Should Govt force docs into rural stint?

Medical students in Tamil Nadu and Maharashtra stepped up their protests on Monday against Health Minister Ambumani Ramadoss’s proposal of a year's compulsory internship in rural areas.

Students say they do not want to do a year's internship in the rural areas but they will go on posting if necessary. They say they are determined about their protests and will even go on hunger strike if necessary.

Meanwhile, Tamil Nadu government has threatened stern action if the strike isn't withdrawn and students will have to vacate hostels and medical colleges would be shut down. As of now, 12 states have joined in the agitation and the students are in no mood to relent.

On the show Face The Nation hosted by Sagarika Ghose, panelists debated whether doctors should be forced to do rural service. To discuss the issue on the show were Dr Abhijit Das, Director of Centre For Health and Social Justice, Dr Ajay Kumar, National President, Indian Medical Association, Anirudha Patil, MBBS final year student at Seth Gordhandas Sunderdas Medical College, Mumbai, and Ashwini Sheoran, a third year medical student at Stanley Medical College, Chennai.

No rural bias?

At the outset, medical student Anirudha Patil clarified that he was against the proposal because it did not make sense for an intern to be posted in a rural area. “An intern is not liable to make any responsible decisions. In case of any negligence, there is no medical officer to supervise us. Instead of sending an under-trainee doctor, we should send an expert who has more experience than a trainee who can serve the community in a better way,” he said.

Abhijit Das, a strong critic of doctors who don’t want to do rural internship, said that argument didn’t hold water.

“Doctors are anyway supposed to receive their degrees after a year of internship. Consider a situation where you are given a posting after that one year. In terms of training, you have received the training you are supposed to receive to function autonomously. You are already a doctor. The question is just of deferring the registration of the certificate. Once the certificate is given, I don’t think the doctor will actually return for rural practice,” he said.

There's a perception that medical students just want to take their degrees and move out of the country as soon as possible. “Right from the beginning, the basics are not very clear. The Minister, without taking any advice from the Medical Council of India, which is the technical body to advice on medical education, has suddenly come out with this funny idea. I don’t think it will hold water at any stage,” said Dr Ajay Kumar.

Socially speaking

Slamming Das’ opinion on medical students, Ajay Kumar said doctors have to work under supervision till they the full registration. “If they work in the rural area, they have to be supervised by a qualified doctor otherwise they will act like quacks. If they are being supervised by qualified doctors in rural areas, it means there are doctors there already. So they are already doing the service, why should one waste the time of the students?” he said.

But the young urban doctors – or for that matter – any doctors have a social responsibility. Shouldn’t they care about what happens to poor people in rural areas and provide them with treatment?

“But they are not still doctors. You can’t get the chicks to work like chickens. I don’t understand this logic at all,” said Dr Ajay Kumar.

To the medical students’ and Dr Ajay Kumar’s argument, Dr Abhijit Das said two different issues were getting mixed up.

“One issue is the perspective of the health situation in the country. There is a health catastrophe is this country. There are 2 million children dying before the age of one. There are 2 million women facing life-threatening conditions in delivery and so on. We need medical practitioners in rural areas. The question is if four and a half years and one year does not make the doctor competent, then doctors should not be made autonomous even after one year of internship.

But if after four-and-a-half-years, a student is still not a doctor, and still not considered capable of treating people in rural areas, how can that one year miraculously make medical students capable of treating?

MBBS student Ashwini Sheoran, who is currently in his third year, feels that things are not being posited correctly.

“In the proposed rural service, a doctor is sent is there for only four months in the PHC.” But the reality, says Ashwini, is that students are posted in the PHCs for only three months.

Of the nature of social responsibility

Ashwini also feels that a there cannot be any comparison between a student intern and a full-fledged MBBS-degree holder.

The degree itself, however, can prove to be the proverbial carrot dangling in front of the donkey.

The question was raised that if students are given their degrees, what is to prevent them from skipping off to the private sector and casting their social responsibility to the wind?

Ashwini was emphatic in his response.

“We are doing our internship in the PHC, so you cannot say that we are not serving the society,” he said. However, he added, there is a problem with the term times, as well, for by the time the intern realises the problems of the rural areas, it will be time for him to leave and the next batch would make its way to the villages.

That would not be beneficial to rural health, Ashwini indicated.

The debate then moved to the entire question of adding further hardships to the life of the medical student, which is already fairly tough to begin with, given that there are few seats and fewer remuneration and incentives.

Rural teachings

Das, however felt that rural experience would help medical students greatly.

“You will also see a lot of rural reality which affects health,” he said.

Then, there is the age factor.

“When you’re at that age, you can take risks,” he explained, indicating that the best time for a medical student to get rural experiences would be when they are free of family responsibilities.

Another concern raised pointed to the ethics of the entire situation: When the Indian taxpayer is contributing so much towards subsidising a medical student’s education, it's imperative the student to give something back to his country.

MSMSA Spokesperson Anirudh Patil agreed with the sentiment. But he felt that the country already gains back a lot during the year-long internship of the medical student.

Anirudh said that the only complaint of the student fraternity is increasing the internship period and thus, the duration of the course.

“In our one year of current internship, we do go in rural areas, we do work there, we do serve our countrymen in villages for three months,” he explained.

Anirudh also brought to light some figures on the nature of shortfalls.

Uneven distribution of rural responsibility

“If you take into account the task-force on medical education by NRHM, it says that there are 13 per cent of shortfalls in the PHCs as opposed to the 38 per cent in the CHCs, which is at the taluka level,” he said, adding, “the 38 per cent they mean are specialists.”

Anirudh did not see the point in posting undergraduate interns, who are already working in the PHCs.

“They should be concentrating on the 38 per cent, which is a big section,” he insisted.

Did this mean that the government had got its priorities mixed up? Instead of actually raising health-care in the country, are medical interns being made easy targets? Would that solve the fundamental problems of Indian health?

Abhijit Das did not think so but he felt that it would be a step forward.

“It has to be seen as one of a continuum of reform measures in health-care,” he said.

Enter the government

But clearly, the government would need to do a lot on its part, particularly with infra-structure-building and giving more incentives to doctors for rural practice.

Abhijit Das agreed and said that legally and technically, interns in rural areas should be paid adequately.

“The year that is being mentioned is actually post-internship, at this point in time. So, there should be adequate pay for it,” he said.

Das recommended withholding the registration certificate for autonomous practice and felt the government can easily do so.

“The government is well within its rights to do so because the Indian Constitution still talks about the socialist, secular, democratic republic,” he added.

In fact, said Das, all professionals need to contribute to nation-building.

That would certainly be a need of the hour given the 10 per cent growth on one side and 400 million people working for less than a dollar on the other.

On the government’s part, it would need to offer incentives, a good stipend, infra-structure, equipment, just to begin with.

Ashwini Sheoran agreed but said that permanent jobs are an essential part of the package and maintained that the MBBS course should not be extended for interns to enter rural service. He further recommended that the UPSC should choose specialists and the best doctors for the purpose.

But the problem with recruiting specialists, interpolated Das, is that specialists don’t with to go to rural areas.

“When you have a problem like that we have to find ways to deal with it,” he said, ruefully.

CNN-IBN Editorial: There seems to be a failure on part of both medical students and the government: an ethical failure of medical students for not giving back enough to the country which gave them subsidised professional education, and a failure on part of the government for not make conditions adequate – let alone ideal – in rural areas for doctors to practice.

Final results of SMS poll:

Should doctors be forced to do rural service?

No: 89 per cent

Yes: 11 per cent

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#face the nation #ambumani ramadoss #doctors #rural posting