Why don’t doctors stay in villages
A few days ago I asked a student of Public Health what was the public health question that bothered him the most and he promptly answered “Why don’t doctors stay in villages?” He knew that India had finally breached the WHO standard of doctor:population ratio of 1:1000 but was concerned about the huge difference in the availability of doctors in cities and in villages. As a diligent student he had looked at the Economic Survey report of 22- 23 that had reported the favourable doctor:population ratio data as well as the earlier survey of 2018-19 that had reported that there were many PHCs without doctors. The Rural Health Survey of 21-22 had also reported that there was a serious lack of doctors and other staff in PHCs and CHCs, he said. Knowing that I had spent several years as a young doctor in the villages of Uttar Pradesh he asked me why I had gone to the village and why I thought doctors were not going there any more.
As a young doctor I had initially gone to the villages of Uttar Pradesh not just to ‘save the lives’ of the rural poor, but to also have an adventure and to be able to live with my girl-friend (subsequently my partner). These were compelling motivations for a young person! The decision to work in villages was made early in the course of my medical studies, but the challenge was where would this be.
I realised that a rural posting was not deemed desirable when
my request for a rural posting during my intership was met with a stunned
silence. Despite the newly introduced
Reorientation Of Medical Education (ROME) scheme to encourage rural posting for
doctors in training I was told ‘ we don’t have arrangements for interns staying
for so long.’ On insisting I was offered an alternative PHC closer to Kolkata
where I could go daily. Unfortunately my faith in public systems took a further
blow when I learnt that the resident medical officer, used my presence in the
PHC to disappear into his private practice. Recognising I wouldn’t be able to
navigate the challenges of the public system, I seized the opportunity to work
in a charitable rural hospital, even though it was in UP.
However, many of my batchmates did join the public system
and served in rural areas for several years. Even today, a significant number
of doctors opt for rural health service. Despite this, there are substantial
gaps in the number of doctors available in rural Primary and Community Heath
Centres, impacting the services being provided. The straightforward query from
the young Public Health student set me pondering whether there was a simple
human and systemic approach to address this issue,
Reflecting on my early days as a Resident Medical Officer in
a small charitable hospital in a village outside Benaras over 35 years ago, I
realise that it was not only what I could ‘do’ that charged me. I was excited
to ‘learn’ about things that I suddenly realised I knew nothing about. How did people
live their lives in which they fell sick and in which I expected them to
recover? The prescriptions and treatments were meaningless if I didn’t
understand these. But I hadn’t been trained to do so. I wonder whether medical
students are trained to do so today?
When I first started working with patients from rural UP I
realised that I needed to learn not only their language, what they called their
body parts, but also how they lived their lives to piece together their
complaints and symptoms. This was difficult in a room teeming with patients
eager for their 3 minutes with the doctor. I had to develop a good humoured
approach to my patients, so that they didn’t mind waiting, so that they knew I
valued their time as well and at the end of the day their visit would be
worthwhile. I met them outside the clinic. I was curious about the lives of my
patients, lifestyles and cultures I was completely unfamiliar with. I adjusted
my own interests as a urban young person and soon I was not missing my urban
life because I had enjoying my adventures in rural living very much.I learned
to be empathetic.
The social and economic differences in both rural and urban
India have changed tremendously in these last 35 years. Those were
pre-liberalisation days and we now live in the age of AI and IOT. Many
rural-urban differences have reduced, others have increased. Material
aspirations among the young have also changed. I am told the youth even now
seek adventure. Living and working in rural India for about 15 years was a very
fulfilling adventure for me. Can we inculcate a continuous quest for new
learning and for adventure within the limits of health and medicine for young
doctors, I wonder? We could, but we may need to reorient our teachers and
training as well.
From what I can make out, the emphasis during training is nowadays
on ‘specialisation’. I often wonder whether the MBBS degree, a weighty set of
alphabets before admission to the medical course, is just a qualifying exam for
the PG degree? There was an emphasis on the PG even in the mid-80’s, but we
still had to go through compulsory ‘housestaffship’ in the discipline of choice
before one could apply for post graduation. I took this opportunity to train in
two disciplines and then didn’t sit for the PG entrance, because I wanted my
MBBS degree to mean something. Today I am told the experience we had as
‘housestaff’ is integrated within the ‘residency’ period of the 3 year PG
degree. So in effect what you have is a ‘specialist doctor’ exiting the Medical
training process. Asking such a person to join PHC and attend to routine
medical problems along with maternal and child health problemss, may be a
profoundly wrong fit of both competencies and aspirations. But couldn’t these
freshly minted specialists be posted at the Community Health Centres (CHCs) where
they could both gain valuable practical experience and provide much needed
specialist services closer to where rural people live?
Another lesson from my own life and career in rural health
is that adventure requires freedom and a team-spirit to problem solving. The
freedom to experiment and support each other to find alternative pathways. Public
systems are unfortunately based on ‘prescription’ and ‘inspection’ and a ‘chain
of command’ that rarely values empathy and camraderie between different levels
of the hierarchy. A diligent young doctor who is developing a team approach for
locally relevant solutions to public health problems, say at the PHC level, may
not get the encouragement she requires from her superiors. Public systems often
are more earnest in castigating than in encouraging, and this can be very
disheartening. In my little experience as an observer and student of public
health systems I have found that they relationship between layers of the hierarchy
are patronising at best and rarely foster a collegial or team spirit.
There are several practical barriers that don’t allow young
doctors to go and serve in rural PHCs and CHCs. However one overlooked aspect
is the social milieu and growth that is integral to any young professional’s
life. The campus colonies attached to factories located in the rural interiors
have addressed this better. Rural districts and sub-districts host several
young professionals, often with families. These families have their own social
and other needs. Does the health system anticipate these needs? Rarely do
public systems create the space or opportunities for such families to meet
their needs. How do I get our child educated is a constant worry for young
couples. I have seen uninhabited RMO’s quarters, simply because they are
unliveable. It is also difficult to live all alone at the edge of village, where
public health centres are often located. Facilities like residential campus,
clubs and other social spaces, or school buses for children of public officials
may go a long way in ensuring young professionals with families continue to
live and work in their rural workplace.
Excellent…..actually an eye opener (personall)👏👏
ReplyDeleteIndeed, many doctors would like both the adventure and the social learning opportunities that a village posting provides. But they also express tremendous frustration at the lack of infrastructure and equipment at the PHCs and CHCs. The desire to make a difference is often mitigated by the inability to make a difference, and that is often a deal breaker. What do you think?
ReplyDeleteNowadays much more equipment is available than earlier. The deal breaker is often the lack of encouragement to innovate, that is often necessary to deal with local specificities.
DeleteFrom SC:
ReplyDeleteWhat a lovely piece.
I think though, that there is also a very real problem of atrophied ambitions and aspirations of a certain class of young people who enter medicine to begin with.I was the only person in my cohort to want to do something political with my career - and it has a lot to do with my identity.
In subsequent years more dentists and doctors are veering into public health but that has happened because the nature of public health has changed and it is a more lucrative career than a clinical practice. Most of those people (we’ve had a lot of interns who were dentists for instance) have ended up in large INGOs or management consultancy organizations.
And if I go by what my father says of his students, it’s not just a rural doctor problem. In general, medical students these days even in urban areas, aren’t interested in excelling at clinical practice either.
ভালো লিখেছিস। তবে সরকারি চাকরির লিমিটেশনের মধ্যেও অনেক কিছু করা যায়। ইনোভেশন ইত্যাদির চক্করে না পড়েও। অনেকেই ক্লাব-স্কুল নেই বলে সেটা এড়িয়ে যায়। সেগুলো বাজে কথা। ইচ্ছে'টা বড় কথা। দায়বদ্ধতাও। সাথে সঠিক ট্রান্সফার পোস্টিং এবং opportunities এ-র প্রসেস জরুরী, সেটা ঠিক। সেটাও দরকার। আর দরকার বোঝা যে আমি ডাক্তারি পড়েছি বলেই ১০টা হাত গজায় নি।
ReplyDeleteThe onus can't only be on the individual doctor. Do different individuals at many levels who together make up the system, care enough for the rural communities?
DeleteFrom SG:
ReplyDeleteEnjoyed reading this... its very much true that today's many of the young doctors (at least whom i met ) take rural posting due to a condition imposed for PG ... and then at the level of medical college how much weightage is given to motivate young doctors about rural postings.. ! and then challenges at the health system level...
From NG:
ReplyDeleteWe chose our specialisations on what we were interested in.Nowadays doctors are choosing their specialty on how lucrative it is and also how risk free it is.Thus Dermatology and Psychiatry which were at the bottom of the heap in our time are the most sought after specialties these days.I simply don’t understand how a doctor can choose a specialisation if he doesn’t have an interest in it.Personally had I chosen a surgical specialty with the view that surgical specialties were more lucrative then I am sure I would have ended up having a lesser than what practice I have as a physician.I simply did not have any interest or talent for surgery!As you have mentioned there is no housestaffship anymore and the end result is that during internship when the young medicos should be starting their journey in the practical aspects of this profession they spend their time in doing MCQs!I am appalled to see that those fresh out of internship do not know the basics of taking a history and doing a basic clinical examination.Not everyone gets a seat in a PG stream and the worst off are those who do not.After trying multiple times and failing(in some case in the specialty of their choice) they are left in a position where they don’t have basic practical knowledge to work as a GP.The MBBS degree has been denigrated to an extent where it doesn’t mean anything anymore.However even docs do not understand that without that degree there would not have been the subsequent MD,MS,DM,MRCP,FRCS etc.The lack of respect for MBBS is also noticeable in how docs write their postnomials.Most forgo the MBBS and simply write MD or MS or whatever their specialist degree is.I still make it a point to write MBBS before my FRCP as my post nomial.
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ReplyDeleteFrom LP:
ReplyDeleteWell said.
How about a rural posting for doctors in the second half of their careers once their kids are schooled and sent off to college? Once the mid-life crisis for meaning hits? Go on an adventure to the rural parts of India with with lots of experience under your belt. At a time when you start thinking more about your own health, fresh air, less noise, less of a draw for restaurants and all that city life offers?
And this desire for more meaning in your life before you pass on?
From AB:
ReplyDeleteMindset ! There's money in the village , probably more , and also in cities .
But it is the mindset that prevents the guy from staying and practicing in the village . Should he/she do that , then the person will also be in a position to effect social change and may be in the long run prevent migration to cities .
But yes , the person concerned must be a doctor worth his salt . So that people have FAITH and BELIEF in him .
That VISION has to be there.
I was interviewing for an MBA seat in IRMA ( irony abounds) and was asked the same Q. It was the first time someone asked me honestly - why don't you go to a village to set up your dental practice. I floundered a bit and finally settled on the combination of my training (that utilized multiple tools, lots of electricity, lot of lab work), and a lack of infrastructure that prevented me from doing so, in my answer. Till my time, we had spent a sum total of about 10 hours, on theory, related to treating dental patients in a village setting ( out of 4 years of theory lectures). Plus as a 20 something sapling, my orientation, personally, for growth was in a different direction. My institution was in city outskirts, and a majority of patients were from surrounding villages and it was an interesting mix of clinical and social issues we got to see. For me to take what I have been trained with, and transplant it into a rural setting seemed all but impossible.
ReplyDeleteEnjoyed reading this piece. As a final year medical student, it was an eye opener, that we can serve people/have opportunities in our own country's rural areas, instead of further studies, in a concrete jungle.
ReplyDelete