Thursday, August 15, 2013

The right prescription



Medical students have an ethical obligation to serve the rural community
Last week, medical students took to the streets of Delhi, protesting against the government's order to extend the rural internship from three months to 12 months. The government had passed such an order to fill up the vacancies in the rural health services. Emotions are running high, and doctors and students have launched a "save the doctor" campaign in response. As a doctor who has worked in rural areas for decades, I would like to shed some light on this debate.
Let us review the arguments raised by the striking students and doctors. The first and most frequently voiced objection to this order is that there is no infrastructure in rural areas for doctors to practise. While this was true a few years ago, the National Rural Health Mission has strengthened the infrastructure, equipment and human resources in rural areas. According to 2013 figures, 92 per cent of primary health centres (PHCs) in the country function from a building. There are more than 2,00,000 nurses working in the 1,70,000 PHCs and sub centres. Each PHC medical officer also receives more than Rs 1 lakh every year to improve health services at the PHC.
The next objection is that the one year rural posting will increase the duration of medical education. The period between entering a medical college and getting the licence to practice will increase from five and a half years to six and a quarter years. However, at this stage, it is important to get an international perspective. German and Brazilian medical students require six years to graduate, while their American and Thai counterparts require seven years. South African students can practise only after eight years of training. It is clear from this that the Indian MBBS doctor has a shorter training period than many high- and middle-income countries.
This could be the reason that students say they do not have the expertise to manage patients in rural areas. Here, the students are correct in their analysis. They are trained in tertiary centres for five years and are exposed mostly to complicated cases like cancers and kidney failures. Rarely do medical students get exposed to patients with basic illnesses. Moreover, they are used to technology and being supervised by their seniors. So it is not fair to send them to a facility that does not have either fancy equipment or the staff to guide them. The government is doing an injustice to the poor of our country by sending a partially trained and poorly equipped doctor to the toughest posting, the PHC. My suggestion would be that the students be posted at the community health centres (CHC) or taluk hospitals. There are two benefits to be reaped from this step. First, students would be able to learn and practise medicine under the supervision of more experienced doctors. So they would be able to provide quality care, better than if they were left to cope alone at the PHC. The second benefit would be for the health system. From my experience in Karnataka, I find that most of the specialists at the CHC and the taluk hospital have to provide generalist care. So a paediatrician sees surgical patients and an obstetrician treats medical patients. This is because only specialists are posted at these facilities and there are no generalists. If generalists (MBBS interns) were posted there, they could manage the outpatient clinic and refer the serious cases to the appropriate specialist. This would improve the quality of care at these facilities, while specialist services are effectively and efficiently utilised.
Last but not least, students demand that the rural posting be shifted to after they complete their post-graduate studies. However, as they have stated, about 45,000 MBBS students graduate annually, but only 12,000 get admission into postgraduate courses. So is it fair to excuse the rest from rural service? Considering that the government spends a lot of money to train doctors and that the patients (especially the poor) contribute to this training by permitting medical students to test their skills on them, it is only ethical that students give something back to the community. Moreover, many of the postgraduates will have trained in non-clinical subjects and so will be of no use as medical officers in PHCs. Hence, it is better to place MBBS interns rather than postgraduates at the rural facilities.
Medical students have an ethical obligation to serve the rural community. But they need to be posted at the CHCs and hospitals, so that they can practise and learn under supervision while supplementing the health services.
The writer is director, Institute of Public Health, Bangalore


Mohit Kurundwadkar said...

i am also a medical officer at a phc what you are saying is ok but security for female doctors in villages will always be an issue no matter what..and if this government has so much fund under nrhm jsy jssk as you might be knowing why not utilise and give salary 1 lkh per mnth.easily the prblm gets solved but compelling someone wont b tolerated it does not happen in any of the countries you have mentioned

shark said...

nwith the new rule in focus,permanent jobs might dissappear altogether. and wat of those students of the older batches who have not done any rural duty? will they not sit for any pg entrance? or the government will recruit them somehow ? frankly speaking, there are really not enough placements if 40,000 mbbs grads have to be placed. wat of those who wiont be placed? will they continue to waste their years like sitting ducks?

sanjquestions said...

I'm presently serving at a phc as part of one year rural service. The administrative medical officer says we want regular doctors and not doctors like me, it just increases their burden. The DTO says you receive rs.25000 salary and national programs are falling behind because of me, I should not be given attendance. On several holidays I reach the PHC before the group D. All other staffs in the PHC enjoy more holidays than me. The staff doubt my ability, and when I tell them to give amlodipine to a patient, they give atenolol. And the village people ... most of them have come and asked me has the doctor not come. The worst thing .. in 11 months I have received salary only thrice and only for 8 months, while all other staff in the phc receive salary in time. Another problem is my studies...the phc is always busy, there are no quarters, I stay with my parents at a place 25kms away and has to change 3 buses and then take an auto to reach the PHC. I do not get enough time to study and I fear I cannot compete with those preparing for entrance exams devoting more time for studies.
All this just frustrates me and make me depressed when I come back home from PHC.