Why do Indian doctors refuse to work in villages?

This post was originally an answer in Quora for the same question

This is often a derisive topic among the general public, the politicians and the doctors. I also feel that people talk and pontificate without knowing ground realities. People expect altruistic qualities from their other countrymen while they sit and criticize everyone including doctors. So for those willing to understand what the issue is here are a few reasons why doctors are refusing to work in rural areas.

Infrastructure
The government hospitals in big cities like Bangalore, Kolkata, Mumbai, Delhi, Chennai, etc themselves are not the among the best in infrastructure. Even the basic infrastructure already present is poorly maintained. Most days in a month the CT & MRI scanners are not working. This is more like a rule than the exception.  So too the instruments, microscopes, endoscopes, cautery machines and expensive diagnostic equipments suffer from the same fate. If for some reason something stops working, then it wont be fixed till the end of the year or sometimes never at all. This is the story in big cities. So expecting any kind of infrastructure in a rural set up in India is like day dreaming. 
There are hardly any drugs that are supplied to the Primary Health Centers (PHCs). At the most you would get one huge carton of Paracetamol and a 5 cartons of Diclofenac injections (painkiller) and 10 cartons of Sterile water injections (yes water!) and many more cartons of syringes to inject these. These are highly inadequate to run any kind of village health program. When antibiotics are required, even when the patient can afford (rarely) to buy there is not a medical shop for the next 20-30kms (the nearest town). How would a doctor who has put in so many years getting a medical degree feel in this situation when he can't even treat the people around him. When people do not get better how will they trust him/her? 
Some people would say why not refer? I worked in some villages 20kms from Mysore during my rural postings during internship. When we want to refer, the patient doesn't even have money to take a bus to the city. We would sometimes have to pay from our own pocket or even take them ourselves to ensure they go. If a patient with a simple throat infection has to be referred to the city for treatment it shows the dismal state of our rural healthcare. Imagine the plight of that helpless doctor in these circumstances.

Personnel
The recruitment for the PHCs is from the state public service commission (PSC). In Karnataka, one of the more prosperous states in India more than 50% of the slots remain vacant. Why do you think? The corrupt officials running the KPSC always recruit less even when enough applicants are present since keeping the demand high is very good business for them. The going rate of bribe in Karnataka for a PHC doctor's job right now is around 1.5-2 lakhs. The job has a listed salary of Rs. 30,000 - 42,000 pm! Many of the applicants are recruited on an ad-hoc basis streching from 6 months to 2 years and then the whole process starts again. Giving permanent jobs reduces the officials' black revenue.

Now we have one politician who wants to win the next election. Who can he target? Oh the new medical students graduating out of medical colleges!!! Give some speeches of doctors only making money in cities and not serving the poor, put in some fines, threaten their PG seats and the job is done. If not the media does the rest. After a year of this forced labour where the doctor is given no agenda nor help to set up anything in a village,  he's just kicked out in the open. If that student really wants to serve the villages for a few more years he has to put in all the efforts I mentioned in the previous paragraph. Will any sane man do this? I fail to understand who is benefiting from this futile exercise?

Then comes the specialists and superspecialists who are posted in the peripheral community health centers without even basic infrastructure or even a semblance of an OT. You won't get gloves, linen, sterile instruments or even clean bed in these hospitals. My oncologist friend served his 3 year govt bond after his post graduation in a remote village in Tamil Nadu. He spent everyday of those 3 years referring patients to the city, most of whom never reached there. Forget chemotherapy and radiation the medical college he served in did not even have pharmacy to buy drugs. My Orthopaedic (bone) surgeon friend served a year in a community health center doing everything from delivering babies to making house to house visits of every panchayat leader in the villages around. There were no mid-wives even. He hardly fixed a bone the whole year because there was not even material for the cast. He could not even buy it himself because his salary never came and he quit after a year. How is this stupidity helping improve rural health? Is this the best use of the specialist's expertise?

Administration
I have many of my friends working in PHCs. There is a huge hierarchy in the government medical service where too many people in the middle are hardly working. The doctor assigned responsibility of a PHC is not given autonomous control over the running of the same. 50% of his/her time is spent in CYA* in the administration rigmarole set up by their superiors to escape blame for anything wrong that happens. Rest of it is spent in seeing patients, managing lower level staff, putting up with all kinds of nonsense from the villagers, inspecting the whole village for any risks of Dengue, malaria, gastroenteritis etc. and of course getting frustrated at the system. Even the staff under him is not under his control. He cannot even fire the group D staff of the PHC he is supposed to be heading. There is so much administrative burden on this one single man and he's not even trained to do that. He just has to jump into this dirty puddle and learn to swim by himself. All he really wanted to do was help treat people in the rural areas.
*CYA- cover your ass

No scope of progress
There is no clear career trajectory for a doctor working in a rural area. They may get some reservation in the PG entrance exams but if you continue to do primary health care in the villages you don't go up the ladder at no time during your job. You will keep doing the same job at 60 what you were doing at 25. There is no mentor, forget that- not even someone bothered whether you are progressing. How would you feel to be an intern throughout your life?

Security
Forget it. I won't even speak about it. We can't seem to protect the doctors in the cities how will we even think of those poor village doctors?

Pay
I put this in last, lest people would comment how inconsiderate thinking about paying a doctor. I don't have an issue with the salaries posted but I am bothered by how they pay. 
Let me give you an example to explain. Four friends of mine are serving in PHCs in very remote villages where no doctor wants to go. They are working there because it is closer to their home. They haven't received their salaries since 6 months!!! They have a protest about this for one day and the media vultures eat them up. I know people expect doctors to be so altruistic that they should work for free but which job in the world gets done if you don't pay people for 6 months at a stretch? 
You demand why this happens and they say this minister has to release the funds and that official has to sign the papers, so it takes time. 
So how do govt employees like Bus conductors, Bus drivers, bank officials, group D and other govt officials like IAS, IPS, IFS get their salaries on the 25th of every month without this "inevitable delay" ? 
Because if you don't pay these people on time they won't turn up to work next day. Simple as that.

I'm sure there will be people disagreeing with everything that I've said above and then go on to complain about the rampant corruption among doctors, commissions they receive and sub-standard care of someone they knew. There are many people in India who are like an ostrich with it's head in the sand and thinking everything is all right. They expect solutions to fall from the sky. If they can blame it on someone else their job is done. But I would like someone to suggest how anyone would be able to improve the situation in rural areas without putting the onus on unpaid, ill-treated and frustrated doctors. 

Can someone suggest a good enough solution? 

"OMG!!! How can they ask that?"

How should a medical student use his Internship?

I got asked this question on Quora

How do i make best use of internship during MBBS in India?

It got me thinking as to what internship meant to me. I finished my internship nearly 7 years back so maybe now I have better perspective on what it meant back then. I answered and I thought it would be a good idea to share it here as well.

How should you spend your internship?
Most of my seniors said study hard for your entrance exams since its so hard to crack them. I'm sure most interns would study anyway as a default. I wouldn't stress on that aspect.

I would say use your internship to prioritize your career goals.

What do you want to be?
Sometimes this question is asked too late in a medical student's life.

To prioritize your medical career you need to use your internship as career sampling. 

More than knowing what to take as a specialty you should know what not to take.

Few things I think might help you in that

1. Keep an open mind. 
Never get bogged down by other people's opinions about what you should do. What you do is your business not your uncle's or neighbor auntie's.
2. No work is too small.
Take up every role that you come across. Cleaning a colostomy tube is as important as putting in the colostomy tube through surgery.
3. Respect the patient.
Work towards making them better always and try your best not to hurt them.  Always remember that patients are your best teachers so give them as much respect as you would your teachers.
4. Take ownership of your patient. You might be just an intern who follows your unit head's orders but the patient is still yours. Try to create a personal bond between you and your patient. It always helps you and the patient. Both sides get what they want.
5. Medicine is art. 
Work hard in the wards. Your books will only take you so far but the warfield (wards) is where you learn the craft. Never belittle any ward procedures. IV lines, central lines, urinary catheterization ,repair of emergency lacerations..... You never know what you will come across in the wards. These skills you can never acquire or experience later. I did one central line during my internship and that experience was exhilarating. Being an ophthalmologist now I'll never do it again so I'm thankful I did it then. Wards and patients will give you all the inspiration you need to propel you towards a speciality.
6. Make your peace with death and disease.
Until you reach internship you never realize how much death and disease of your patients can affect you. This is because you will have a personal investment on the patient. You will sometimes feel helpless in the face of mortality and morbidity but that is necessary.
7. Find your role models.
It could be anybody you work with and even your own batchmate who has probably figured it out better than yourself. One is never short of people to look up to.
8. Recognize the wrong people. 
You will come across people who are not good at their job, people who insult and look down on their colleagues and juniors, people who are unethical and so on. Identify those people and make note to yourself never to be like them. Do not let a bad doctor ruin a good speciality option for you. I didn't have good teachers for ophthalmology in my medical school but I didn't let it spoil my opinion of ophthalmology.
9. Maintain your sense of wonder
I feel we need to find wonder in what we do and work towards what we want to be. I would advise the same during one's internship. Never lose that wonder.

From Oculoplasty and back

“Just don’t give up trying to do what you really want to do. Where there’s love and inspiration, I don’t think you can go wrong.” —Ella Fitzgerald

Its been an incredibly long time since I've been active on this blog. Partly because I have been busy and mostly because I haven't been inspired to write in a long time. I was in Bhubaneshwar sometime back and it has kind of brought me back to a place where I almost gave up on Oculoplasty as a career. In my earlier blog posts I had professed immense interest in Oculoplasty and haven't really updated what happened afterwards. Its a huge story worth a potboiler at the very least (ha ha I'm kidding). Well I wont bore you with all the details.

But something incredible happened in the end of September 2013. I got an offer letter from National University Hospital, Singapore accepting me for their Orbit and Oculoplasty clinical fellowship program. I had applied to NUH after my residency  just like the many other institutions I had applied to. Somebody there had seen a spark in me and selected me. I was ecstatic and that hunger to get into the fellowship kept me from giving up during the protracted paperwork process to start my fellowship.

I'm now more than 4 months into my fellowship and its been an amazing experience till now and I feel I'm in the best place that I could be. I have finally found a mentor who could really shape my career the way I would want it to go. I'm learning new things everyday and things I never thought I'll be doing.

I'm training in navigational surgery of Orbital fractures,small incision endoscopic browlift, Aesthetic procedures, attending orbital fracture implant courses and a myriad things I hadnt even imagined I would be able to do.  I realize that i'm at the forefront of technology and innovation in my field here in Singapore. The real challenge will be to use the knowledge and training that I have gained here into a place like India where there are always impediments to one's growth. A lot of it is economic and most of the rest of it is politics and nepotism that thrives in my profession in India. I sometimes worry that I'm getting spoiled by all the high tech gadgetry that I see here in Singapore and I fear becoming obsolete in India. Also I'm recently married so to get the kind of solid support from my wife has been comforting but I understand the sacrifices she's making for my career and it sometimes troubles me.

But after a lot of reflection I realize that the basic emotion here is "Joy". Joy in what I am doing despite hectic schedules of this fellowship and finding happiness in an equally important marriage at the same time. This beats every fear that I'll ever have. I figure that if I'm enjoying what I'm doing I'll find a way to make a living out of it.

The Surgeon Conundrum

“From inability to let well alone; from too much zeal for the new and contempt for what is old; from putting knowledge before wisdom, science before art and cleverness before common sense; from treating patients as cases; and from making the cure of the disease more grievous than the endurance of the same, Good Lord, deliver us.”

Sir Robert Hutchison, 20th century physician, British Medical Journal, 1953

I often hear descriptions of famous surgeons as “great”, “amazing””, “brilliant”,etc. and wonder how those adjectives get decided. The corollary used in describing a surgeon is somewhat akin to a performing artist or an athlete. The problem with such an approach is unlike an athlete who can be assessed by statistics or artists who is assessed by cultural expertise of common people, a surgeon does not lend himself to such assessment. A surgeon does not have a publicly available success rate statistic nor do common people have any expert knowledge of surgical procedures to know if a surgeon is great or not.
Is surgery so hard? Yes and No.
YES because one needs to put in years and years of study to even have the opportunity to hold a scalpel and from then on has to practice relentlessly for many more years to actually master the surgeries in his/her specialty. For that relentless pursuit the surgeons usually have to sacrifice the prime years of their lives to this task, having no time of their own, decreased social and personal life and often living under debt or their parents’ financial benevolence for a little less than half their lives. 
NO because its not magic. Most surgical procedures have certain established techniques which if practiced over many years become second nature to the surgeon. So if you know the rules you are set. Of course it goes without saying that you would need a certain level of aptitude and intelligence to learn the complex machinations of the human body,decent memorization ability and a whole load of patience but essentially surgeons are human beings like the rest of us. Only that we surgeons are the lucky ones among humanity who get to wield the scalpel to help humanity as a reward for all those years of hard work.
Skill can vary of course like in any profession, they can be excellent, good, average, poor and miserable. Skill, we surgeons are often told is what separates the great from the rest and yet there are many average skilled surgeons doing incredible service to mankind which many highly skilled surgeons could not.
So does mere skill of a surgeon decide his greatness? Here its a big no. From what I see from the inside of a surgeon’s world, having started my surgical career 3 yrs back, the greatness of a surgeon has to be measured beyond just skill. Like my Professor in college used to say, “ Any fool can operate,even that cobbler on the street or that OT technician, maybe even skilfully but what should separate you from those fools is that you should be able to judge what surgery the patient needs or if he needs surgery at all?” (he had more colourful words to say, this is the watered down version of it, LOL). I recently heard an amazing perspective from a very famous surgeon (he’s a brilliant surgeon by the way) : “ The reason older experienced surgeons do lesser types of  surgical procedures than younger newer surgeons is not because they are any less fearless or capable than the younger ones its because they are tempered with the wisdom of what works and how well. The ability to cut down on trying too many things and to bring more efficiency and longevity to surgery is what experience brings”  These are two different perspectives with a converging opinion on the importance of clinical judgement of a surgeon being paramount!
Doing too much or doing too little? Where do surgeons draw the line?
For that the “art of judgement” is the crucial quality of a surgeon. I sometimes feel we as surgeons are often guilty of “surgical over-aggressiveness” . There are times when doctors operate when in hindsight just waiting would have done the trick. Sometimes when a medical treatment would be far more beneficial than a surgical one. Other instances when after surgery the patient is worse off than before. It’s not to say these doctors have any vested interests to operate. They mostly always want to help the patient and often in their zeal probably do too much. Sometimes its more harder for the doctor than the patient to accept that nothing more can be done. But again in trying to solve the “doing too much” problem, surgeons should not fall into the “doing too less” trap which so often happens in many hospitals these days where patients aren't demanding or in the know. There are several instances when doctors just chooses to delay instead of taking that acceptable risk to operate since they don't want to be responsible for somebody’s poor surgical outcome. Some don't even refer to a specialist who is capable of doing the surgery with lesser risk. In the end such a patient’s surgery is not done at the correct time resulting in handicap or he/she succumbs to the disease. This attitude is worse than the “doing too much” phenomenon. As an example i distinctly remember one little girl of 5yrs who came with multiple metastatic cancer to my hospital when the original small eye tumour which was detected a year earlier was not operated by the doctor assuming it to be benign. A clear case of doing too less and the experience is so heartbreaking for everybody concerned.
There are no definite answers to most surgical decisions because medicine is a field where results cannot be predicted with pinpoint accuracy like a mathematical model. But surgeons have to take these calls everyday and no one else can do it for them.The surgeon’s judgement sometimes lies between life and death of a patient so its not as simple as people believe it is. I am happy to say with full confidence though that for the most part more good than bad gets done in the full balance of things. The ability to do as much as possible to help the patient yet never letting one go overboard is a balance every surgeon should aspire to attain and this balanced judgement is what makes a surgeon truly GREAT.