Question: According to you what is the status of the medical profession in India today?
Answer: The medical profession is in a state of transition. There is an identity crisis and people in the medical profession are victims of a distorted perception or bias. There is a general perception that doctors are making a profit out of misery. It is very unfortunate because doctors are also the prisoners of the system.
Question: Really, but why?
Answer: Well that is because we are shifting away from an individual general practitioners based prescription model to a hospital-based healthcare system which is for-profit in nature. This has become necessary because of the advancement of science as well as heavy investment in the healthcare delivery system. We have for-profit hospitals everywhere, especially in the tertiary care system. These tertiary-care centers need a lot of cutting edge technology and evidence-based medicine which makes them very expensive to maintain. Also, a lot of capital is required to provide fine quality care. Naturally, the motive of the stakeholders who invest heavily in hospitals is to make a profit. You don’t blame them too. But when a doctor expands his practice and builds a small 20 bed, 30 beds, or 40 bedded hospital, it is called an extension of his practice and expected to run ethically. We have a system where the secondary care, is mainly in the hands of the medical profession, whereas the cutting edge technology in tertiary care is provided by the corporate hospitals. The law recognizes them as an industry and business. The image of the corporate hospitals affects the doctors too because doctors are at the frontiers of providing medical service. This image also automatically gets translated into the image of the medical profession which is very unfortunate. Had the government invested more in territory care and had there been public hospitals like AIIMS everywhere, the medical profession would have loved to be there. But there is a vacuum in the public sector because individual doctors cannot invest in a tertiary hospital. It is unfortunate but the medical profession is a slave of the for-profit healthcare system which the country has adopted.
Question: Do you think that there is a decline in medical ethics?
Answer: As far as the medical profession is concerned every doctor would want to follow medical ethics. But in corporate hospitals where there are targets and protocols, it is difficult for a single doctor to fall out of step. The solution lies in encouraging medical doctors to establish small secondary care hospitals while the government or cooperative units may fund the territory care hospitals. There can be an isolated case of a corporate hospital, but it cannot be like today where we have literally handed over the territory care to the corporate or what I call for-profit hospitals. It is quite natural that the ethics collide since the doctor is only an employee.
Question: There has to be a line between the business and the profession.
Answer: It is a matter of fact. At present, there is a dichotomy in the system and the doctors are on the wrong end of it.
Question: Of late there have been a number of suicides by doctors. Do you find a trend in that?
Answer: Suicides amongst doctors are mostly among young doctors who are frustrated because of a lack of opportunities, and extremely poor working conditions. In any institution – be it public or private the doctors are required to put in inhuman hours of work, even more than physical laborers who are restricted to work not more than 48 hours in a week. There are institutions where doctors are expected to continuously work for 36 hours. Even as per international labor norms a person should not be made to put in more than 5 hours of intellectual work per day but most of the Resident Doctors have to work continuously for at least 36 hours twice a week. This is a blind spot.
Question: The biggest tragedy is that medical students have to invest a lot of time and money to get into medical colleges. And when they come out of the medical college – they want to quickly recover whatever they spent in a span of 1-2 years or so. If they are able to do so, it is ok otherwise they land up into trouble… Is that so…
Answer: I would say this is a phase that lasts up to 4 – 5 years after graduation as they complete their MBBS and head for post-graduation. Many of them fail. At least 60-70% of them cannot get entry into PG courses. So there is anger, frustration, and depression. This is a very serious issue that we (Indian Medical Association IMA) are addressing. We have a committee that looks into stress among young doctors. There is lot of unrest among young doctors. We define ‘young doctors’ as someone who has put in around 10 years in the medical profession. This is the segment in which suicide rates are very high.
Question: What is the solution?
Answer: Solution is that the Government has to invest in healthcare and gainfully employ medical graduates… Every year around 78,000 students graduate from the medical colleges. Only 23% of them get admission in post-graduation. The employment avenues in the primary healthcare sector in the country are decreasing. As things stand, there is no dearth of doctors. There are at least 1,50,000 young unemployed MBBS pass doctors. But there are artificial barriers between states. If I am registered in Delhi I cannot practice in Uttar Pradesh. South India has an excess of doctors who are going abroad. Had these artificial barriers been removed, these doctors could have been productively employed in other parts of the country, wherever there is a deficiency.
Question: Are you referring to the fact that Bihar has an acute shortage of doctors – which is why at any given point of time nearly 25-40 % patients in AIIMS are from Bihar. And the fact that there is a surplus of nurses in Kerela; while there is a shortage of nurses in North India?
Answer: In Bihar, there are only 8,000 nurses registered with the nursing council. If we want one nation and one identity, why should there be artificial barriers preventing doctors belonging to a state to practice in another state? I don’t understand the logic behind it. If there is a National Medical Commission and Medical Council of India then whoever is registered should be qualified to practice anywhere. Such things need to be reformed.
Question: Is it really so that Doctors registered in one state cannot practice in another?
Answer: Yes. If I want to practice in some other state, I will have to take all my certificates and get registered in that state’s Medical Council, but then I cannot go back to practice in my native place. Even if I am expert in some procedure licensed to practice in Chennai and I want to teach students how this surgery is to be done to students in Mumbai I cannot do that. Before operating a patient I should have a license provided by Maharashtra.
Question: This means that even if you are an expert who specializes in a certain aspect, you cannot be invited to supervise or assist a surgery in another state?
Answer: For that, I will have to first register temporarily. If I really want to do so, I need to register temporarily with the Maharashtra Medical Council.
Question: Is this practice being followed?
Answer: It has to be because health is a state subject. Our (IMA’s) demand is that health should become a concurrent subject. Our point is just like IAS or IPS why can’t there we have an Indian Medical Service (IMS) – not as a big or glamorous post for Doctors but to deploy them in the field. Today the young Doctors are ready to go anywhere. They just need two things – safety at the places where they go. That is because 50% in the medical profession today comprises of lady doctors. There has been a feminization of the medical profession so they need care, they need safety. This has to be ensured. There has to be some amount of professional satisfaction out of serving somewhere. There have to be basic amenities.
Second is they must be recruited through the Public Service Commission. Today there is a vacuum because they haven’t regularized any posts, and no new posts have been created anywhere. This is a turmoil affecting the young MBBS doctors while the government is repeatedly saying that we have a shortage of doctors. This is a myth. On the contrary, there is a shortage of nurses and paramedical staff –which is more acute than doctors. We as a country produce the largest number of medical graduates every year – 78,000 MBBS graduates pass out of 526 medical colleges every year. No other country in the world produces so many doctors.
Question: But isn’t it a fact that most of these MBBS graduates are unable to enroll in PG courses, as a result, they are found unfit for employment.
Answer: The problem is that our society does not respect or value the services of an MBBS doctor. They say… so you are just an MBBS? Well, you need to be a post-graduate. The entire health services in the United Kingdom are run by MBBS doctors. Nobody can see a specialist without being referred by an MBBS doctor. Here in India, anyone who has a headache may visit a Neurologist first before going to the family doctor. Here in India, there is no value of an MBBS doctor in the private or government sector. There are so many fine graduates but only 23,000 of them can become postgraduates every year so every year we get a backlog of 45,000 medical graduates. At any point in time, there are 1.5 lakh good quality doctors sitting in the libraries and the coaching centers for getting a PG Degree. It is for the government to recognize this problem and deploy them gainfully.
Question: We also have a problem related to continuous up-gradation of skills. There are so many diseases like SARS, Dengue and Chikungunya which never existed five years back, hence many doctors who passed out of medical college before that weren’t adequately trained to deal with the new diseases. Still, most of them would like to see a patient who is going to pay them instead of going back to the medical college to upgrade their knowledge. Do you see this as a problem?
Answer: Yes, that’s a failure of the system. The entire burden of continuing medical education is being borne by the IMA and specialty organizations like the Association of Surgeons of India, Association of Physicians of India and the Academy of Pediatrics. We have many organizations which are predominantly focused on a specific branch of medicine. They are highly sophisticated and updated. In some of the states, there are CME credit hours fixed by the state councils for regularization and reregistration. The specialty organizations have a presence up to the state level but we penetrate into a bigger sub-district level. So in small towns, the CME’s are being done by IMA. We are the largest organization our penetration is into mofussil towns. In state-capitals, you will find all the specialty organizations but when you go down to the sub-district level IMA is there alone. There is no financial support from any quarter. These are some of the issues that need to be addressed.