Faculty shortages may thwart India’s plans for more AIIMS-like institutions in every state
BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g4822 (Published 25 July 2014) Cite this as: BMJ 2014;349:g4822All rapid responses
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Mr Mudur has raised a very pertinent question on the importance of experienced academicians and their role in building the health system of our country. As a layperson, does it please my soul that an AIIMS is coming up in every state? We will end up spending millions of rupees building these huge facilities which may become overcrowded and burdened like the AIIMS at Delhi in the years to come if we do not plan and address the basic healthcare needs of our people at the primary level and tune our health workforce to task share and our communities to be tuned to have faith in the health system to address their varying medical needs.
The commercialization of medical education is the biggest mistake a country like India continues to make where an investment in a medical seat is like a investing in a mutual fund, where the medical students in commercial like medical colleges are looking at pocketing crores during one's career and they aspire to be a prize winning commodity which calls for a "swayamvar" by parents to make a winning bid. Having personally interacted with doctors who practise for the real benefit of mankind, I think that India really needs to ensure doctors are accountable for the work/practice they do. Hence young medical students need to be trained by academicians with the expertise and who understand the pure essence of being a doctor who is a ' person who is trained and licensed to treat sick and injured people.’
As far as the rigor academicians are required to undergo to teach young aspiring doctors, with a sudden spurt of institutions will the government be able to get enough faculty to meet this demand or will we continue to show vacant posts due to lack of trained faculty?
While announcements may like this might be seen as problem solving, it may be helpful to view the overall health system in totality and giving the States the necessary expertise for them to design the functioning of their tertiary care institutions and to make tweaks at a policy level in the health system to address the immediate requirements of their populations and address pressing health problems which they face on a regular basis. In this process they will be also be able to look at the human resources for health requirements and build a framework to ensure all is in place.
Competing interests: No competing interests
Thank you for a thoughtful and thought-provoking, balanced, factual and constructive report.
Some decision makers in India remain (metaphorically speaking) confined intellectually and culturally to their offices. The principles of evidence-based policies and actions are not universally applied (as is the case in all parts of the world).
India has managed to take an evolutionary leap in certain industries like telecomms and health tourism. It is acknowledged in private conversations that the same needs to happen with medical governance, education, research and standards of care, for Indian providers to gain international credibility.
Those from abroad have played an important part in the health care developments of India, as in several other fields. There are many good reasons for the international community to remain engaged with medical education here -- not just the faculty crunch/shortages. Ensuring that attitudes and behaviors in India reflect the accepted international norms can sometimes be a challenge, especially for those who wish to come here to participate and make a contribution.
There is probably a generation now of large number of doctors of Indian heritage who will soon be close to retirement, considering and potentially able to bring their inputs to India. Whether they make a positive impact or become disillusioned may depend to some extent on those who need them here.
It may be helpful if the establishment in India is able to engage its attention to following priorities:
1. Setting benchmarks for fees that are payable (sometimes both above and below the table) for medical education and care
2. Setting competency and governance benchmarks for the health sector
3. Ensuring that in this God-fearing Country the retribution for breaking the law is not just confined to the afterlife
4. Robustly implementing the minimum standards of care
5. Balancing the focus on tertiary care by more attention to Public health and Primary care
6. Reviewing the outdated norms of recognition of medical colleges by the MCI which include (for example) the size in square meters of a medical library
7. Benefitting from the experience and expertise in the UK of deploying Nurses, Paramedics, Pharmacists and other professions to provide services that are traditionally considered to be reserved for doctors.
Competing interests: No competing interests
The article has come at the right time. India's public sector is woefully understaffed and there is no easy solution.The Medical Council of India stipulate that the entry qualification for a teacher is an MD which is a taught three year post graduate course in India. In most specialties there is a parallel Postgraduate Diploma course which is again a structured 2 year PG course. In my experience, this is as good as MD as far as teaching and training is concerned. However, when it comes to counting qualification as teachers, these Diploma holders are considered on a par with basic degree-MBBS holders.This is grossly unfair. When trained at good institutes these Diploma holders are as good as MD holders in teaching undergraduates. If given a good career path there will be enough people to apply for these institutes.The current option is to do an extra two years as a trainee of the National Board of Examinations.The entry into what was once a parallel MD course has now become tougher. Any attempt to simplify the specialization path is thwarted by vested interests.The NCHRH bill which would have revolutionized the PG training system has been aborted in the Parliamentary Committee.
If India can utilize the existing cohort of PG Diploma holders it can have quality faculty.
Regards
Dr. Santhosh Rajagopal
Competing interests: I am myself a holder of a Post Graduate Diploma in Child Health.
Apart from the salary disparity , many things do not go well with India’s premier institutes. All good institutions , be it medical , engineering or any other discipline face a faculty crunch today and future looks bleaker than the present. The disinterested fresh breed of doctors enter the workforce everywhere but academic bodies. And they alone can not be labeled greedy for heading towards greener pastures. There are ample reasons to support their choices.
Almost every institute has one or two examples of faculties caught up in administrative logjam or legal tangles regarding pity matters like promotions , seniority issues apart from genuine issues. Corporate hospitals and private medical institutions offer a hassle-free ride in professional hierarchy and ensure that one becomes a professor much earlier than the government run institutes. And all this with bigger pay cheque. Which way a young doctor will opt is anybody’s guess. Besides it the charm of a label like AIIMS, is used to improve their ‘market base’ by many people as they join and spend a couple of year there before hitting a plum offer. There are some who after twenty to thirty years of service have left AIIMS to be director or dean of a corporate or private hospital. This job hopping causes more trouble for well running institutions as good team of faculty, diligently working toward new benchmarks with continuity is key to success for a role model like AIIMS. Herds of doctors coming and leaving in large numbers is a bad business proposition.
It is high time that top medical institutes go for a makeover and learn a lesson or two in talent retention from policymakers of big and successful business houses. Talent retention is a key issue the world over but companies that adapt with time, bending rules for the most important asset – the human resource may soon start rewriting the old glory.
Competing interests: No competing interests
Re: Faculty shortages may thwart India’s plans for more AIIMS-like institutions in every state
Medical teachers are a rare commodity in India. The growth of medical colleges in independent India has been very rapid. At the time of independence there were only 20 medical colleges admitting about 1500 students. Today, there are some 350 colleges admitting 45,000 students every year. Every year new colleges are coming up both in the private and public sector. Even organisations like Employees State Insurance Corporation (who look after the health of employees and their families in organised sector) have set up medical and dental colleges. Some of the states like Haryana and Himachal Pardesh who had fewer medical colleges are in the process of establishing more such colleges. The Government of India is on a spree to increase the number of seats in existing public sector medical colleges. At one time it toyed with the idea of ‘one district-one medical college’. The plan to set up high-end tertiary care AIIMS like institutions in different states has twin purpose, one to take the load off from institutions like AIIMS Delhi, PGIMER Chandigarh and SGPGI Lucknow and secondly to improve quality of medical education.
However, those who embarked upon such a massive expansion plan failed to realise that there were not enough medical teachers to man these institutions. This shortage is not limited to basic sciences departments alone but also extends to para-clinical, clinical and super-speciality departments. No efforts were made in the preceding decade to prepare a supply line of medical teachers. Naturally there were knee-jerk reactions when the pangs of shortage of medical teachers were felt. These included a rise in retirement age of medical teachers (which now has been fixed at 70 years for private and 65 years for public institutions) and a lowering of faculty requirement norms and increase in number of post-graduate seats by allotting two candidates per year to a Professor instead of earlier one candidate (while no attention was paid towards improvement in teaching faculties).
While the rise in retirement age did serve to halt the depletion of medical faculty, it resulted in a lot of heart ache amongst junior and younger faculty. They felt their promotion avenues were being taken away from them. Even the bureaucrats who are at the helm of affairs did not take the idea kindly as their own retirement age is 60 years. In Punjab, the retirement age of medical faculty in two state run colleges is still 62 years despite the fact that there is a significant shortage of teachers. As the teachers continue to retire and few people are available to fill the vacant slots the condition is bound to worsen. The poaching of this precious commodity by private medical colleges is yet another problem.
The problem is not limited merely to quantity; it also involves the quality of medical teachers. There are only a few colleges which impart induction training to teachers. The concept of faculty development programmes (FDP) is still in its nascent stage. The Medical Council of India has now drafted a plan in this regard but it is yet to take root. One FDP run by PGIMER Chandigarh has been discontinued. In the absence of any formal training, the ideas of curriculum development or implementation, evidence based medicine or even the use of modern teaching facilities is alien to both junior and senior teaching faculty. The lack of quality research in majority of medical colleges is still a far cry. The concepts of research methodology and scientific publication have yet to take root.
The shortage of medical faculty in India thus exists both in terms of quantity and quality. The raising of the retirement age of medical faculty is nothing more than a stop-gap arrangement. An increase in the number of places in post-graduate courses with a matching improvement in training environment is a long-term solution. In the mid-term there has to be a sharp increase in number of places for Senior Residents. Within a span of three years the country will have a big force of potential teachers ready to join as Assistant Professors.
However, if the governments both in the centre and in the states fail to build up a supply of medical teachers the grand ideas of setting up AIIMS like institutions will remain grounded.
Competing interests: I am myself a medical teacher working in government run college.