Family Medicine: A Solution for Career Inequalities among Doctors in India.

Career in medicine is challenging. Medical education system is a ever evolving entity. Due to certain bottle necks in the medical education system, young medical graduates in India are facing difficulties in career progression. Author draws from the experience of Britain and explores how family medicine could be answer to many question which the Indian health system is challenged with.

Background

Getting into a medical college demands a great deal of focus, effort and sacrifice. Moreover, the MBBS training itself is quite rigorous and demanding. One would be inclined to think that almost all medical school graduates would be intelligent, committed and hardworking people. One would wonder how much of a difference there could be in the caliber and abilities of the doctors who were in the same class in their medical school.

The Problem

After medical school comes the great divide in the form of the post graduate (PG) entrance. As per the government of India in 2008, the intake capacity for PG medical seats was only one-third of the number of seats for MBBS courses all over India in a year.[1] Hence, there is a real bottleneck and only a few get a preferred PG seat in the first attempt. Many doctors would be studying for the PG exams sitting at their homes or libraries 1-2 years very commonly.

These doctors are a precious resource in this country with great health inequalities and disease burden. However, they are out of the professional pool for so many years, getting demoralized, and de-skilled.[23] By this time most of the other professionals would have started climbing the career and income ladder.

Just one mark in the PG entrance exam can translate into a difference of hundreds of ranks. I wonder if there really is so much difference in the abilities of qualified MBBS doctors that would justify the glaring inequalities in their opportunities. A study on life perceptions after MBBS, published in 2012 concluded that after years of studying even the brightest students faced an uncertain future and were perplexed.[2]

The Cause of the Problem

I was wondering how this inexcusable situation came into being. Many decades ago, an MBBS degree was considered enough for a doctor to start a professional career. However, this is no longer valid for a number of reasons. Firstly, most MBBS doctors will aspire, quite rightfully, to do a PG training[4] and find dissatisfaction in being “just an MBBS doctor”. Secondly, patient expectations have risen. Thirdly, in this era the MBBS level training alone, does not give a doctor the confidence, competence and the necessary practical approach to practice independently.[5] The under graduate medical training in India, which is in need of modernization, is responsible to a large extent.[67]

Hence almost all doctors want to be well-trained at a PG level, but there are not enough seats. This is probably because of the system's age old assumption from the Bhore Committee report of 1945[8] that the majority of doctors would serve as general practitioners (GPs) and be well-distributed to serve the rural areas. Hence, there were only a few specialist hospitals and a few specialty training seats. However, 67 years have passed since that report and the government policy has failed to keep up with the changing times to plan the medical work force effectively. As a result, the majority of the doctors who were supposedly the primary care base of the health-care system have been left abandoned without any career plan or training. I would use the term “professional exile” to describe this situation where the young doctors are forced out the health-care system and workforce.

Ironically, the country from which Sir J Bhore hailed, i.e., Britain has since then formed the National Health Service and is now among the world leaders in primary care delivery, training and universal health coverage. Unfortunately, India failed to see the importance of a structured primary care as a result of which we have reached a state of near collapse of the public health system.[9]

The generalist or the family medicine based health system has much better outcomes.[10] This is evident if one compares the USA to many European countries where primary care physicians lead the health system. In the UK, being a GP is a very attractive, interesting and respected career where the opportunities are boundless.[11]

However, very few doctors who ranked low in PG entrance have any desire to become family physicians because there is no proper training, no career pathways and no opportunities in academic medicine and leadership. Importantly, there are no role models of successful family physicians in these capacities. It is simply not inspiring.[4]

The Solution

I really think the answer to this dire situation is family medicine. India needs to rapidly and urgently implement good opportunities in family medicine through MD or DNB programs.[11] This should make up for the short age in PG seats. The system should make it possible and encourage all MBBS to get into a PG training program within a year of completing internship.[12]

But, for this to be successful, the medical students need to have an open mind and a good understanding of family medicine. Many students have a mindset that only by becoming a Neurosurgeon, Cardiologist or some other esoteric sounding specialist will mean achieving success in life. All medical students should have postings in good family medicine set ups.[1213] The prominent doctors from the specialty of family medicine could be role models and could counsel students. Students entering MBBS training should be counseled right from the beginning about the prospects of a career in family medicine.

In the UK, it is expected that about half of all the newly qualified doctors will enter GP specialty training.[14] Being a GP is a very attractive career prospect in the UK. About 34.3% of UK Medical graduates regarded general practice as their sole first choice after 3 years of graduation in 2005.[15] There is a high level of overall job satisfaction among the GPs in the UK.[16]

Furthermore, the family medicine training programs have to be well designed and true to family medicine.[13] Unfortunately, very few people, including doctors, in India understand the concept of family medicine. There are huge numbers of Indian medical graduates who are family medicine doctors/GPs in other countries. They are an untapped resource for developing training and employment opportunities in India.

We also need to increase the professional opinion of family medicine among the existing doctors. This can be done by having a high standard of training, presence of departments in the medical colleges and academic pathways among other options.

I really believe this that expansion of family medicine is something that cannot be ignored anymore and is a matter of urgency. This could restore the balance of the entire health-care system. Finally, it will make a real difference to the lives of thousands of doctors and millions of citizens.[810]