Misdiagnosed: India's medical education struggles to treat its own ailments

“Violence isn’t new to us. It’s common for patients' families to cross the line, but no systematic action to protect us is ever taken,” says Suvrankar Datta, a radiologist and AI (artificial intelligence) research resident at AIIMS. “Many of my colleagues are now considering leaving the profession altogether,” he adds.

The Broken System

Safety and security are just one of the arms of a plethora of much-spoken-about structural issues like the devaluation of merit in admission through NEET, particularly in private institutions, at times leading to the admission of suboptimal quality students. The exceptionally high capitation fees. The reported alarming shortage of medical teachers.

Amid these pressing concerns, the National Medical Commission (NMC), the regulatory body overseeing medical education, professionals, institutes, and research, has been focusing on building more private medical colleges—in a country that already boasts the most medical institutions in the world—which has raised further doubts about student admissions and the quality of education. In his Independence Day speech, Prime Minister Narendra Modi also promised 75,000 more medical seats over the next five years.

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“Government, in general, is insensitive to health care, as it is a state subject,” rues Dr RV Ashokan, president of the Indian Medical Association, a representative body of doctors in India. He elaborates on the potential reasons behind the push to establish more medical colleges. “Establishing a medical college attracts the attention of local constituencies and provides political dividends to leaders, hence the push for more colleges,” he says, adding that there is an inverted priority. The number of MBBS doctors is increasing, but minimal effort is made toward job creation.

“There is a big mismatch between quantity and quality. India is producing more doctors but not improving their quality,” says Amrita Agarwal, a health care policy researcher with the Centre for Social and Economic Progress (CSEP). “There has to be a clear policy roadmap which encourages large hospitals to scale up production versus just adding more medical colleges in remote areas, which again do not have quality faculty or equipment,” she adds.

The focus has primarily been on creating more medical graduates than producing specialists. The postgraduation (PG) to undergraduate seat ratio in India is lower than that of other countries; this figure is 0.67, compared with 1.85 in the US, 1.01 in China, and 5.98 in the UK.

Data on PG specialists in community health centers (CHCs) shows the shortfall widening between 2005 and 2022, from 46 percent to 80 percent. This is concerning, considering that the disease burden associated with six of the top 10 causes of death in India requires the attention of specialist doctors. Select states have attempted to address this shortage by promoting alternative routes to specialisation (e.g., DNB, CPS). But a lack of uniform recognition across states and by the National Medical Commission has affected the uptake of these courses and, in turn, the availability of specialists, a CSEP report points out.

“Creation of more specialised doctors needs more faculty. There is a massive faculty crunch,” says Ashokan. “The monetary and other incentives for faculty are bare minimum,” he adds. There is a high vacancy in teaching positions, even in premier institutes like AIIMS Delhi—as represented in the graph, pointing to the structural shortcomings in the current recruitment and compensation structure for teaching faculty in medical colleges.

“Blindly increasing doctors does not address the issue of having enough specialists. And unless you increase faculty seats, you can’t increase postgraduation seats… the effort is less because this needs high human resource investment from the government’s end,” explains Dutta. While teaching faculty shortages have been addressed through piecemeal reforms such as relaxing retirement age, allowing visiting faculty, etc, the key structural barrier of the disincentives of moving from practice to teaching remains to be addressed.

Bonded Slavery?

Another highly questionable practice is India’s bond system, which requires newly trained doctors to serve in rural areas after their education. While designed to address rural health care shortages, the system often results in young doctors serving under-equipped medical centres with limited growth opportunities.

“This bond system feels like slavery,” says Mishra. “We’re made to work in rural hospitals that don’t have the right equipment and very few resources, which doesn’t benefit us or the communities we serve in the long run.”

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Dr Ashokan agrees: “Long-term initiatives are needed to attract and retain physicians in these areas, with proper infrastructure development rather than relying on quick fixes like the bond system.” He emphasises that bonds should be done away with if the quality of doctors is to be enhanced.

Burnout and Barriers Pushing Students Abroad

In India, admission to medical colleges is highly competitive through exams like NEET-UG and NEET-PG. These exams are often criticised for fostering rote learning rather than clinical understanding. Shah recalls his experience: “In India, we had to memorise answers without truly understanding clinical logic. I learnt the most while preparing for the USMLE [United States Medical Licensing Exam] exam, which presents questions as real patient scenarios, encouraging critical thinking.”

“No doctor today wishes for their child to become a doctor. It’s one of the least rewarding professions,” Mishra says candidly in between bites of a quick lunch during her 36-hour shift. “We devote our youth to medicine, but administrative mismanagement leaves us drained. We can’t focus on anything else in life.”

The administrative issues that Mishra mentions refrain Indian medical colleges from being among the best in the world. Agarwal elaborates: “If you look at the top 50 medical colleges globally, most are part of university settings with affiliations to teaching hospitals. In contrast, in India, most teaching occurs in hospitals with minimal affiliation to universities. This model limits cross-disciplinary understanding in India,” she says.

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“I do not think the Indian authorities aspire to be among the top medical colleges. We're very inward-looking. Whereas what is required is a complete shift from this old-fashioned hospital-driven teaching model,” she expands.

Problems further escalate due to several economic barriers. Given that education loans in India do not cover tuition costs related to attendance at private coaching institutions, students from unprivileged backgrounds continue to face substantial difficulties in accessing residency positions. India doesn’t have the same homogeneity in trainee salaries to the extent that some institutions do not pay their residents. Where they do receive a salary, it is typically meagre. “Imagine being in your early 30s and making bare minimum salaries after devoting more than 10 years to practice... the return on investment in this profession is slow,” says Mishra.

“The system works against individuals coming from difficult backgrounds while supporting those with financial resources, resulting in, at the end of the pipeline, a workforce that is wholly different from the population it serves,” states a National Library of Medicine research report titled ‘Financial barriers and inequity in medical education in India’.

The Turtle in the AI Race

Globally, the integration of AI and technology into health care is advancing rapidly. India again remains on the sidelines. "In the US, AI tools are improving diagnostics and patient care. Here, we’re still struggling with paper-based records," says Shah. While India’s National Digital Health Mission (NDHM) aims to digitise health care records, experts believe it will take at least a decade to see significant results. The country’s reluctance to invest heavily in health care technology leaves both doctors and patients at a disadvantage.

Dutta, an AI researcher himself, stresses the need for better funding and equipment. “Digital health and AI advancements are critical, but most Indian doctors are unaware of the advantages. We need more governmental push in this direction,” he says.

But What is the Solution?

The National Medical Commission (NMC), the regulatory authority overseeing the sector, has been sluggish in implementing long-term structural changes. The reasons are complex, and rooted in the challenges that come with governing a diverse and vast nation like India. Achieving swift, unified reform across the country is difficult, but even at the state level—where education policy is primarily shaped—there has been little progress in driving effective change.

Instead, problematic initiatives like the three-year Rural Medical Assistants (RMAs) diploma course, introduced in Chhattisgarh in 2001 and Assam in 2004, have raised questions about the unclear career path for RMAs after training. “This course is illegal and unethical. It labels people with dangerously low knowledge as doctors and gives them a licence to practice. Medicine takes years of practice and understanding, these three-year halfway doctors are a danger to society,” says Ashokan.

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Another reason why medicine is put on the backseat in India can be attributed to the lack of a national administrative body to check. Experts in the health care sector have recently called upon the Union Health Ministry to re-introduce the Indian Medical Service (IMS) on the lines of the Indian Administrative Service (IAS), Indian Foreign Service (IFS), and Indian Police Service (IPS).

Indian Medical Service can formally address the structural issues and enhance medical education infrastructure. IMA is a strong advocate for establishing this arm and believes it can reduce health crises by improving preventive health care at the primary level and can also enable seamless coordination between states and the Centre for health care policymaking while monitoring better education policies.

“Administrative services are the backbone of India’s problem resolution. Every subject that has an administrative arm gets due diligence. Health care hasn’t been a priority so there’s no concrete action on it,” expresses Dutta.

In 2017, the central government expressed interest in creating the Indian Medical Service on the lines of IAS and IPS. Following this, the health ministry sent a circular to the states asking for their views on such a move. However, even after years, no further action has been taken. Its creation faces opposition due to concerns over the potential marginalisation of state authority and the complexities involved in integrating such a service within the existing administrative framework.

“This argument against establishing IMS that health is a state subject falls flat on its face through the existence of IPS even when law and order is a state subject,” says Ashokan. When asked if the inaction around the structural issues can lead to a decline in youth's interest in pursuing medicine, Ashokan says, “The scientific curiosity will always triumph all odds, and the desire to serve for good will always bring to fore the good breed of doctors in India, however, the government needs to be more sensitive.”

“The ethics and etiquette of the profession should be maintained. Health care shouldn’t be defined by for-profit hospitals or viewed as a set of targets to be achieved. We need to regulate policies to ensure that profit is not the driving motive in health care, and instead, focus on building a robust public system,” concludes Ashokan.  

The numbers tell a grim story, but solutions are within reach. To prevent the current doctors' protests from escalating further, immediate, bold reforms are needed. The question is: Will India’s leaders take action before it’s too late?