Unethical practice is high when service motive is low

On one hand, students have every right to pursue training in their chosen field of interest and this will ensure tertiary care in our country with a possible spin-off of research and medical advancement.

On the other hand, has the obsession with specialisation detracted from the primary objective of developing healthcare resources and manpower that will address the larger need of society and the country?

The doctor-patient ratio in India is 1:1,700; way below the WHO recommended 1:300. The ratio is desperately worse in north Indian states and far-flung rural areas. Even basic medical attention is unavailable and the medical infrastructure in the form of rural clinics, delivery rooms, nurses and medicines is close to non-existent in such areas. If the ministry of health budget is increased and used to improve the infrastructure and salaries payable to personnel, doctors with an MBBS degree can effect major changes in rural health. It is hard to imagine how specialists can practice satisfactorily or be relevant is this scenario.

In urban centres too, medical specialists disappear into the high towers of corporate hospitals that provide them with the environment to practice their skills. To what extent then, are they available to the larger majority who need to be seen or treated for minor ailments and disorders? The concept of the family doctor has all but vanished, as has the neighbourhood clinic. Which means there is no first line medical care that can be accessed, with an onward referral, if necessary. Patients throng the hospitals and get frustrated by queues, procedures, investigations and high costs for minor illnesses.

At the heart of this issue is the very reason that students train to be doctors. In our country, it has become a default choice for academic toppers, whose personal choice is silently subverted. Society places a premium on this profession as career choice for children as it is considered respectable and aspirational. Yet, it is hard work, dedication and service that are pre-requisites for a good doctor, not academic brilliance per se.

With limited career guidance at hand, students fall in line and enter the race for a medical seat, which then becomes an end in itself. If the goal is to acquire a socially acceptable badge or amass wealth, there is bound to be a crisis in standards of practice and ethical behaviuor. Specialisation then, is just one more step towards this goal.

Critical fallout

The ministry of health and the MCI are least concerned with this critical fallout of a sub-standard process of selection of candidates for the MBBS course. In a bid to close the personnel gap, there is instead, a preoccupation with increasing the number of medical colleges and PG seats, controlling the allotment of seats and dictating fee structure. This is just one aspect of a larger malady. A former registrar, RGUHS, described the appalling state of the post-graduate selection in these very pages, citing MD radio-diagnosis seats going for Rs 1.2 crore in private medical colleges! How is this justifiable when only wealthy students can avail such seats? Can we expect much of a social objective in the mind of a doctor who has invested such large sums in his education? Then again, is the price of the radio-diagnosis seat in some way linked to the high earning potential of this specialty through scan centres and ultrasound clinics?

A good doctor is motivated not only by the academic challenge of medical science but also by the desire to serve and care for others which is an intrinsic part of the profession. Practice that is devoid of the latter is clinical, non-empathic and incomplete. Besides, unethical practice is lowest where the service motive is high.

When the motive is altruistic, the need comes into sharp focus. Do we really need so many specialists who will gravitate to corporate hospitals to play their part in the high-stakes game of cornering the ‘market’ in tertiary care?

The overwhelming need is for medical graduates to spend at least some part of their career in rural areas. As recommended by the Rao Committee, only these students should be eligible for post graduate seats. The ministry of health has the urgent responsibility to facilitate a suitable environment so graduates will choose rural service. In the cities too, it is MBBS doctors, in the form of family doctors and general practitioners, who are needed as the first point of medical treatment. With referrals only when necessary, it will reduce the cost and complexity of care. In their absence, patients are understandably driven to alternative practitioners and even quacks in their search for cost-effective care.

Candidates for MBBS selection should be required to demonstrate some social motivation that could include prior volunteering at health camps, clinics and health organizations. Every academic year should have at least 15 days devoted to health planning, rural health or health reform. This would orient the student to the national health agenda. The implementation of the NRHM reform directive of a compulsory year of rural service for all medical graduates will go a long way in bringing much needed health service to underserved areas.

(The writer is a medical consultant and bioethicist)