Year : 2013 | Volume
: 2 | Issue : 1 | Page : 1--3
The politics of medical practice license and its impact on primary care workforce: International developments and Indian perspective
Editor-in-Chief, Journal of Family Medicine and Primary Care, President, Academy of Family Physicians of India New Delhi, India
B-32 Chanakya Place Part 1, Opp C-1, Janakpuri, New Delhi - 110 059
As a country India has to her credit the largest number of medical colleges in the world. More than 40,000 seats of MBBS (Bachelor of Medicine and Bachelor of Surgery) are available annually but only a fraction would enter into primary health care vocation. It is a matter of common perception and also of great concern that a large majority of young Indian doctors are not willing to serve the rural, remote and underserved population. An observation on human resource policies of several developed countries reveals interesting patterns. Beyond willingness and interest of the medical students and young doctors, there are real factors which prohibit their engagement with the health care delivery system in India, especially in the area of primary health care.
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Kumar R. The politics of medical practice license and its impact on primary care workforce: International developments and Indian perspective.J Family Med Prim Care 2013;2:1-3
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Kumar R. The politics of medical practice license and its impact on primary care workforce: International developments and Indian perspective. J Family Med Prim Care [serial online] 2013 [cited 2020 Sep 21 ];2:1-3
Available from: http://www.jfmpc.com/text.asp?2013/2/1/1/109924
Indian Doctors Failing in Key Licensing Examinations in UK
There is a recent report from UK that Indian doctors are failing in the key licensing examination in general practice. Approximately 60% of medical graduates from India, South Asia, and Africa have failed in the licensing examination conducted by Royal College of General Practitioners (RCGP). ,
There is a lesson to be learnt by medical students and young Indian doctors. In general, we are inclined to think that most meritorious persons should get license to deal with human lives. We also like to believe that the best Indian doctors emigrate abroad. However, there are other larger invisible forces, other than merit and capabilities of individual doctors, which govern license to practice a trade such as medical profession. For decades, countries like USA and UK have exploited postgraduate training opportunities as a tool to attract young trained medical graduates, from developing countries like India, Pakistan, Bangladesh, Philippines, China, and Africa to strengthen their own healthcare workforce. It is to be noted that undergraduate training is much more expensive. ,
Postgraduate Training Positions as a Strategy Towards Strengthening Healthcare Workforce
In USA, the number of postgraduate (MD/MS) seats is almost double the numbers of the undergraduate (MBBS) seats. For 16,527 US medical school students, 26772 positions of post graduate residency training were available in 2012. Of these postgraduate seats, approximately 50%are available in generalist disciplines such as family medicine. These excess of postgraduate training opportunities are the bait for IMG (International Medical Graduates). 
Interestingly in India, we observe the reverse scenario. Though the official ratio for MBBS and MD/MS seats is said to be 2:1, there are various types of educational qualifications which define the practice privileges, restrictive barriers and independent trade license. There are degrees, diplomas, DNBs (Diplomate of National Board) in non clinical, pre and para clinical disciplines. At the end only one in ten doctor will secure a clinical practice trade licence. While the majority of medical colleges are operating in the private sector, the license to practice is available for a handsome capitation fee on demand. The cost of these seats is directly linked with scarcity of residency training opportunities/ specialist trade licence in India. (There is a shortage of post-graduate opportunities because if you open it up, capitation fee will collapse and then the [medical education] industry will collapse- Dr Devi Shetty, Former Member, Board of Governors, Medical Council of India , in an Interview, March 23 2013 Forbes India). DNB qualification offered by National Board of Examination (NBE) is largely perceived by young doctors as a platform for exploitation. This system lures venerable medical graduates and makes them work for three years as trainees and a great majority among them end up without securing a specialist trade practice license. ,,
Today there is a scarce chance for a fresh medical graduate to evolve into a competent medical doctor equipped with full trade licence. It is no wonder that a good number of Indian medical graduates are aspiring to immigrate abroad not necessarily due to personal ambition but due to difficult professional conditions. Back home, many of them have already started seeking opportunities in civil services, business management, clinical trial, call center jobs, pharmaceutical industry, real estate, travel business, cosmetic and beauty industry etc. Irrespective of the talent pool of youth in India, only a very limited few will get license to practice as a clinical doctor which is a paradox itself; given the billion plus population.
The Impact of Limited Number of Medical Practice Trade License
Our system is surviving because of abundance of merit (population supplies for it) as compared to the available opportunities. The hard work of medical students and young doctors compensates for the intrinsically weakened medical education system. In this flawed environment, medical students and doctors tend to judge themselves by the difficulty and toughness of the entrance tests they are subjected to at undergraduate / post graduate level. However, the training and licensing system operate differently. Therefore majority of our young doctors spend years of dysfunction, preparing for MD/MS entrance without stopping to think by their own minds, in spite of the statistical odds.
Limited opportunities create a false hierarchy and hegemony among the most capable persons of our society. While a few enjoy the privileged and glamorous life, majority constitutes an unsatisfied workforce. In the absence of necessary processes, majority of MBBS doctors are ending up as cheap labor supply working at large hospitals in metropolitan cities as ward RMOs (Resident Medical Officers); stretching up to 100 hours per week ( employed at two to three hospitals) struggling to meet their end needs. In public sector they have an option to work as contractual worker engaging in a bulk of nonmedical work, which could be very well taken care of by a non licensed person. Contrary to the perception of the scarcity of medical doctors, there is no campus interview or fat pay packages even at premium institutions like AIIMS (All India Institute of Medical Sciences). This is unlike the opportunities available for top management and engineering graduates, indicating towards some fundamental flaw in the intent and direction of medical education system.
Given the clinical morbidity and the burden of huge population, one of the major challenges lies ahead is expanding the opportunities, training, and complete license for the available workforce, specially the MBBS doctors. Lack of recognition for primary care as a trade/vocation of medical practice and non availability of training posts in family medicine is the reason for scarcity of training residency positions in India.
Medical Practice License is Not Governed by Merit Alone
In country like Australia, it is very tough for International Medical Graduates (IMG) to get a license to practice. However, if someone is willing to work in rural, remote location and area of need, work permit is available without having to clear the licensing examination. In Canada, physician recruitment agency of Saskatchewan (government agency) has recently conducted interviews in India for direct recruitment with license to practice for family physicians. In UK, we cannot be sure about the racial bias, however message is loud and clear. You are welcome to work under supervision but not entitled for an independent trade license, that is, allowed to own your own business. After formation of European Union, direct license is available to European doctors. Asians and Africans are bound to be edged out. ,
Lessons for India
The impression and perception that young doctors are not eager to work for community setting in India is an unfortunate and a wrongful misconstruction of the facts. In India, unfortunately due to healthcare workforce mismanagement, majority of the young doctors do not get a fruitful opportunity for engagement within the healthcare delivery system. There seems to be no initiative and eagerness to end this deadlock by the people who are in a position to influence. Given the morbidity pattern and population, there is a genuine need for practicing and skilled doctors in the primary healthcare sector. However, the concept of gate-keeping by efficient and assertive workforce in the community intimidates many interest groups. There is a willingness to continue with the centralized administrative process of the public health fund distribution system. At the same time unrestricted migration of patients continues from under served and rural areas to feed the urban un regulated tertiary level heath care services. Since the inception of medical profession, license to practice has remained a political issue and governed by political forces.
Limiting medical education to tertiary care institutions and allowing teaching exclusively by doctors with specialist qualification is an obsolete concept. Restricting entry of primary care doctors into mainstream medical education system as faculty and not legalizing community health services as accredited sites of medical education is not an inadvertent act of omission. Rather it is a well thought out strategy towards supporting the existing monopolies. As an outcome, doctors engaging in primary health care also do not occupy leadership positions at academic institutions and therefore do not have any representation on the regulatory bodies such as Medical Council of India and National Board of Examination.
Primary Healthcare is Future for Medical Graduates in India
Primary healthcare is the future of medical graduates in India. Recognition, development, and execution of primary care as a vocation for medical doctors are the way forward. Universal Health Coverage (UHC) and National Health Mission (NHM) will open up new horizons and expand the career opportunities. 
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