Since Independence, the medical profession has been one of the most sought-after career choices for young Indians. Apart from the nobility of the profession, it also offered career security—whether one worked in the government sector or ventured into one’s own practice. Teaching and training in India were of a good standard, both from the standpoint of professional skills as well as ethical professional practices. As a result, medical professionals in 20th-century India earned tremendous respect, both within the country and abroad.
During the 1960s to 1990s, many Indian doctors went abroad—mainly to the USA, Canada, the UK, the Gulf region, and other developed countries—for more lucrative career prospects. Most, if not all, achieved success. Even today, healthcare systems in many Gulf countries continue to be largely managed by Indian professionals. Recently, when Prime Minister Narendra Modi visited Kuwait, he praised the Indian medical diaspora for their contributions to meeting the healthcare needs of the local population.
However, due to some unfortunate developments in recent years, this lifesaving profession has lost its sheen and appeal as a career path of choice for India’s brightest students. We need to analyse and understand the reasons for this decline so that remedial steps can be taken. I will focus on a few causes that seem obvious to me.
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From noble to money-driven
The onset of the problem, in my view, can be traced to the improperly regulated privatisation of medical education, which began in the early 1990s. Most private colleges were established with the sole aim of making a quick buck. Some of these colleges even attained the status of Deemed Universities, giving them greater autonomy over their admission processes. This led to a badly compromised system where admissions began to be granted based on capitation fees rather than the merit of the candidates.
Further, many such colleges appeared to enjoy political patronage. The Medical Council of India (MCI), the statutory body tasked with regulating medical education, failed to live up to its solemn duty. Over time, the malaise deepened. In effect, medical college seats in many private medical colleges—both at the undergraduate and postgraduate levels—became reserved for the rich.
The problem was compounded by the recruitment of mediocre faculty in these private colleges. Original research, the hallmark of any good university, was totally ignored. Thus, the quality of medical education suffered—both because of a of lack of good teachers and the poor academic standards of many admitted students.
It cannot be overemphasised that those dealing with human diseases must be of the highest calibre. They must also be hard working and imbued with an innate sense of service and compassion. When dealing with human lives, mediocrity is unacceptable.
With growing public criticism, the government took steps to dissolve the MCI in 2010 and created an Interim Board of Governors to take over its functions. The board members made sincere efforts to streamline the college recognition process and, in 2012, notified the much-needed National Entrance Examination Test (NEET) to ensure merit-based admissions. Although NEET was initially rejected by the Supreme Court, but, on review, the court accepted this much-needed reform in 2016.
While NEET may not be perfect, it is a significant improvement over the past. Further steps need to be taken to streamline and improve the NEET regime as well.
Unaffordable fees in private colleges, unattractive salaries
The hefty fees charged by private medical colleges are another factor dissuading bright young minds from choosing the medical profession. The apex court had recommended the establishment of fee fixation committees in each state to regulate fee structures, but this appears to be ignored by many state governments.
On achieving their medical degrees, students are forced to contend with the harsh reality of low and unattractive remuneration during the residency period and also at the junior faculty level. The salaries that medical doctors are paid in some states are a pittance compared to their contemporaries in other walks of life. In some states—Punjab, for instance—for some years, the government has been paying only basic pay during the probation period of two years. Even in private hospitals, academic residents and senior residents do not receive pay that would enable them to provide a good quality of life for their families.
It is hardly surprising, then, that over 1,000 seats in super-speciality courses went unfilled last year. Until recently, an assistant professor on contract, after completing DM training, was paid a meagre salary of Rs 95,000 at one of the major public health institutes. To face such prospects even after 13–14 years of rigorous study and training is most demoralising.
An environment of fear and pressure
What has made matters worse is the mechanical application of the consumer protection regime to the medical profession, without realising that the nature of this service is vastly different from other transactions and services.
The unique nature of medical and healthcare services must be properly appreciated before addressing legal issues related to them. Medicine is a science of uncertainties. Each drug can have a different degree of effect on different individuals. Some may develop side-effects, while others may not have any. There are known complications associated with different lines of treatment, which may arise in individual cases without any deliberate negligence on the part of the doctor. These complexities and limitations can only be truly understood by someone with the requisite professional background and experience.
Legal cases drag on for years, creating a sense of fear, frustration, and uncertainty among doctors. A feeling of distrust is engendered between the patient and the doctor, which taints this most sacred of human associations. Even complications that arise naturally during the course of treatment are viewed through the lens of suspicion and negligence. Consumer Court issues have led to a defensive and ‘play-safe’ mindset in the medical profession, leading to the increased healthcare costs due to the prescription of avoidable—and sometimes unnecessary—medical investigations and diagnostic tests. The net result, in my view, has not served patients well.
Of course, one cannot turn a blind eye to instances of unethical practices by some doctors, often driven only by monetary gain. But this is also a systemic issue. Medical professionals are increasingly working under a system of financial ‘targets’ fixed by some private hospital managements. This is totally out of sync with the very spirit of our profession. To meet financial targets, costly surgical and interventional procedures are sometimes advised even when the available evidence does not justify such treatments.
The malady of referral ‘commissions’ for referring patients to private hospitals also needs to be tackled. Some hospitals have marketing departments that ‘network’ with private practitioners and offer commissions. This malpractice was even highlighted in the TV serial Satyameva Jayate over a decade ago but still continues.
Restoring medicine’s glory
A thorough relook at the current system of accountability for doctors is overdue. A more efficient and balanced system must replace the current one. Any new system should be geared to provide more optimal outcomes for all the stakeholders— patients and doctors alike. Sympathy for the patient and their family, as well as fairness for the doctor, must be the twin guiding lights. A system that implements a speedy and credible decision-making process, with outcomes steered by scientific evidence, is the need of the hour.
Let us not blindly follow the American litigative culture, which has only added to the commercialisation of a noble profession like medicine. Instead, India should lead the way and emerge as a role model for the rest of the world.
It is imperative that we restore society’s confidence in its doctors, and that of bright school students in the medical profession as a career choice. Bright and competent medical professionals are an invaluable asset, not only for providing quality healthcare to patients but also for innovating and, through evidence-based research, discovering newer and better tools of treatment. India needs sound and capable professionals who can take on new and emerging health challenges like Covid-19.
Over the years, our medical professionals have earned high laurels, both at home and overseas. Let us rebuild this national asset and restore the glory of this noble profession.
Dr KK Talwar is the former chairman of MCI’s Board of Governors, ex-director of PGIMER Chandigarh, and chairman of the Heart Institute at PSRI Hospital, New Delhi. Views are personal.
(Edited by Asavari Singh)
The number of students writing NEET is skyrocketing every year, while those appearing for engineering exams like JEE continue to decline. This is despite the fact that there are far fewer medical seats than engineering, and the scope of engineering is much broader.
At this point, it is more than twice as many medical aspirants compared to engineering.
What is the basis for saying that the best and brightest no longer opt for medicine? The view is not a reflection of reality.
I squarely support Dilip Gogoi’s and Shekhar G’s observations about medicine. The medical field does need a high degree of intelligence, but that is nowhere near the IQ required to be a good mathematician or physicist or computer scientist or an economist.
The best and brightest students must opt for careers in maths, physics, statistics, computer science, economics, etc.
Medical science can be left to the next rung of students – thise who are very intelligent and more importantly very disciplined and hardworking. The medical field does involve rote learning and cramming in a massive way and no high-IQ student will ever enjoy that.
My personal experience:
A cousin who was tremendously brilliant had even represented India in the International Maths Olympiad. But was continuously pressured by his parents to opt for medicine because his father happens to be a doctor. Quite obviously, he secured high marks and got admission into Calcutta Medical College. Just a year in and he left the course. Said it does not do justice to his talents. Just rote learning day in and day out. Got admission into the prestigious Indian Statistical Institute (ISI), completed MSc from TIFR and is doing PhD now from MIT Boston.
This is what truly brilliant students with exceptional IQ yearn for. Medical science can safely be left to the second rung of students.
Dr.Talwar makes great points. Lack of prestige, Cost of education, Length of education, Medico legal Challenges, physical violence, Defensive practice, low salaries and accepting referral pays are all practical troubles that face the profession and obviously inter related. Some of these things cannot be reversed as the proverbial train has left the station.
However there is a lot that can be done. Infact the one way to fix the entire system is to make Government Hospitals and Medical Colleges better. It is a tall ask, but it can be started by forming these centers of excellence within these institutions where staff can be incentivized to work better by paying them 4 or 5 times the prevailing government wages.
If Government hospitals can put out clean, competent, cheap, timely and accountable care then lot of the issues plauging the system will wither away. Private hospitals and corporates will self correct, referral pay acceptance will drop, dedicated people will join Medicine etc etc..
But the business of Medicine will suffer and hence those stakeholders will not let this happen. Unfortunately the political will that is needed for such an endeavor will be compromised due to these special interests.
In the end just like a people get a Government they deserve, they will also get a Healthcare system they deserve. It will only be a mere reflection of themselves.
It think you have never met a doctor in your life. Do you know what it takes to be doctor? Are you aware of any cognitive skills like critical reasoning, decision making, observation and of course empathy.
You think one acquires these by rote learning. The very concept of IQ has been outdated now on the basis of which you are passing judgement about professions and demeaning them.
If top-students have opted for medicine, it’s just because of the social prestige a doctor enjoys in our society. Medicine is a profession for rote-learners. It’s meant for people who are good at cramming – it hardly requires a high IQ person.
If a student is indeed intelligent and harbours great ambitions he must choose subjects like maths or physics ir computer science. These subjects require a very high IQ and there is negligible rote learning involved.
Medicine is a profession which requires great analytical ability and high IQ as well as as EQ. In emergency as well as day -to-day clinical practice, you need to diagnose the disease correctly and administer the treatment as per guidelines directed recommended therapy. A symptom like chest pain / fever can have several differential or multiple diagnosis, and therefore, one needs to have high analytical ability to rule out other diseases and rule in the correct diagnosis with high precision. So, i disagree with your point that Medicine attracts / needs rote learners.
The points raised by Prof Kk Talwar in this article are absolutely correct. Mushrooming of sub-standard private colleges in 90s were responsible for degradation in medical education.
The points raised by Dr Talwar are very relevant. His analysis for the deterioration of the profession are spot on.
The solution lies in growing community owned medical schools funded by tax resources where fees are realistic, every student is entitled to sufficient educational loan. The loans must be paid back by a 5 year service at community medical establishments like primary care centres & secondary care centres. To enable this these fresh graduates must be paid salaries which must t be adequate eg. 25 % to repay the loans and 75 % to afford them decent living. A similar model can be rolled out to finance those who wish to pursue specialisation. This time they commit to 3 to 5 yrs providing service at secondary and tertiary care centres and also faculty positions in teaching institutions. After providing this mandatory pay back to the system they may be offered hybrid contracts where they can opt to work within the public system for variable hours & also do private work at private medical centres. This will also help to break the monopoly of the corporate health care establishments which impose unfair monopoly over the rights of medical practitioners.
Finally, the folly of bringing medical practice under the Consumer Protection Bill must be corrected. Good, ethical medical education will create a pool of competent, ethical practitioners and the black sheep can be disciplined by the Medical Council. Defensive medical practice to avoid litigation is something what a poor country like India can ill afford..
Great read. Thanks for a systematic dissection of the problems.
However, if we also not include the failure of the beauracry to safeguard and implement the checks and balances within the system of medical education, we will be failing to address one more fundamental issue as a part of a systems thinking approach? Beauracry is not just meant to formulate systems and processes but actually to see that they followed, safeguarded and implemented. Tell this and beauracrats will show you hundreds of excuses and reasons. They won’t won up even a bit of it.
Please don’t only focus on development of medical field .
The development of allied healthcare is extremely important to develop overall health infrastructure of India.
Private colleges distributing allied health degrees without any restrictions. This need to be curved .
Many bright allied healthcare rehab professionals such as Occupational therapist and physiotherapist , speech therapists are working on junior level even though they have masters degree
Government need to give utmost importance to this issue as well
Regulation of both medical courses, allied healthcare course and paramedical courses are important.
We have to note that many important healthcare professions such as Occupational therapy and physiotherapy are independent practitioners as well
Top students should study mathematics, statistics, computer science, physics and economics. These disciplines require high intelligence.
Medical science is more of a rote-learning profession.
Why would a high IQ student wish to go for medical science? Makes no sense at all.