Chaos over medical graduates' compulsory rural service

With the President giving assent to the curiously (and confusingly?) titled Karnataka Compulsory Service Training By Candidates Completed Medical Courses Bill, 2012, the stage is set for a period of uncertainty for the new medical graduates, both undergraduate and post graduate.

What does this mean? Simply stated, all graduates and post graduates in medical sciences, after passing the university examinations (and after completing the Compulsory Rotating Internship in case of MBBS graduates), will have to undertake one year of Compulsory Rural Service before they are given their degree certificates.

While some have welcomed this move stating that the graduates owe it to the government which has spent on their education, need for social commitment and such other reasons, we have to examine whether this legislative action has been clearly thought out. It has not been.

The government is thinking that every year, 5,000 medical graduates and post graduates will be available for rural service. Really? Let us look at the statistics provided by the state government itself. A few days ago, the cabinet approved draft rules to recruit 983 specialists, 331 general duty doctors and 87 dental doctors.

If 331 general duty doctors are required, where are you going to send the nearly 3500 MBBS doctors who pass out of the 30 odd medical colleges in the state?  Where will they go and what will they do in the absence of infrastructure needed even to sit and examine patients?

If you saturate the present PHCs with general duty doctors who do not have any experience, since they have just passed out and completed their internship, there will be nothing but chaos.  Inexperienced, what kind of service will they provide? Is it not actually a disservice to the rural patients?

And there seems to be couple of exem clauses in the Act. One, the government will have the power to relax the rules and allow doctors to obtain their degree certificates without the rural service. Now what does this mean? The relaxation is for whom?  The rich, powerful, influential? Then why the Act? Two, if an MBBS doctor wants to pursue a post graduate course, no need to do rural service now, but do it after post graduation. Does this mean that if all 3,500 MBBS graduates say they want to pursue post graduation and get waiver of rural service, they will all be provided post graduate seats? Not possible!

Then?  
Can the government order the State Medical Council to not register them before they conclude rural service?  No. Because, without registration, they cannot practice and cannot see patients.  If one has passed the examinations and is registered, can you order the university to not give the degree? Without the degree and the medical council registration, he/she cannot practice. That is the law. Are we going to let these 3500 odd uncertified doctors loose on the unsuspecting rural populace? 

To be fair, a new doctor, despite having a degree in his hand, needs experience before he can independently handle cases and take crucial decisions. This Act is not fair to the new doctor also.

Infrastructure for specialists
Now, in this Act, the situation is slightly better for the PG diploma and /or degree holders.  Many district and taluk hospitals have some infrastructure for specialists. But even there, the situation is not exactly ideal.

A general MD, MS or MD (OBG) could be of some use to the patients. They can also perhaps experiment and learn. But what happens to specialists? Say an ophthalmologist, ENT surgeon, orthopaedic surgeon, pathologist?

All the infrastructure necessary for all these specialists to work is certainly not available in all places.  You might say, okay, we do counselling and send them to places where they are needed. Even then, there will be an excess.

I am sure pathologists will completely be lost because most health centres and even district hospitals do not have even a reasonable infrastructure for them to work. Many places will not even have bandage cloth and this Act is sending hordes of specialists into a literal wilderness.

The point is that planning has to be from the bottom to the top. First create the conditions and then ask doctors to serve and if they don’t, use the whip. Public health planning and spending is among the lowest priorities for our governments, both at the state level and Central. Both medical education and health care are rapidly going down into the hands of private players and the governments have abdicated their responsibility. Acts like this are nothing but mere tokenism.

Will this Act stand the test of law?  A student goes through a course, appears for examinations and passes out of an institution, all according to the provisions of and recognised by the Medical Council of India, which includes the Compulsory Rotating Internship. After all this, how can you say that he will not get a degree certificate? What will the courts say about this, because this legislation will certainly be questioned, and perhaps the government also knows it!

This Compulsory Rural Service stipulation has been going on forever, since the 1960s, to no avail. The remedy is: build well equipped Primary Health Centres with residential accommodation for doctors, nurses and other staff, pay good salaries, and then qualified doctors will go. 

The way the new medical colleges are being allowed to come up, with the ever increasing number of seats, and avenues to go abroad slowly but surely closing, a day will come when our doctors will have no option but to go and serve in our villages!

(The writer is former Director, Kempegowda Institute of Medical Sciences, and former Registrar, Rajiv Gandhi University of Health Sciences, Bengaluru)