Soham D Bhaduri: Why compulsory rural service for new doctors is a terrible idea

Soham Dinabandhu BhaduriIt’s been about four months since the Indian Ministry of Health proposed to mandate the NEXT (National Exit Test) for MBBS graduates before they become licensed and practising physicians or enter postgraduate courses. Although I have already published a rejoinder to the proposal, I left out there the one major aspect of it that irks me most of all. Together with the proposal of a mandatory exit exam for all medical students, the ministry announced that states can reserve up to 50% of the places in postgraduate courses for those who have served for three years as medical officers in rural areas. It was also proposed that after their postgraduate course, doctors may be required to do up to another three years in rural service.

Even though this measure displays the government’s steadfast commitment to bolstering rural healthcare, I would argue that there are disturbing and distressing aspects to enforcing rural service for freshly minted doctors.

I remember when I enrolled to complete my rural service bond with Maharashtra state—fulfilling the agreement that candidates who enrol in a MBBS course have to sign a bond with the respective state government (worth ₹10 lacs or one million rupees) to fulfil one year of rural service or pay that amount back. I wanted to take the United States Medical Licensing Examination (USMLE) just after my MBBS was over, but was told by my college to finish my compulsory rural service first, lest my application for USMLE would not be approved. There is no rule on paper to say that this should be the case, but it’s an idea that flies around, and which is perceived to be something that influential people in such institutions may have strong preferences on.

When I think back to my stint of rural service, what I predominately remember is the feeling of utter cluelessness that surrounded me for the first few months. Being made the lone medical officer of a primary health centre (PHC)—entrusted with both clinical and administrative responsibilities, after just a year of experience as an underling to specialists to back me up—was like being left alone in a ship without a sail in the middle of the ocean to fare on my own. I can easily relate to other novices who find themselves in a no man’s land as they join their bonded rural service–and can imagine that a lot of them may either desperately seek a reprieve or give way and flee.

I am a fervent crusader of an overhaul of our medical education system. The 4.5 year MBBS is a cursory overview of the colossal science of medicine, rather than a process that churns out an “expert.” Most of it consists of memorising basic information related to different medical specialties, and the exams are devoted mainly to testing the fundamental theory of medicine. What then debases our medical education is the undue preponderance of theory and a sloppy practical training and assessment system.

In the last year of their MBBS course, students spend a year rotating through different specialties as an intern, which again is inadequately regulated and is largely insufficient to confer to students a sound practical approach in medicine. Owing to this, freshly minted doctors need additional years of rigorous supervised training before they can practise independently. Yet making graduates carry out bonded service as medical officers just after their MBBS defies this.

Another important point is that prospective bonded medical officers are given no formal training, or even an orientation, in medical and public health administration. It’s not too long after my own studies for me to forget 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 brief overview of the roles of medical officers and other public health staff. The proposal for bonded medical service makes no mention of accommodating this education and training need.

You can only imagine what can happen when a half baked clinician and inexperienced administrator is recruited as the lone medical officer serving an entire area where they are responsible for the healthcare administration. You can easily conceive of the numerous legal and social intricacies one could become 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, it can also jeopardise their career if things go awry out of clinical and administrative inexperience.

In addition to all this, episodes of violence against doctors keep surfacing more frequently now than ever before. And doctors in PHCs–as the first point of contact for patients with the healthcare system, and with their often ridiculously poor infrastructures–run a high risk of experiencing violence.

Without adequate mechanisms in place, bonded medical service for newly qualified doctors 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 the valuable resource that doctors are. What’s more, it abdicates our responsibility towards patients by allowing an inadequately trained physician to independently run a government dispensary that is meant to cater to thousands of people.

Medical officers are meant to be exalted positions. They are supposed to come with an innate prestige–and in a country like ours, with a largely rural population and an ambitious primary healthcare framework, they should be highly attractive positions. Rather than focusing on how to eliminate the factors that render such positions unattractive, the government has instead eroded the dignity and prestige of these positions by coercing inadequately skilled doctors into occupying them.

With this in mind, a lot more needs to be done before we stack another mindless measure on top of the ones we already have. We need a thorough repair of the fairly archaic medical education system we have today. It would be imprudent to obstruct the course of those fresh graduates who wish to proceed with a postgraduate course just after their MBBS, which in many ways is the best time to do so. The solution to India’s shortage of rural doctors lies not in coercion, but in creating attractive work prospects in those places.

Prospective medical officers should receive formal and adequate training in all aspects of their work, not just to avoid mishaps and ensure optimal care for patients, but also to preserve the dignity of such positions. That we’ll need to equip our PHCs fully and spend more on healthcare goes without saying. But unless we work to bring about positive systemic changes, reserving up to 50% of the postgraduate places for rural medical officers will prove to be a feeble incentive, which is unlikely to solve the shortage of rural doctors in India.

We need to question where we are heading with such inept fixes, because it’s more than just rural healthcare that is at stake here. If this is implemented poorly, we risk alienating the entire next generation of India’s medical workforce and potentially harming patients in the process too.

Soham D Bhaduri is a medical doctor and takes a keen interest in mental health and medical education. He blogs at The Free-Thinking Medic.

Competing interests: I have read and understood BMJ policy on declaration of interests and declare the following interests: None.