Tag Archives: BRMS

Make-believe doctors for Rural India

This article grabbed attention today in headlines:
Sounds good- doesn’t it? Doctors will have to serve in rural areas for 6 months so they can get their degrees. Most would think that’s a good idea- gets the doctors to work where it matters- give something back to the community and don’t become these money-hungry urban medical factory workers. 
This seems to be the result of a little compromise the Govt has come to in discussion with the MCI and IMA- their original idea of extending another year of training in rural area for the doctors was even more stupid than this one.
Now let me tell you why this is not a good idea:
Argument 1- This will bring more doctors to serve in the rural areas:
Well, these guys are not really ‘Doctors’. They are just out of medical school, have nil to minimum experience in actually dealing with real clinical situations and managing patients yet. These ‘Doctors’ are not ready to work in unsupervised position. This will not serve the rural population- this will clearly put the rural population under a huge risk. 
This may actually drive more doctors away from actually serving in the rural areas. Many of them will end up despising working in rural areas in unsupervised, under equipped and unsupported places where  they will be literally forced in these early times of their life and practise. That rare one in a thousand doctor that actually wanted to work in rural areas and make some difference may be driven to be averse by this ‘compulsion’ they are put into.
Argument 2- This is good for training of the interns in rural medicine:
Internship is not meant for providing ‘Medical Service’. It is meant for training the doctors in the actual clinical environment. Ideal internship is where the interns are involved fully in a healthcare unit, being closely supervised and guided by seniors of various levels of experience who instruct, criticise and modify their clinical behaviour. This year is the most important part of the medical training. The 4.5 years in the medical college are taken up absorbing all the theoretical knowledge, and the clinical postings where they observe the clinical correlation of the knowledge of theory they’ve gained- but there is no clinical decision making and reasoning during the medical school. These faculties are trained during the internship- and you need a mentor to guide you if not to hold your hands at this time. It’s ‘illegal’ for an intern to work without adequate supervision.
One year of internship involves rotations of short periods to various specialties: Medicine, Surgery, Primary Care, Emergency, Paediatrics, Psychiatry, Obstetrics, Forensics etc with subspecialties like ENT, Ophthalmologh, Orthopaedics, Oncology etc. This time is hardly enough to get a good overall training. Taking 6 months away from this time for rural posting will substantially affect the core training of the other major branches.
Now let’s look at the data from the same article:
-There is 76% deficit of doctors in rural areas
-53% deficit in nursing staff
-85% deficit in radiographers
-80% deficit in laboratory technicians.
This means these trainee doctors will either be thrown into a place where they won’t even have a supervising qualified doctor to train them and guide their actions, they won’t have access to basic investigations like x-rays or simple laboratory tests. These are the situations that even experienced generalist physicians will find it difficult to confidently diagnose and manage patients- but they will throw these patients at the mercy of doctors under training without supervision! 
If they stick to the law and place the interns only in the places where supervisors are available, that means these interns will only serve in the centres where already doctors are working- so they won’t be adding anything in the services- and then the whole idea of bringing this rule in is pointless.
Argument 3: Doctors owe the society:

Yes, I agree the doctors who train in the public hospitals and in government run medical schools get their training pretty cheap and they do owe to give something back to the society.
Firstly, let me tell you; a doctor in practise- regardless of what or where he practises and how he charges- is already giving something back to the society. There is no denying that.
To make someone work in a directed place and not having choices is a violation of basic human rights. We live in a free, democratic country- we don’t live in China or any other communist state where human population can be mobilised according to the needs. Every doctor just like every human being must have a freedom of choice in where he would work and live. The article itself says over a quarter of the rural medical centres are lacking basic water and electricity supplies- how can they force a doctor to work there? 
Are they at some point going to make it compulsory for Civil Engineers to work in these rural areas and bring up the infrastructure?
And what about the huge number of doctors that the Private medical colleges are churning out these days? Aren’t those doctors going to say that they have actually already paid the cost of their training and may be even tenfolds of that as the capitation fees to their medical schools? Why and how do they owe to certain parts of the society?
Some practical solutions:
Forcing the untrained, unwilling doctors in ill-equipped medical centres to ostentatiously treat underprivileged rural majority of India isn’t the answer. It is a mere hogwash that the Government makes to make everyone believe that they are trying to make a difference.
If a real difference is to be made:
Improve: the infrastructure at the rural clinics and medical centres. Make water, electricity, basic amenities and basic medical set-up at these places. This will attract doctors to work there. Believe me, there are enough doctors out there who would work in even a rural hospital only if the place was worth working at.
-Incentive: Instead of forcing the posting in the rural set up, give some incentive to young doctors to work in the rural areas. Give a better pay-scale, perks, better chances at promotion etc than the urban areas to those who work in Rural areas. May be give certain ‘brownie points’ for rural service for those who want to get into specialist training later on. These steps will bring in enough post-training doctors to work in these areas. 
The more experienced practitioners may also be brought to the rural areas by giving them special ‘Retirement Packages’ for the last few years of practise in the rural areas. I am sure many ‘burnt out’ urban specialists etc will not mind working in a slowed down pace of a rural life and practise for a year or two.
-Involve: The private medical colleges and hospitals classically lack clinical material for maintaining their accreditation. Involve them into providing services through satellite set-ups in the rural area. This way they can rotate their specialists in the team with their trainees through the rural areas for short durations.
Also, private medical colleges make a huge amount of money- Tax them specifically. This tax- is to represent the ‘Bond’ fees that the public hospital graduates make for pledging services to the rural sector. The revenue generated from these institutions can be specifically set aside to be used to develop the infrastructure and incentives in the rural set up.
Forcing undertrained doctors to the rural hospitals is dangerous both for the doctors and the target population; please get this right. Give them the doctors they deserve, not the unwilling recruit.