Dr M C Gupta, a doctor turned lawyer, writes why the government should revive the short-term medical course — Diploma in Modern Medicine and Surgery (DMMS) — that existed earlier and why the Indian Medical Association (IMA) should welcome a DMMS course and should not oppose it.
Dr Gupta holds an MD (Medicine) from All India Institute of Medical Sciences (AIIMS), New Delhi; an LLB from Delhi University and LLM from Kurukshetra University. He has served as a faculty member at AIIMS for 18 years and as professor and dean at the National Institute of Health and Family Welfare. Currently, Dr Gupta is a practising advocate with health and medical law as the area of special interest. He is a member of the Supreme Court Bar Association and Indian Law Institute.
Question: What are your views about the three and a half years medical course?
1 — A three and a half years medical course is not something that is new or never existed or cannot exist. As a matter of fact, a large number of courses, basically similar, were offered by various universities and medical colleges in India and these were immensely popular and useful and served the backbone of modern medical care to the masses. Titles of seven such courses, listed in schedule 3, part 1 of the Indian Medical Council (IMC) Act, 1956, are listed below:
i) DMMS — Diploma in Modern Medicine and Surgery (Orissa)
ii) DMS — Diploma in Medicine and Surgery (Madras, Indore)
iii) LCPS — Licentiate of College of Physicians and Surgeons (Bombay)
iv) LMF — Licentiate of Medical Faculty
v) LMP — Licentiate Medical Practitioner
vi) LMS — Licentiate of Medicine and Surgery
vii) LSMF — Licentiate of State Medical Faculty
2 — The erstwhile LSMF (Licentiate of State Medical Faculty) course co-existed with the MBBS course till 1956. Both degree holders having LSMF or MBBS degrees were registered with the state medical council. Both were recognised medical qualifications in terms of section 2(h) of the IMC Act, 1956. Holders of both qualifications could have their names on the state medical register in terms of section 15(1) of the IMC Act, 1956. They could also have their names on the Indian Medical Register qualifications in terms of section 21, 22 and 23 of the IMC Act, 1956.
3 — However, the government took a decision to stop the licentiate courses mentioned above. The result was that we have no licentiates in modern medicine today. Unfortunately, they have been replaced by quacks of all sorts, including those not registered with the medical council but still practicing allopathy.
4 — The logical and common sense answer to the twin problems of quackery and shortage of doctors in rural areas is to re-introduce a short-term medical course, which would be duly registered by the medical council. This is exactly what the government wanted by introducing the course known as BRMS (Bachelor of Rural Medicine and Surgery). It was recommended by health planners and experts including professors of AIIMS (All India Institute of Medical Sciences, New Delhi).
5 — The background of the government’s proposal regarding the BRMS/BRHC/BSc course proposal is as follows:
i) — Dr Meenakshi Gautam, a non-medical public health specialist, filed a Writ Petition (Civil) No. 13208 of 2009 in which the Hon’ble Delhi High Court had vide its order dated 10.11.2010 given the Medical Council of India (MCI) two months’ time to finalize the curriculum and syllabus of the 3.5 year Primary Healthcare Practitioner Course, the implementation of the introduction of which was approved by the Union of India. The course was named ‘Bachelor of Rural Health Care (BRHC)’. A further period of two months was given to the Ministry of Health and Family Welfare for the enforcement of the same. Thus, BRHC should have been introduced by March 2011 as per the timelines stipulated by the Court in its order.
ii) — The facts in brief stated in the Writ Petition No. 13208 of 2009 leading to passing of the order dated 10.11.2010 are as follows:
a) — The existing healthcare systems are entrenched with inequalities and unable to meet the needs of the people. The main source of professional primary healthcare in rural areas is through the network of Primary Health Centres (PHCs). However, these are very few and far between. Many of the remote PHCs do not have doctors in position. On the demand side, people living in India’s roughly 600,000 villages need a well-trained health provider within easy walking distance who is available 24 hours and who can take care of the bulk of common illnesses and who can provide first aid in emergencies, and who can identify and refer complicated cases in a timely manner. In the absence of trained primary health providers, this care at first contact is currently delivered by quacks.
b) — The National Health Policy, 2002 made several recommendations including a cadre of licentiates of medical practice.
c) — In the high-level 9th Conference of Central Council of Health and Family Welfare chaired by the Union Health Minister, where all state health ministers and officials participated, the resolution was passed that all states should introduce a 3-year diploma course in Medicine and Public Health in order to provide manpower to address rural healthcare needs, on the lines of Chhattisgarh and Assam legislations
On 13.11.2007, it was resolved in this Conference that “All State Govts bring out an enabling legislation… so as to introduce a 3-year diploma course in Medicine and Public Health in order to provide manpower to address rural healthcare needs.
d) — In 2007 a Task Force appointed by the Ministry of Health and Family Welfare, Medical Education Reforms for National Rural Health Mission, recommended the introduction of the 3-year Rural Practitioner Course to fill the vacuum of healthcare providers in rural areas. However, all these proposals had run into opposition from vested interests and in particular MCI. This is despite the fact that MCI’s own sub-committee in 1999 had noted that the existing system of medical education has “utterly failed” the health needs of the majority population in our country.
e) — There is ample evidence of different types of models of mid-level cadres from many countries, including both nursing as well as non-nursing types of models of mid-level practitioners. These include: Health Assistants and Community Medical Assistants in Nepal; Clinical Officers and Assistant Medical Officers in 47 sub-Saharan African countries; Health Officers and Health Assistants in the Western Pacific Region etc.
iii) — Thus, the petition 13208/2009 was filed seeking directions to the Government from the Hon’ble Court to introduce a short-term course for training mid-level health workers for primary healthcare in rural areas and then license and regulate graduates of the said course.
iv) — The course was delayed and the petitioner filed a contempt petition in the Delhi High Court. It is still pending. In their reply, the government informed the court that delay occurred because MCI had declined to be involved in this course due to certain legal issues and that the government had now got the NBE (National Board of Examination) to help in place of the MCI. The government has given an undertaking to the court that the course will be started in the forthcoming session, which means July 2013.
6 — Where the government goofed was this:
i) — The course was named as BRMS (Bachelor of Rural Medicine and Surgery), giving a handle to the critics by raising the human rights issue, saying that rural people are not inferior to be catered by less qualified persons.
ii) — There was unnecessary emphasis on restricting the graduates of the short-term medical course to rural areas for 10 years after graduation. Such an approach was wrong for the following reasons:
a) — A person competent to treat patients in a rural area cannot become incompetent to treat patients in an urban area.
b) — Nobody can be ordered to stay put in a rural area for 10 years if he wants to come to an urban area. If he translocates to an urban area, his rights under Article 21 of the Constitution cannot be curbed.
7 — What the government should have done was to revive the erstwhile DMMS (Diploma in Modern Medicine and Surgery). Such persons, produced in large numbers, would be an asset because:
i) — They would be real grassroots physicians / GPs (General Practitioners) working in the community, especially rural, remote and slum areas.
ii) — They would be duly licenced in terms of the IMC Act, 1956, and hence no laws would be broken.
iii) — They would continue to be GPs because, not being MBBS, they would not be able to take the MD route or the migration abroad route.
iv) — They would not compete with MBBS doctors but might work under them or as assistants to them.
v) — They would be an effective antidote against quacks.
vi) — They would provide cheap and reliable medical care to the poor people who cannot afford to go to MBBS/MD doctors.
8 — Also, the government should not have tagged the course to service in the PHCs as CHO (Community Health Officer). A bond of say, Rs 2.5 lakh could have been fixed on the payment of which the graduates would be free to practice in the community or get a job.
9 — It is unfortunate that the IMA (Indian Medical Association) decided to oppose the above course. They forgot that the course was recommended by no body other than the IMA’s hero and past president Dr Ketan Desai in his capacity as president, MCI. It is surprising why MBBS doctors should feel threatened by short-term course doctors. Such short-term doctors would any day be better and preferable to quacks, including AYUSH quacks.
10 — The government further goofed up in the following manner:
i) — It should have taken the R out of BRMS and named the course as BMS. This would have taken care of the objection related to “treating the villagers as second class citizens”. It should have removed the restriction about compulsory rural service for 10 years. Further, preferably, it should have named the course as DMS (Diploma in Medicine and Surgery) to cause even less irritation to the IMA. The IMA would not have objected to a DMS/DMMS course.
ii) — It renamed the course as BSc (Community Health). This was an unwise move, which immediately invited the objection that a BSc course cannot be a medical course and no arrangement had been announced by the government as to by which regulatory and registering council would such a course be supervised.
11 — Those MBBS doctors who criticise the course say that the proposed course is a ploy on the part of the authorities concerned to make money by granting recognition to short-term course colleges in an underhand manner. Such apprehension is unrealistic. It seems the government plans to conduct this course in government institutions and not private institutions. There is no question of underhand dealing / recognition in respect of government colleges unlike private colleges.
12 — There is no evidence that the short-term medical courses listed above had any disadvantages. The doctors having the above degrees were very effective as medical care providers to the general public. They acted as real GPs because they did not look forward to become specialists and super-specialists, which was possible only after an MBBS degree.
13 — The MCI/GoI’s decision to abolish the short-term medical courses was not a sound idea for the following reasons:
i) — LSMF doctors were rooted in the community, including rural areas. They worked as real GPs. They never boasted about themselves and never competed with MBBS doctors. Even the public knew the difference between an LSMF and an MBBS.
ii) — They were destined to remain life long GPs because they could not get an MD specialist degree without an MBBS degree. This was good for the community because the public needs more GPs, not more specialists.
iii) — They tended to work in rural areas because they knew and acknowledged that an MBBS was superior to them. Most of them preferred not to compete with MBBS and MD doctors.
14 — There is no reason why a short-term medical course, which was useful 50 years ago should not be useful today, especially when the trend even in the West is to have nurse practitioners discharge some basic medical care.
15 — Summary and Conclusions:
i) — The government should revive the short-term medical courses that existed earlier. The proper name for such a course would be DMMS. The revival would not need any legal backing because the IMC Act, 1956, already provides for such courses.
ii) — The government should not have the following names:
a) BRMS — This artificially differentiates between rural/urban medicine and practitioners of medicine.
b) BRHC — This is not a medical course name and hence cannot entitle a person to be registered with a medical council.
c) BSc — This is a strict no-no. A BSc (Community Health) cannot be given the responsibilities carried out by a physician.
iii) — The IMA should welcome a DMMS course and should not oppose it.
iv) — A large number of DMMS graduates means that much reduction in AYUSH quackery.
v) — Graduates of this course should be on a bond to serve in the PHCs for 10 years, failing which they should pay up the bond amount to the government.
vi) — The introduction of the short-term course will, from the point of view of the modern medicine graduates, have the following beneficial effects:
a) It will markedly reduce quackery (including quackery in the nature of allopathic practice by AYUSH graduates).
b) It might lead to a situation when AYUSH colleges either close down (like the MBA courses/colleges nowadays) or convert into BRHC colleges.
c) It will lead to the creation of a large number of new jobs for modern medicine graduates who will be needed as faculty in the BRHC colleges.
d) It will raise the status of MBBS, which has been currently reduced to the lowest degree in the medical/health field. With BRHC in place, MBBS doctors may as well act as referral doctors for patients referred by BRHC graduates.
e) When BRHC graduates are in place, the need for obligatory rural service for MBBS doctors would decrease.
f) When the BRHC graduates are in place, MBBS doctors posted in rural areas will not find that they are left to fend for themselves with no staff, equipment and facilities in remote areas. It is natural that equipment and facilities will have to improve with BRHC graduates in place. In other words, service in remote and rural areas will be less of an ordeal for MBBS doctors.
g) MBBS doctors having nursing homes will be able to employ BRHC graduates without any problem instead of employing AYUSH graduates which is illegal in terms of the NCDRC (National Consumer Disputes Redressal Commission) decision in Prof P N Thakur Vs Hans Charitable Hospital (16 August 2007).
Dr M C Gupta (Former Professor and Dean)
MD (Medicine), MPH, LLM
Advocate & Medico-Legal Consultant
(Delhi Bar Council No. 857/2001)