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?"

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.

Healthcare in India: myth busted

The other day i read that India is one of the top destinations for medical tourists.for those not in the loop this refers to foreigners mostly from developed countries like US, Russia, Germany, Singapore, Korea, etc who do not qualify for healthcare insurance in their home countries who come to India for cheap medical care so that they can get similar or better care for less than one tenth of the price in their home country.When i read this article i couldn't help but wonder whether we should really be gloating over treating foreigners for cheap while millions die in our country due to dire need for basic healthcare.We in India apparently follow a socialistic policy in healthcare. Is it really so?
I recently read an article by Dr. Devi Shetty,a famous cardiothoracic surgeon and leading philanthropist in the field of healthcare.He said only 8% of the people needing cardiac surgery actually get operated and in a country like India we have a huge backlog.In his own words this is ridiculous even for a developing country like India.He has bought down costs of heart surgery to less than Rs. 1lakh and he’s desperately trying to get it to less than Rs. 40k.He’s doing a commendable job and needs every bit of adulation and support he can get.But really where is the Government in all this? its conspicuous by its absence!
I work as a resident in the premier Govt. Eye Institute in West Bengal which incidentally is the top govt  eye inst in the whole of eastern India. we have top of the line instruments, microscopes, lasers, machines, diagnostic aids and first class infrastructure.we undertake all kinds of surgeries done in any of the top institutes of the country.This should in effect should help the masses.But unfortunately not everything is free.True cataract surgery covered by the national program for control of blindness in India is free but nothing much else is totally free of cost for the patient.the patient still has to buy consumables for surgery such as silicone oil or perfluro-gas(Retinal Detachment surgery),silicone prosthesis,sutures and many other consumables.A typical RD surgery costs the patient around Rs. 12,000 in our institute(only consumables).In other diseases for proper diagnosis CT scans,MRI,histopathology,expensive blood reports,immunohistochemistry,etc. needs to be done for which the patient has to shell out from his/her own pocket.All this and not to mention other daily expenditures in eye drops,costly antibiotics,pain killers and sometimes hospital fees.Drugs supplied by the govt. form a woefully short list or for the most part ineffective probably due to adulteration and poor quality control.So many expenditures in a Govt Hospital which is a premier institute at that in a supposedly socialised medical healthcare.This much expenditure to a man/woman who probably earns less than Rs. 100 a day.does it sound right? can our conscience make peace with this fact? if this is the state in a premier institute what is the state of peripheral hospitals.I’m not blaming the people who run our hospital for all this.they are doing a great job to the masses with the limited resources at their disposal.the costs that are being borne by the patients is due to the helplessness of these doctors and due to their endeavour to provide world class care to patients with limited expenditure to the society. In this scenario doctors are stressed to provide healthcare and the public blames them for any incident that happens. This is the reason why doctors in govt sectors are getting frustrated with the system. its not them but our healthcare policy that is to blame.It is flawed left right and centre!
I’m speaking in the midst of one hospital and i’m talking of ground realities in one govt hospital as i’m a part of one.But this is the story of nearly every govt hospital in India.it is just that the categories of expenditure changes.Our society will be judged by how we treat the weakest(read poorest) among us.And our country falls terribly short of an ideal.
As i have mentioned previously in my blogs,Indian govt. spends less than 1percent of our GDP on healthcare.Even countries like Bangladesh and Sri Lanka spend 16 and 32 pc respectively.UK spends 7pc and yet provides Universal free healthcare to every citizen and immigrant.In India 80pc of the health care burden is borne by the pvt. sector.We are quick to downgrade the insurance based healthcare of the USA but in India we neither have an Insurance based healthcare of USA nor a Socialised Healthcare like UK,France,Sweden,Denmark,etc. the common retort by the govt is India is a poor country and we do not collect sufficient taxes to sponsor universal healthcare in India.But this is a poor argument because though only 3 pc of the population pays income tax,we all pay tax in every other way.sales tax,wealth tax,property tax,road tax,service tax,luxury tax,custom tax,education cess,advertisement tax,service tax,value added tax,….phew just to name a few!!!! Only birth tax and death tax is left to be enforced.where does all this money go? We have a horrendous education system,pitiable healthcare and a treacherous bureaucracy and yet we have any non-descript politician worth his salt(not necessarily elected) being ridden across the country in a fleet of 10 cars or helicopters or jets! govt officials,bureaucrats and govt aides lead a life of extreme luxury.our politicians and bureaucrats must be among the richest politicians and bureaucrats in the world(and we are a poor country mind you!!!)No other country in the world has more black money in Swiss Banks than India.So who do you think owns all that money? the above people and also some huge businessmen. So do I still hear somebody call India a poor country. We now know who are the beneficiaries of these many taxes.
Solutions are quite often very simple but simple things aren’t done without a political will in this country.The masses don't demand healthcare because they have nothing to eat so why will anybody talk about health? Healthcare needs to be removed as a state subject and be transferred to being a union subject.Doctors and healthcare professionals need to be paid more as professionalism demands money.you can’t attract the best talent in any industry with pitiful pay packets.same should hold true for healthcare.Govt budgetary allocation to healthcare should increase to 5pc of GDP for a start and should eventually increase to at least 8pc.another 10pc to our education system because to sustain a healthcare this massive we need an educated population.All these budgetary allocation should come from defence cuts.We don't need bombs and missiles.we need medicines and medical care.there needs to be a stringent quality control body for healthcare delivery and of course for the quality of drugs and consumables being supplied.In effect we need a complete overhaul of our healthcare and education policy.Do these sound difficult. hell yes!!! because attitudes need to be changed,awareness needs to be increased and most of all corruption should be minimised.All this is easier said than done but it still is simple stuff no?
I sometimes feel really bad when patients suffer because they either can’t afford treatments or we are restrained from giving them the best treatment due to the many impediments i have mentioned above.There is a certain joy in treating patients and you need to have empathy to understand their varied problems.Its a hell of a tough job but there is nothing else in this world which gives the same high as that got by alleviating suffering of people.It is for this incredible satisfaction that most doctors work even in trying conditions,amongst apathetic govts.,and high personal sacrifices(both monetary and social).So if we doctors can treat our patients without worrying about whether the patient can afford the treatment we can at least bring back nobility to our profession.its not only the rich who deserve to get sick and be cured.even the poor have every right to lead a healthy life.So the next time you fall sick and get treated think about the millions who are not as lucky as you and be grateful for the same.Also try in your own way to do something about it.sometimes a simple thing such as a change in attitude will do.

17th April,2011                                  Raghuraj Hegde