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ORIGINAL ARTICLE
Year : 2019  |  Volume : 8  |  Issue : 7  |  Page : 2401-2404  

Career destination and reason for career destination preferences among medical graduates from Christian Medical College Vellore – Does rural service obligation increase retention of medical graduates in rural service?


1 Department of Medicine, Christian Medical College, Vellore, Tamil Nadu, India
2 Department of Geriatrics, Christian Medical College, Vellore, Tamil Nadu, India

Date of Submission13-May-2019
Date of Decision13-May-2019
Date of Acceptance17-Jun-2019
Date of Web Publication31-Jul-2019

Correspondence Address:
Dr. Ramya Iyadurai
Department of Medicine, Christian Medical College, Vellore - 632 004, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jfmpc.jfmpc_388_19

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  Abstract 


Objectives: To find out the career destination of a cohort of doctors who have graduated from Christian Medical College (CMC) and to identify the reasons for their choice. Background: CMC is a training institution for medical graduates among a network of mission hospitals in India. After their graduation, most students complete a sponsorship obligation of 2 years in primary or secondary, rural and semi-urban hospitals. Methods: Study population: The study population was obtained from the electronic database of the medical graduates. The batches of medical graduates from 1966 to 1995 were analyzed. Quantitative data regarding the career destination were obtained from this database. Survey Instrument: A structured qualitative questionnaire was devised with both open and closed questions regarding their present area of work and the reason for their choice. This questionnaire was sent via email and posted to others who did not have email access; 17.5% responded to this questionnaire. Results: Data revealed that 57.4% of our alumni were working in India and 42.3% were working abroad. In India, 29% were working in the corporate sector, 21% in CMC, and 10% in rural hospitals. The pull factors for the doctors who stayed in India and in rural area were a felt need to serve. The pull factors for doctors to go abroad were pursuit of academic excellence and perceived better quality of life. The push factors against the pursuit of rural career were prior adverse experiences in the rural hospitals they had worked in. Conclusion: The career destinations depend mainly on satisfaction with work and familial expectations.

Keywords: Brain drain, career destination, medical graduates


How to cite this article:
Iyadurai R, Viggeswarpu S, Zachariah A. Career destination and reason for career destination preferences among medical graduates from Christian Medical College Vellore – Does rural service obligation increase retention of medical graduates in rural service?. J Family Med Prim Care 2019;8:2401-4

How to cite this URL:
Iyadurai R, Viggeswarpu S, Zachariah A. Career destination and reason for career destination preferences among medical graduates from Christian Medical College Vellore – Does rural service obligation increase retention of medical graduates in rural service?. J Family Med Prim Care [serial online] 2019 [cited 2019 Dec 12];8:2401-4. Available from: http://www.jfmpc.com/text.asp?2019/8/7/2401/263795




  Introduction Top


Emigration of physicians from the developing to the developed countries is a global phenomenon, leading to physician shortages and healthcare crisis in the feeder countries. About 60,000 Indian physicians practice in the United States, United Kingdom, Canada, and Australia accounting for 10% of total Indian physicians' workforce educated and trained in India. This departure of highly trained medical professionals is a serious loss of human capital in countries where these physicians were trained. In addition to the lack of physicians all over the country, there is skewed distribution of these doctors in the urban areas.[1] The current physician-to-population ratio in India is 1/11,528.[2]

A previous study from the All India Institute of Medical Sciences has shown that 53% of their graduates prefer to work abroad.[3]

Christian Medical College (CMC) Vellore is a 114-year-old institution, dedicated to training medical graduates since 1932. CMC Vellore has a network of around 200 rural/semi-urban mission hospitals dependent on it for training medical graduates. The hospital has a unique system of selection of medical undergraduates; the students are selected from areas of need from all over the country, and after they complete the medical studies they are required to work in the area of need, previously identified by their sponsoring body for a period of 2 years after graduation.

This study intended to find out whether after exposure to work in rural areas after graduation improves retention of physicians in rural areas of need.


  Methods Top


The medical graduates who began their training between the years 1966 and 1995 were included in this study. These batches were selected since they were people in current active service. The students in these batches were more likely to have finished postgraduation and joined service. The details of the physicians were obtained from an electronic database maintained by the alumni department in our institution.

The physicians were contacted by e-mail, telephone, and post. The details of physicians who could not be contacted were obtained from their classmates.

After preliminary details were obtained, a questionnaire was prepared and vetted by two senior physicians and it was sent to the alumni by email and via post.


  Results Top


Analysis of the electronic database revealed that there were 1617 medical graduates between the years 1966 and 1995 [Figure 1]. Among this group of physicians, 933 (57.4%) of our graduates are working in India and 692 (42.3%) of the doctors are working abroad.
Figure 1: Study enrollment and follow up

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Among the doctors working in India, 280 (29%) are working in the corporate sector, 195 (21%) continue to work in CMC Vellore, and only 90 (10%) chose to serve among the rural poor in rural mission hospitals. Most of the doctors in India have settled down in the Southern region of the country, 795 (85%). This disproportionate number could be because of the alumni working in the alma mater which is located in South India.

Among the doctors who are working abroad, 305 (19%) are in the United States and 162 (10%) in the United Kingdom.

The important factor that the physicians quoted as influencing their choice of workplace either in India or abroad was the need to address family concerns. The push factors to work abroad were better amenities.

Quotes from the physicians on the pull and push factors for working abroad

“There were bank loans to be paid off, lack of job opportunities in alma mater.”

“I did not get a post in India.”

Pull factors for working in corporate sector

“Freedom of movement choice of working or not working was refreshing, private sector gave me the freedom to practise medicine it should be done, financial stability associated with private sector was a positive spinoff.”

Pull factor for alma mater

“Work environment, motivation by teachers, and love for the Alma mater.”

Pull and push factors for rural hospitals

“Fulfilling, providing specialist care for people, satisfying to understand financial and social needs of people, increases faith in god, would love to get Continuing Medical Education cd's there is a lack of journals, so I feel out of touch fear and also I fear children may be at disadvantage due to lack of educational opportunities.”

“Working in a government hospital where care is given to even the poorest patient without any payment from him, so while doing PG joined Kerala government service and somehow I felt I should never work in private hospital not even CMC.”

Family as a pull factor for rural service

“Enjoy the work and I am the 3rd generation to serve this organisation was keen to work for charitable services.”

Women and career choices

“Husband is cardiothoracic surgeon which cannot be practised in rural hospital.”

“Children had finished their studies and wen to Canada we went to be near to them.”


  Discussion Top


Among the developing countries, India is the largest exporter of trained medical graduates. Indian doctors account for 4.9% and 10.9% of the entire medical workforce in the United States and United Kingdom, respectively.[1] The total number of Indian physicians in these countries amount to 59,095 which is 10.1% of the total medical workforce in India (592,215).

Emigration factor is defined as the number of physicians from a source nation practicing in a recipient country divided by the total number of physicians practicing in the source country.[1],[4] Emigration factor for India to the United States is 10.7, ranked second in the world after Sub-Saharan Africa with an emigration factor of 13.9 topping the list.[4],[5],[6]

This brain drain leads to enrichment of the medical workforce in these countries, but an outright loss to the source country. The cost of training a medical graduate in India is estimated to be around Rs. 17,500,000.

Among the physicians who stay back in India, a majority practice in urban areas among the urban elite. The urban doctor–patient ratio is six times more than the rural doctor–patient ratio. The gap in medical care is filled with alternative medical practitioners or sometimes even quacks.[7] The output of medical graduates has increased from 11,000/year in 1990 to 24,500/year in 2005, and the total seats available for MBBS in 2017 was 61,370 but 42% of these students are from private profit-based medical colleges which may lack in clinical material and faculty.[8],[9]

To motivate medical graduates into entering rural service is a major challenge faced by developing nations where most of the people still reside in rural areas. Asia has 52% and Africa 60% of their population distributed in rural areas.[10]

So why do our medical graduates leave our country? There are many factors which determine the career choice of graduates. Everett S Lee classified the factors that determine migration as push and pull factors. Push factors are unfavorable factors that push a person to leave the country, while pull factors are the reverse; they are favorable factors that attract a person to a particular country or area.[11] Studies from Sub-Saharan Africa has shown that the major pull factors include attractive pay packages and perceived better educational and career opportunities.

Most of the physicians who remained in rural service are often male, as high as 84% in a study done in rural India.[12] This highlights an important problem that women are underrepresented in rural service. As quoted by the female physicians in our study, spousal choice is an important factor to be considered when they decide their area of work.

A significant pull factor frequently quoted by both male and female physicians in our study was “to be with the family;” a study from Canada has shown that spousal contentment was essential in retaining physicians in rural practice. The familial factors depended on the physician workload and community integration. The community integration further depended on having a previous rural background.[13]

The push factors within the healthcare system that drives the doctors away from the country of origin are low salaries in the public sector, compounded with poor working condition and those outside the healthcare system such as unstable political situation in the country or state.[14] This is similar to the results of our study. Our study participants sometimes stayed back despite poor remuneration. In India, the concept of CCA (city compensatory allowance exists in government service); this concept should shift to rural compensatory allowance where physicians work under severe manpower, infrastructure constraints, and lack of or absent educational and other developmental opportunities for their children.

While the physicians who stayed in urban India quoted good financial remuneration and better work ambience as their pull factors. These are not unexpected results. Previous studies have shown that rural doctors have longer working hours, lower remuneration, and professional isolation.[15]

The doctors who decided to serve the rural underserved areas said the most important reason that they decided to serve in these areas was humanitarian need, inspirations from people serving in these areas, and desire to serve God by serving the poor.

The push factor quoted by the doctors who had served their rural service obligation but later moved outside the rural mission hospitals was poor amenities, lack of proper schools for education of their children, and finally lack of financial security both for their families and the mission hospitals they were in.

From our study, it is evident that despite many challenges, physicians work in rural areas. Hence, positive efforts must be made to improve the working conditions of rural physicians. Studies have shown that recruitment is not a problem, only retaining the rural physicians.

A study done in Vietnam among rural physicians revealed that incentives – financial (better income) and nonfinancial such as appreciation by the community, the managers, and job stability – lead to physician retention in rural practice.[15]

Since financial remuneration and better lifestyle were quoted as the pull factors to work abroad, government should increase financial remuneration for rural physicians (i.e. rural compensatory allowance). There should be strengthening of the research facilities within the country with a focus on research among the rural areas leading to a steady increase in income and job security. This should be possible if we increase the spending on health.

Instead of encouraging the private sector expansion in private medical education and medical service provision, the government should strengthen rural government health services.[8]

Most of the awards for medical excellence in India, for example, BC Roy Award, are targeted toward physicians working in urban tertiary care medical colleges. The government must establish special awards to appreciate the untiring hard work of the rural physician which is very important in maintaining health.[16]

A recent study among third-year medical students has shown that only a small percentage identified an advantage of working in rural areas and that is of added marks in the postgraduate medical examination – this has been removed by the current NEET exam system for postgraduation. The major disadvantage quoted by the students was lack of infrastructure and educational facilities for the children. Unless these concerns are addressed, it is unlikely that medical students will consider rural service as an employment opportunity.[17]

Unfortunately, instead of addressing the concerns of the medical graduates and problem of doctors in rural service, the current MBBS curriculum changes recommended by the Medical Council of India have moved toward specialized care and tertiary hospital–based care. The curriculum has introduced early clinical exposure communication and medical ethics but has totally neglected primary care and family physicians. This is a dangerous trend that will deny the patients of preventive care and holistic care provided by the family physicians.[18]

Our study also shows that rural obligatory service need not translate to increased graduate retention in rural hospitals. Most of the students choose careers based on the pull factors of felt need to serve the community and inspiration from medical missionaries, but even these physicians reported working in adverse conditions such as lack of basic amenities and lack of financial security. If we want to retain medical graduates in rural service, then these factors must be addressed.


  Conclusion Top


This study shows that despite challenges such as poor amenities, lack of proper schools for education of their children, and finally lack of financial security in rural practice, physicians stay back in rural service and active measures need to be taken to improve facilities in rural practice.

Acknowledgement

We thank Dr. JP Muliyil and Dr. Geetha Ann Joseph who helped with the qualitative analysis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Mullan F. Doctors for the world: Indian physician emigration. Health Aff 2006;25:380-93.  Back to cited text no. 1
    
2.
Bagcchi S. India has low doctor to patient ratio, study finds. BMJ 2015;351:5195.  Back to cited text no. 2
    
3.
Kaushik M, Roy A, Bang AA, Mahal A. Quality of medical training and emigration of physicians from India. BMC Health Serv Res 2008;8:279.  Back to cited text no. 3
    
4.
Mullan F. The metrics of the physician brain drain. N Engl J Med 2005;353:1810-8.  Back to cited text no. 4
    
5.
Kasper J, Bajunirwe F. Brain drain in sub-Saharan Africa: Contributing factors, potential remedies and the role of academic medical centers. BMJ 2012;97:973-9.  Back to cited text no. 5
    
6.
Arabi M, Sakchri-Tarbichi AG. The metrics of Syrian physicians' brain drain to the United States. Avicenna J Med 2012;2:1-2.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Express news service Unani, Ayurvedic doctors can prescribe allopathic drugs now Published: April 29, 2015.  Back to cited text no. 7
    
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Lee ES. A theory of migration. Demography 1966;3:47-57.  Back to cited text no. 11
    
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13.
Mayo E, Mathews M. Spousal perspectives on factors influencing recruitment and retention of rural family physicians. Can J Rural Med 2006;11:271-6.  Back to cited text no. 13
    
14.
Padarath A, Chamberlain C, McCoy D, Ntuli A, Rowson M, Loewenson R, et al. Health Personnel in Southern Africa: Confronting Maldistribution and Brain Drain. EQUINET Discussion Papers, Harare, Equinet 2003.  Back to cited text no. 14
    
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Dussault G, Franceschini MC. Not enough there, too many here: Understanding geographical imbalances in the distribution of the health workforce. Hum Resour Health 2006;4:12.  Back to cited text no. 15
    
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17.
Jain M, Gupta SA, Gupta AK, Roy P. Attitude of would-be medical graduates toward rural health services: An assessment from Government Medical Colleges in Chhattisgarh. J Family Med Prim Care 2016;5:440-3.  Back to cited text no. 17
[PUBMED]  [Full text]  
18.
Kumar R. The tyranny of the Medical Council of India's new (2019) MBBS curriculum: Abolition of the academic discipline of family physicians and general practitioners from the medical education system of India. J Family Med Prim Care 2019;8:323-5.  Back to cited text no. 18
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