It's been about three months since the Indian Ministry of Health proposed to mandate the NEXT (National Exit Test) for MBBS graduates for becoming licensed and practising physicians. Though I did publish a rejoinder to it earlier, I left out one major aspect of it—the one which irks me the most of all. Together with the proposal of a mandatory exit test, the ministry announced the provision of 50% reservation in PG seats for those serving for an extended period as medical officers in rural areas. Even though the measure displays the government's commitment towards bolstering rural healthcare, there's another side to it. The scenario has several distressing aspects for freshly minted doctors.
I remember the time when I enrolled to complete my rural service bond with the Maharashtra government. I wished to take the USMLE exams just after my MBBS was over, but was told by my college to first finish my compulsory rural service, lest my application for USMLE would not be approved. This is no rule on paper but is something that flies around owing to the clout of influential people in such institutions. It isn't surprising how widely such unfair and coercive clauses are imposed in the name of service to the nation. But coming to my stint of rural service—what I prominently remember is how utterly clueless I felt for the first few months. Being made the lone medical officer of a Primary Health Centre (PHC), and entrusted with both clinical and administrative responsibilities with just a year of experience as an underling to specialists, was like being left alone in a ship without a sail in the middle of the ocean. I can easily relate with other such novices who find themselves in a no man's land as they join their bonded rural service—and can imagine why a lot of them either desperately seek a reprieve or simply flee.
Freshly minted doctors need further years of rigorous supervised training before they can practise independently. Bonded service as medical officers just after MBBS clearly defies this.
Now, I am known as a fervent crusader of an overhaul of our model of medical education. The 4.5 year MBBS is a cursory overview of the colossal science of medicine, rather than a process that produces an "expert". Most of it consists of memorisation of basic information related to different medical specialties, and the examinations are devoted mainly to test the very fundamentals of medicine. What then debases our medical education is the undue theory preponderance and a sloppy practical training and assessment system. After medical school, students spend a year rotating through different specialties as interns, which again is inadequately regulated and is largely insufficient to confer students with a sound practical approach in medicine. Owing to this, freshly minted doctors need further years of rigorous supervised training before they can practise independently. Bonded service as medical officers just after MBBS clearly defies this.
Another important point is that prospective bonded medical officers are imparted no formal training, or even an orientation, in medical/public health administration. I clearly remember that the only time I came across something relevant to medical administration in my MBBS curriculum was in Preventive and Social Medicine(PSM), which only gave a mere overview of the roles of medical officers and other public health staff—and that too in flowery, rhetorical language. The clause on bonded medical service misses out on this aspect too.
You can imagine what can happen when a half-baked clinician and an inexperienced administrator is recruited as the lone medical officer serving an administrative division. Keep aside the cluelessness of the candidate—you can conceive of the numerous legal and social intricacies one could get entangled in, and the amount of dread it could instil in the mind of someone whose career has just taken off. Not only can it crush the morale of a novice but can also jeopardise their career if things go awry because of clinical/administrative inexperience. As a norm in India, you can hardly expect anyone to step in to your rescue in such situations, unless you have a relative holding an exalted public office.
The solution to the shortage of rural doctors lies not in coercion but in creating attractive prospects of work in those places.
Above that, no one is oblivious of the changing trends in the doctor-patient relationship that we are witnessing today. Episodes of violence against doctors keep surfacing more frequently than ever before—and PHCs, being the point of first contact of patients with the healthcare system, and with their ridiculously poor infrastructures, pose a high risk of them. Should such an unfortunate situation arise, you can imagine the anguish of that solitary inexperienced doctor employed in a PHC.
Bonded medical service for freshly minted doctors, without adequate mechanisms in place, isn't just a mindless attempt to cure the intractable doctor shortage affecting our rural areas—it reflects the utter neglect of our ministry in properly handling a valued resource called doctors. Furthermore, it abdicates our responsibility towards patients by allowing an inadequately trained physician to independently run a government dispensary meant to cater to thousands of people. Medical officers are meant to be exalted positions of the gazetted rank. They are supposed to come with an innate prestige—and in a country as ours, with rural predominance and an ambitious primary healthcare framework, should be highly attractive to primary care doctors. Rather than focusing on how to eliminate the factors that make such positions unattractive, the government has actually eroded their dignity and prestige by coercing inadequately competent doctors into occupying them.
With the above in mind, a lot more needs to be done before we stack another mindless measure upon the ones we already have. We need a thorough repair of the archaic medical education system we have today. Further, it would be imprudent to obstruct the course of those fresh graduates who wish to proceed with postgraduation just after their MBBS, which by the way is the most favourable time to do so. The solution to the shortage of rural doctors lies not in coercion but in creating attractive prospects of work in those places.
Prospective medical officers should receive formal and adequate training in all aspects of their work, not just to avoid mishaps and assure optimal functioning but also to preserve the dignity of such positions. Equipping our PHCs and spending more on healthcare go are essential. As regards the provision of 50% reservation for medical officers in NEXT, it is easy to anticipate that it will prove to be a feeble incentive towards solving the shortage of rural doctors in India, unless we work to bring about positive systemic changes.
We need to question where we are heading with such inept fixes, because much more than just rural healthcare is at stake here—we risk of alienating an entire generation of doctors in our country.