The Precarious State of Indian Medical Education

Part III: What is the real problem?

The life of a medical student amusingly resembles the myth of Sisyphus, the Greek legend, who was condemned with the eternal task of rolling a rock up to the top of a mountain, only to have it roll back down to the bottom every time he reached the top.

The Sisyphean toil begins with NEET-UG prep. After grinding for two long years and cracking the exam, one feels like they’re on the top of the world, only to realize that the journey ahead is long and hard. College is grueling but five years and a gazillion moments of regrets later, as one earns the “Dr.” in front of their name, the memories of a life prior to this become blurry and the title gets cemented not only to the name but also to one's identity. Well, so long, the rock goes rolling back down to the bottom, as residency – the most humbling chapter in the life of a doctor – begins. Three years later, you’re at the top again; an MD/MS, ready to take the training wheels off. But wait, there are giants out there and the market is saturated with MD doctors; you feel like a dwarf. To up your game, you decide to pursue a super specialty. 10 years later, here you are, a first year Cardiology resident, in your early 30s, doing exactly what you did in the first year of MD training (for those of you wondering what it is that first year residents do? Don't bother; it's worse than you think). Another three years pass you by, but it’s worth it. You have successfully reversed the order of the letters on your degree. Congratulations, now you’re a DM. The market is still relentless, but the hard work starts paying off. It takes a few more years, a couple of fellowships abroad, perhaps an MRCP (Membership of the Royal College of Physicians, England), and if everything goes according to the plan, the Gods absolve you of the punishment. From here on, there is no looking back.

This is the story behind the fancy abbreviations one sees on a doctor’s name plate. We live in desperate times, where bagging credentials after credentials is imperative to stay relevant in a world replete with human resources. Hustle culture plagues healthcare just as much, if not more than any other profession. But how did we get here?

The introduction of an entrance exam-based admissions to postgraduate MD/MS courses in the 1970s, shifted the focus of academics to multiple choice questions (MCQs). Subsequently, coaching classes emerged to fill the knowledge gap. They would hire the best faculties from across the country and spoon feed ready to chew information to students, outperforming regular college lecturers on every level. Soon they became so popular that students only attended college for attendance. The importance of classroom teaching and reading standard textbooks further declined with the advent of online platforms and live/recorded videos. Subscribing to a coaching class today is so convenient and trendy that students sign up from second year of college itself; no one wants to be left out. MBBS students spend more time solving MCQs than acquiring the skills necessary to become well-adjusted physicians. We’ve created a system wherein MBBS is reduced to a bridge course to MD/MS, where the real learning begins. Naturally, most MBBS graduates today are not doctors, rather NEET-PG aspirants.

For a developing country with a rudimentary primary healthcare, producing incompetent and unmotivated primary care physicians is a rather self-destructive idea. Unlike the developed world, India has poor penetration of healthcare, especially in the countryside; doctor absenteeism and scarcity of resources are lingering issues staring us in the face. The Nobel Prize winning economists, Abhijeet Banerjee and Esther Duflo, in their riveting book, Poor Economics, have revealed some very alarming statistics concerning doctor absenteeism and physicians’ incompetence in India. A paper published in 2011 revealed that the average rate of absence of doctors in Primary Health Centers (PHCs) across 19 states was 43% (Bihar outranked everyone else with a staggering 67%).

The lack of qualified doctors or rather, the lack of incentive to deliver among qualified doctors in rural areas, has led to the monopolization of healthcare delivery by quacks and AYUSH practitioners, who unabashedly practice allopathy. To mitigate this problem, the government has increased the number of undergraduate seats, and many states have introduced a mandatory bond service post MBBS, which, if forfeited, levies a penalty of 10,00,00 rupees. Some states have gone as far as to introduce an in-service quota for medical officers (MBBS doctors who've served in government set ups) in the state counselling for MD/MS courses.

Have state coercion and populist policies solved the problem? Does not look like it. It is an open secret that doctors serving the bond often bribe their way out of it. Many students sign up as medical officers during their gap year for NEET-PG preparations and bribe local officials to forge their attendance. Poor accountability and lack of audits let them get away with it.

To gain more insight into the problem, I looked up the latest Union Health ministry rural health statistics (RHS); the data was preposterous. Contrary to popular belief, of the 37 States/Union Territories, 26 states have a surplus of doctors at the Primary Healthcare Centers (PHCs) - healthcare delivery units at the level of villages. For instance, the required number of doctors at PHCs in Maharashtra is 1839; whereas the number of sanctioned positions is 4021 (more than double) of which 3252 are filled. Surprisingly, the data wasn’t all that different 20 years ago. What happens on the ground is another story but, the shortfall on paper was unremarkable then and it is unremarkable now. In fact, a research study conducted in 2018 predicted that India will achieve the WHO recommended doctor population ratio by 2024. So, numbers aren't the real deal here; two decades later, PHCs still fail to deliver despite an adequate number of doctors. What really caught my attention in the RHS were the numbers at the Community Health Centers (CHCs) – healthcare delivery units serving as referral centers for four to five PHCs, at the block level. In 2005, the shortfall of specialist doctors (Surgeons, Obstetricians & Gynecologists, Physicians and Pediatricians) at the CHCs across the country was 6110; today it is 17,435 (a 185% increase in shortfall). Isn't it counterintuitive? After all this time, things have taken a turn towards the worse.

Let us double click on this problem. In an earlier post, I had talked at length about the government's campaign to increase the number of MBBS seats across the board in the last 5 years. We looked at the infrastructural and HR ramifications of the policy and saw how a sudden bump in the number of seats is not as good as it sounds. The only arguments that justify disproportionately increasing the number of MBBS seats compared to MD/MS seats, are improving doctor patient ratio, increasing the number of primary healthcare physicians and allowing healthcare to penetrate the peripheries. While the doctor-patient ratio is catching up with international standards and PHCs are overstaffed on paper, is healthcare becoming more accessible? Or has it led to unhealthy competition in metro cities where you'll sometimes find more eye clinics than supermarkets?

The yearly intake of undergraduates in government medical colleges is around 55,000; whereas NEET-PG offers admissions to approximately 35,000 MD/MS seats (to keep things simpler, I have not included DNB, diploma courses and private medical seats). What puzzles me is, how adding more undergraduate seats alone going to solve the deeper problem of absenteeism and poor delivery? In fact, it creates a bottleneck and worsens competition for the limited number of PG seats. Circling back to the shortage of specialists at CHCs; if it is so bad on paper, how bad must it be on the ground? It is abysmal. Understaffed rural facilities kick the can down the road and the disease burden falls onto the shoulders of district hospitals and tertiary centers, with many lives lost on the way.

Will increasing MD/MS seats alleviate the problem? It might, it might not. For all we know, it’ll end up flooding cities with MD doctors instead of channeling them to the peripheries; soon we’ll have super-super specialists competing in metro cities ;)

What I’ve gathered so far from the literature available on this subject and my personal experience in healthcare is that firstly, on paper, there are enough primary care physicians but there’s an acute lack of incentive to deliver; they are a no show because they can be. Secondly, few specialists would want to devote their time at the CHCs when they can run a promising private practice in a more comfortable setting; and they’re not wrong. Earlier, I’d have pinned doctors for being unconscientious but in the wake of instances undermining doctors’ safety at so many levels, I don’t think I’d volunteer to serve in the middle of nowhere without formal security and adequate compensation either. Why would I work relentlessly for 10 years to be employed in a place which is divorced from my reality, where I'd have to pine for the materialistic pleasures of life and where my kids don’t get the opportunities that their counterparts in the cities do? It is a tall ask.

The geographical and cultural divide between cities and villages is so stark that expecting doctors to serve in rudimentary rural settings is not feasible. In fact, kids who’ve wriggled out of the villages in search of a better life wouldn’t want to sink back in the trenches either. They’d want to uplift their families to the next level. Of course, there are exceptions, and this argument is subject to a generalization bias but nevertheless, there is some truth to it. Many well-meaning doctors take time out to organize camps and clinics in the villages, but permanence is off the table.

The picture in tier one cities is starkly different. In private practice, doctors are needy for patients, and not the other way round; while tertiary care centers are overwhelmed with undertreated, undiagnosed patients from the peripheries. Skewed distribution of healthcare, the enormous gap between public and private healthcare services and poor quality of medical education will have a lasting impact on the health of the country. When people talk about India being a young country with enormous potential, I imagine a crippled 20-year-old. What good is the age if we’re going to be debilitated and unproductive?