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?"

Life of a 21st century doctor!

The medical science has seen a sea change over the last century.....more than what has been achieved in the previous 5 centuries put together. The change has been for the better for patients as people are getting cured of diseases which previously had no cures.

In this state of change to expect the medical profession not to change is simply naive. I would like to enumerate the good, the bad and the ugly of the medical profession in general and the joys and challenges of doctors in particular. This is in no way a negative or cynical post. It is more of a perspective of how things are and how it is going to be.

Medical Education

Over the years the field has grown leaps and bounds and this being the era of super specialization.....now doctors are moving on to micro specialization. It has become harder for students to keep up to the whole gamut of information which keeps changing every few years so "specialization in minutiae is inevitable" is  the new world order for doctors. I agree with this in principle but the path to specialization especially in India is difficult, unrewarding and involves a lot of factors unrelated to your capability to be a good doctor. First on the list comes low pay right from the time a medical graduate passes out. This pay never reaches the amount appropriate to his/her level of expertize all through their career unless he/she indulges in any wrong practices or his/her family owns a hospital. Second is the high cost of medical education not only monetarily but in the quality of life a medical student has to endure throughout his student life. An equally capable professional in another field is pretty much well set by the time a doctor can come out to practice and by which time the doctor has a mountain of debt and an unforgiving society. There is very little incentive for a student in India to join the medical profession unless their family owns a hospital or have unending disposable income to spend. This puts the profession beyond the reach of the middle class since there are no returns for the incredible amount of mental and financial investment required from a doctor. So is it any surprise with the quality and character of the doctors of the new era. The brightest and smartest don't want to become doctors since it's simply not reasonable for a middle class family to sustain a medical student. This makes way for corruption and only the people with the insane amounts of money can become doctors in the new era. Are these the kind of doctors you want to trust your lives with?

Those fortunate to be bright enough enough to secure a government medical/ residency seats which they can afford are treated so shabbily by the system. They are often put up in slum like living condition in hostels with bug infested rooms, mosquitoes and the works by government colleges. They are often made to work 80-100hrs a week resulting poor nutrition and low morale. A lot of them end up sick and in extreme cases even dead. On top of that, the added danger of flash mobs assaulting the emergency doctors on call. The general feeling is the residents are often disgusted with the system and with their seniors for perpetuating this unfair system. This is how the brightest in the field are treated by the society. Some links below which might give an idea of how big the problem is.

https://in.news.yahoo.com/why-indian-doctors-fear-for-their-lives-043955469.html?fb_action_ids=10202670862286429&fb_action_types=og.recommends&fb_ref=facebook_cb

http://www.dnaindia.com/mumbai/report-who-takes-care-of-doctors-in-bmc-run-hospitals-2029755

The specialist doctor problem

These days everyone wants to be treated by the specialist. To a lay person it might seem like the most correct thing to do and may feel that super specialist is very accomplished hence also the most capable to treat his disease. In practice however it is a huge waste of resources. In most patient surveys around India and the world 80% of the sickness can be treated at the primary healthcare point. The consequences of making the cardiologist treat a common cold is that the patient is wasting a cardiologist's expertise and overpaying his consultation as well. People don't realize the importance of a general practitioner or general physician in their healthcare. This discourages newly minted medical professionals from taking up general practice. It is just not viable for them. What is the government doing about this problem. They are completely ignoring the issue and like they have treated primary education, they are treating primary healthcare with the same disdain. They aren't hiring permanent staff for their rural areas and those hired are paid salaries once in 6 months. They are forcibly making new residents serve in rural areas. This again is a huge waste of valuable resources. Orthopedic surgeons are doubling up as midwives and delivering babies in rural areas since there are no other doctors. How will this change our primary healthcare in anyway? GPs are not
average doctors as people would like to think. They have a different set of skills than a super specialist. While a super specialist is restricted to a very narrow field of medicine the GP is trained to look at the patient as a whole. More amazing diagnoses is made in a GPs chamber than a neurosurgeon's. But in the new era this important medical community is dwindling.

Quality of life of a Doctor

I'm not saying it is the toughest job on earth but a doctors life now is harder than it has ever been. Very few vacations- no money during student life and no time once you are practicing. 
Family suffers. My father is a doctor and all through my childhood I resented the fact that we took so few family vacations and that my father was never there for the most important events in school or others. All the while he was working day and night to make ends meet and ensure that we, his children get the right education, amenities and taken care of. This made sure that I was a reluctant doctor for the most part of medical school. I eventually found my calling and was "reformed" but it was a painful journey nonetheless. 
It is going to get worse for the future generations. There is this underlying myth that doctors make a lot of money during their careers which is really not true. I had a conversation with a friend from the money making tech industries and he had this to say

"Doctors can't contribute enough financially to the nation to command higher salaries. A doctor ONLY saves lives but engineers,financial analysts and CEOs create wealth which they distribute among themselves."

This is how much value saving lives commands. I was angry at what he said at first but later realized this is how the money creating industries think of doctors: overpaid and untrustworthy. Life and death can't be quantified in stocks and bonds and hence that is not enough. It made me sad as to how this came to pass and this perception is precisely what the next generation of doctors will have to work against. 
Governments post newly minted doctors into rural areas on compulsory postings but on temporary jobs. It is cheap labor for the exchequer, vote banks are taken care of and they don't have to bother about a permanent solution for a complex problem like rural health. 

What these people don't realize is that by having this attitude they will ultimately increase healthcare costs and then everybody suffers.

This inability of the society to acknowledge their altruism will be the reason to discourage the next generation of brilliant students from taking up this unforgiving profession. Doctors are no more demigods or authorities in their field. Their medical decisions will be altered by arm twisting untrusting patients, fear of malpractice suits, defensive medicine, target hounding corporate hospitals, a populist government and an inefficient law system. All this stress while their family still suffers from the lack of their time and money.

http://www.kevinmd.com/blog/2014/11/wish-knew-advice-spouses-doctors-residents.html

Doctor and patient relationship

To a doctor who is just starting out I would say this: ' Your decisions will be questioned at every step. You cannot dismiss patients like you are doing a favor to them. You will have to get down to the level of the patient and sometimes lower'. It will be a big let down in a doctor's life that they keep having their motives questioned every day of their professional lives. I think this is for the better as the doctor community has been too arrogant for far too long. They spend so little time with patients giving the excuse of long patient lists and surgeries. I think this is why people are so distrusting of what we do. Doctors of the new era have to respect the "new patient" who is educated, informed and has 1000 questions. There will be unreasonable patients just like other professionals have unreasonable clients. You have to approach it like how other professionals do. 
Any drug that you prescribe you should know all the side effects. Any surgery that you do you should know all possible complications. Ignorance is never an excuse anymore. It is your job to know. Never be dogmatic and steadfast about your decisions or opinions. Learn humility, patients appreciate that. State your professional opinion clearly before educating your patient about his/her disease and give them more than one choice when possible. Let patients take ownership of the decisions that need to be taken. All this takes time and you would be well advised to give it to them in the first instance or you'll be forced to give it in court. This sword of Damocles hanging over your head seems very unfair when all you wanted to do was do your job well. There is no point complaining about it and we have to make peace with our present day realities. If we want to be counted as professionals we have to be accountable. Period.
Also you need to connect to every patient you meet. For you will have several patients but for a patient you are the only doctor at that point of time. Learn more about your patients and make them feel like you are their doctor rather than make them feel they are your patients. There is a world of a difference in that.

http://mattandjennimurray.blogspot.sg/2014/09/in-defense-of-doctors.html?m=1

http://www.buzzfeed.com/lukelewis/16-doctors-on-the-dumbest-patients-they-have-ever-treated?bffb

Doctors and the media
Doctors in India are the vilified lot and not for small reason due to the unrelenting attitude of the media to slam doctors at every given opportunity. Media misuse their privilege to become just the loudest voice in the room. Most of the popular channels give out gross wrong health advice, unhealthy diet fads and advertisements of dubious cures. If that was not enough we have enough doctor slamming shows like Satyamev Jayate. Shows like these invite doctors and patients to discussion forums and post recording heavily edit the discussion in a very biased fashion to suit only their pre determined point of view and to create sensationalism to increase the TRPs of their shows. Doctors are the favorite punching bags since doctors in India have no voice. They don't form vote banks since they are an educated community which can't be swayed by politicians. They don't have a lobby to fight these instances of injustice since doctors in general don't make enough money impact the finance of any political entity. The Indian Medical Association and its state counterparts sometimes have token protests against these wrongs which not surprisingly never gets reported in the media. Doctors in hospital emergency rooms get beaten up every other day almost in all instances for no fault of theirs. This almost barbaric treatment of junior doctors in hospitals across the country are never reported in the media and if reported would highlight "some mistake" on the part of the treating doctors and never anything defending the doctors. This is because in most instances these assaults on doctors are perpetuated or encouraged by media persons. And strangely if there is any instance of a doctor strike  protesting archaic quota system of medical education, low pay or assault of doctors in hospitals, the same  media will come raining down on the doctor community of holding people's life at ransom. What I'm sad to see is that people don't realize that doctors are not anarchists.They would be more happy treating patients rather than be in protest rallies and fight lathi charges. If they are forced to do these things one has to realize how desperate and frustrated they are with the system. Nobody else is fighting for them and doctors have no choice but to protest in what little way they can. It is sometimes heart rending to see doctors who are on hunger strikes still running emergency clinics in these protest areas since they don't want people to suffer.

Doctors and Doctors

Over the years in the medical profession I have seen as a young doctor trying to make a mark that doctors work against doctors. There is too much professional jealousy and Godfather complex in the doctor community. There is a culture of disrespect which is passed on from the senior doctors to the junior ones. A senior doctor would not bat an eyelid before running down his junior colleague or rival in front of the patients. When you can't respect your own profession how can you expect the patient to respect it. Doctors cannot treat their junior colleagues like slaves at their beck and call. If you don't respect your colleagues the feeling will be mutual. So the first step in the new era will be to respect for everyone from medical student to super specialist. While we are at it there should be respect for everyone concerned with your patients....every person in the health delivery system forms a vital cog in the machinery. The future of healthcare is in creating effective teams rather than hierarchy. Nobody would believe me now but things will change in the near future in India to prevent hierarchy from setting into a system. Only when you remove nepotism , favoritism and godfathers from the picture will we gain a meritorious medical community. Mentors are the need of the day. Only if the present stalwarts mentor the next generation of doctors will there be continued value of our art. But if these stalwarts are insistent on running their personal fiefdoms then its a bleak future ahead.

Finally the joys of being a doctor

Being an optimist has helped me still enjoy my profession in a positive way despite the injustices that are being done to doctors in India. Its been a very long road from being a reluctant doctor to an empathetic doctor and this journey has taught me a lot of lessons. 
One of the joys of being a doctor is having the power to change a person's life and livelihood with one accurate diagnosis and appropriate treatment. A doctor may not move nations or even sometimes not even impress the patient he's treating but power to positively impact another person's life is incredible to say the least and I suspect is the reason why doctors still continue to perfect their art and science. Doctors may not make millions of dollars like lawyers, engineers, management consultants and businessmen but the value they give the patient with their work is not measure able with any material affluence.

What women want…

Before you mistake this for another sexist diatribe against the female sex by a testosterone charged male, let me clarify its no such thing. To the contrary I want talk about how society is oblivious to what women want. News channels these days are filled with “human interest stories” of sex crimes, rapes, assault, domestic violence, etc. on women and children all over India. It is as if there is a sudden epidemic of perversion and sexual frustration by men India-wide. I see a lot of people on these TV channels and outside say this is due to western influence –their clothes, relationship concepts and habits. It is as if sexual crimes never existed in India before. Well what the TV channels are gladly ignoring in their project to create this “breaking news” phenomenon is that these crimes are not new events in Independent India. The perverts,the sadists, the paedophiles were always there but we as a society never acknowledged them. We protected them among lies, cover-ups and  false family honour. Every time we see some new report on a ghastly crime, we as a part of society give an appalled shocked expression, shrug it off and move on believing such things are rare events in civilized society. The real fact of the matter is the problem lies in the mindsets of society as a whole. The sad part is the crimes are not as surprising as the comments by leading political figures and officials in law enforcing agencies. These politicians and the police are supposed to be representatives of our country’s people and if they think thus by projection the country also thinks like that.What do they say?

“The woman who got raped was wearing a mini skirt, was an alcoholic and a prostitute. She tempted that rapist to rape her. She had it coming”
“ The man’s affection for the child has been misconstrued as child sexual abuse. There are no paedophiles in India. It is a western phenomenon”
“ Women should know how to dress decently in order not to get raped”
“ Women should not work in offices after dark so that they will not tempt rapists at night”
“ The western influences are ruining the culture of our country. Women should not dress in western clothes, should not drink, not use mobile phones and internet, not have male friends,……(list goes on)”

If these statements shock you then you really haven’t been reading the news lately. There are many more such banal statements being given on a daily basis.I don’t know who was asking for their explanations but nevertheless they did provide their distorted logic for public consumption. What is unfortunate is that these statements are coming from not just religious fundamentalists,policemen and politicians but from some members of the National Commission for Women. If people appointed to safeguard interests of women (who are women themselves) think like this then really women in our country have no hope. I think the actual rape has happened in the brains of these commenting people.

The ploy to put the blame of rape squarely on how women behave is an old one. They will tell you men don’t have any control over their sexual craving and its only natural that they will rape someone who will sexually arouse them. They believe that the onus is on women to avoid rape. It’s like saying that any man can become a rapist if present in the given circumstances which commonsense should tell us is not the case. Chivalry and gentlemen have not died in this world and not all men are rapists if it even needed to be said. The rapist will rape anyone without regard to looks,clothes,behaviour, age and sometimes even gender. Instead of acknowledging this problem these people will try to put morality and culture into the equation. Aside from the fact that I don’t think two hoots about the culture of our country (much less ruining it), there is no credence to the belief that it is somehow ok to rape a sex worker or a lady who drinks or a woman who wears revealing clothes. It is behind this belief that rapists, sadists and paedophiles in our country find shelter in. If society acknowledges that the crime is committed in the minds of rapists rather than due to situational happenings, only then something can be done to curb these crimes.

Women in our country should be free to wear the clothes of their choice, work in professions they want to, go to any place at any time,to eat and drink whatever is legally allowed to all citizens AND STILL NOT GET RAPED. That should be the societal standard and not primitive ideas of these dinosaurs called politicians and policemen who are probably living in a cave.

The idea that women are respected in our country is a myth. Except in certain pockets where women find a pride of place, in most places in India everyday we see women being insulted, abused and exploited. The IT boom and corporate culture has improved the stock of women in our country. We find that more girls are getting educated and making a living for themselves than the previous generations did. But societal prejudices still remain and the behind those signs of progress among women hides an ugly truth. A truth nobody is willing to acknowledge : “Society still considers women as inferior to men.” These men and women( the voices of society) who give statement after statement believe that its always the woman’s fault (even some in the NCW think so).Unless this mindset is not corrected no law will control these savages committing crimes.

The media which is supposed to be the progressive voice of our country is as regressive as can be. Recently we saw footages from a Guwahati based news channel showing images of about 20 men molesting and stripping a 17yr old girl. This episode teaches us two things. ONE: People who would seem normal are the people capable of such serious crimes. There are no signs to separate these savages from society as a whole. TWO: There are no ethics and sensitivity left in the media. While seeing the video we are also listening to the cameraman actually encouraging the molesters to go further in their ghastly crime despite futile pleas by the girl to leave her alone. The reporter of that news channel even has the gall to interview the molested victim and ask her personal details immediately after the incident. Then they broadcast it live all over India and say they actually helped identify the culprits while actually they were just creating a TRP raising story. They did not even try to help the poor girl. This is how depraved our media is. Its not just one news channel, every news channel in India broadcast it without any shame. The identity of that girl was flashed like a sign of victory thus destroying the last shreds of humanity. The govt. did one better (rather worse), they sent some elite high brow delhi socialite women who claimed to be from the NCW who conducted press conferences along with the victim. Even a molestation is treated as platform for politicians. What law will these politicians bring in when they themselves behave worse than those molesters.

This is not to say some good work is not going on. The child abuse bill and domestic violence act are some examples of good legislation. But unless the powers that be change their prejudicial stand point no law can be enforced to actually decrease such crimes.

feel free to read what western media thinks about the rapes in India:
http://www.slate.com/blogs/xx_factor/2012/10/26/rape_in_india_a_sexual_assault_spree_in_haryana_brings_out_the_crazy_in.html