an ideal solution: there is a real problem; people are dying for the lack of a trained, credible care giver. And standing at the juncture of such a problem it seems trivial to cavil over one year this way or that. But then again, one cannot also take the matter of the lives and careers of thousands of the best minds for granted. This is a catch-22 situation and any policymaker would hate to take a call either ways. There is no right decision. There is only derision and criticism. There is choosing between disenfranchising the poor further (or providing them with band-aid healthcare) and pushing the best minds of a generation away from the system, by encouraging brain drain with a policy that is viewed a punitive (or populist). One can only wait and see how things work out over time; whether a graded, incentivised rural posting system can be brought in; or whether a blanket system is enforced, coercing students to go to “serve” against their will, dispensing a service they are ill-equipped to provide.
I began the post with a quote from Osler. I would like to end with another quote. This one from one of Osler’s disciples and one of his best known followers (though not a direct student). This reflects our belief in the nobility of the profession, reflects our passion, pride and joy in being doctors, our destiny as physicians… and this reiterates that we are not petty, feudal, feuding clans clashing for personal aggrandisements but we still have an iota of passion to serve left in us. It is a reminder for each one of us, to lift our noses from our sweat-stained books, and for a moment, remember how romantic it is to be a doctor…