Hello NL team,

Like everyone else, I used to write a reactive post to Hafta – but this time I’ve decided to be proactive. And that is because if I don’t raise this issue, I’m sure it won’t be discussed at all.

(Disclosure: I am a doctor who studied in Maharashtra and am currently not practising in India)

There was a news dated October 13, ‘Maharashtra cancels registration of 4548 MBBS doctors for not serving in rural areas’.

I want to discuss this news at length – so the word limit will be breached.

1. Maharashtra produces the maximum number of MBBS doctors in the entire country – mainly due to the large number of municipal corporation, state government and Central government medical colleges plus an ever-growing number of private medical institutes (Karnataka comes a close 2nd due to the private college numbers).
2. This new government rule based on which the registrations will be cancelled will only apply to government medical college graduates as they are the only ones required to sign a legal bond (while entering the first year) undertaking to serve a year in rural Maharashtra after MBBS completion for which they will be paid a decent salary. Or pay the government a compensation, the amount of which has been persistently raised almost every year, the most recent being Rs 10 lakh for MBBS graduate. It goes up to become Rs 50 lakh for a specialist and Rs 2 crore for a super-specialist doctor. The government claims that it spends a similar (or more) amount of money in training a doctor, which is pure bullshit at its best. The government only runs a hospital for the Aam Aadmi. Apart from two-three basic science department faculty, everything and everyone in medical education is a by-product of running a government hospital.
3. What happens when the Medical Council registration is cancelled? The doctor is unable to practice in Maharashtra anymore. If he still chooses to practice, he will be treated a ‘bogus’ doctor and can be penalised/prosecuted therefore. Laymen may call them quacks for better effect.

Why don’t the doctors go to the rural areas, then?

Post-graduate education: This is the most-common reason. The medical graduates are usually considered more brainy and hardworking among the students. Imagine this when these brainy students start preparing for a post-graduate entrance exam, they know that the chances of getting a clinical seat are about 1 in 10, even less if you take the private college and reserved candidates into the equation. And we are talking about mostly brilliant and hardworking people here.

What happens to the other 9 of these 10 students? They sit and prepare with more discipline to study for the next year’s entrance exam. Making the chances 1 in 19 for the next year.

And this goes on, till the time they either settle for a lesser discipline or stop preparing and accept to remain MBBS graduates. “Chaalu doctors” in the minds of most of the general population.

“No facilities in rural hospital” is the most commonly cited reason by doctors who decline to go to rural areas. Well, as someone who has served his term, I can say that it is not totally incorrect. The resources there are abysmal indeed. It’s really not easy to see someone deteriorate or die in front of your eyes. It is worse when the person is under your care. But that’s nothing compared to the feeling of knowing that had resources been available, you could have saved him. Or at least tried your best.

It is a deeply scarring experience and you can either grow indifferent to it and keep doing your job; or become depressed and wish to get the hell out of the field of medicine itself.

I have not yet mentioned the fact that since it is a rural place and you likely won’t know the local dialect well (despite being fluent in Marathi), it is extremely difficult to explain the mostly simple villagers why his ward couldn’t be saved when THE DOCTOR was available. Believe me, you have ZERO security in such a place. And you know that you have to stay 364 days more at that place.

4. ‘Somebody could be bribed at the post-allotment office and urban posting can be done to get a rural posting certificate’: Not uncommon. And it is not illegal to do an urban government job as the vacant urban centres jobs still need to be done by someone- many people chose this option.
5. ‘Job is way below my skills’: Also not uncommon. Remember the 1 out of 10 MBBS doctor who became MD or MS or even reach up to the level of a DM or MCh? Yes, when they return to apply for the job against their government bonds – they are, not uncommonly, sent to rural areas as a regular medical officer (mostly as a punishment posting, if they refuse to oil the babu-machinery or if they have remained too uptight and rules-citing doctors during their training). Now, I fail to understand this part – how can a plastic surgeon or a cardiovascular surgeon or a psychiatrist use their special skills to treat a snake bite or malaria patient? It doesn’t make any human resource management or ergonomic sense.

What can happen next:

1. Doctors will run helter-skelter to get a rural posting. I don’t have the exact number at hand, but the total number of rural medical officer posts in Maharashtra is way below this 4,548 figure.
2. Doctors will pay up the bond money with interest, if they can afford it.
3. Doctors – individually, or a group like IMA – may challenge this in court but I don’t have much hope here.
4. Leave medical practice and start doing something else, they may even start enjoying it.

My personal take:

1. I am glad that the government has finally thought out a way to enforce the rural service bond. However, unfavourable the terms of service are; and no matter how much the government overestimates its expenditure in training a medic – each medical student has given the undertaking knowingly*- fully understanding the implications of not serving (they were the brainy students, remember?). There is no way one can claim victimhood by not even trying to perform his duty.

{*A subset of MBBS students (mainly from the 2004-2005 admission batch) who obtained admissions after clearing the then AIPMT (the all-India entrance exam) were made to sign this bond in their 3rd year of education- some of whom have challenged the government on this backhanded tactic- but still paid up the bond money because the government and courts are great at “taarikh-pe-taarikh”.}

The rural facilities may, in turn, improve if such caring young medics choose to make a change- though, it is still terrible working condition (I’m not saying ‘living condition’) and totally not worth whatever the salary they are paying now. But every once in a while, a medic can be pleasantly surprised after really working at such places.

2. Class XII students will in general feel more apprehensive about entering this never-ending and ever-worsening field of medicine. Or, the affording ones may choose private colleges (mostly run by politicians, for whom these are hugely profitable business), even after knowing that government institutions offer better education here.

3. What about the ‘real quacks’ and ‘bogus’ doctors with no medical degrees, freely practising in urban India, including most of our metros? How come they are still thriving despite so many legal provisions in place?

4. If one pays off Rs 10 lakh (or Rs 50 lakh, or Rs 2 crore), he will most likely recover this money by unscrupulous ways – which may lead to further harm to the patients; or they may leave the country and get their just compensation with the largely professional work culture and patient safety. Whose loss will that be then?

I know I would likely be criticised by both the doctors and the general public for this article – but that’s fine. If no one talks about it, nobody will care about it.

Few words to the aam janata:

People should try and trust their doctors – not blindly, but after reasoning and sharing the decision-making and thereby the responsibility of their own health.

When the doctors say ‘so and so medicines’ or ‘such and such investigations’ are not available – then instead of just hurling profanities against the doctor, they should try to get their leaders’ and media attention on this issue. Not by name calling or blaming someone, but in a ‘constructive quality improvement’ manner.

Work with the doctors to get your own public healthcare equipment and facilities, instead of beating him and worsening the public health services further.

And the media should stop making it doctors v/s patients – it never was, and it will never be. It is (doctors + patients + media) versus status quo of the governments.

Remember, doctors alone are not able to get the best services in government hospitals till now – not for the lack of trying, but because of the fact that they are not a significant vote-bank.

Rahul Pandey