The playwright aphorist, George Bernard Shaw was once asked by a lady, ” Have we lost faith in God?”
In his sui generis satirical manner, Shaw responded, “Certainly not! We have only transferred our faith from God to the General Medical Council!”
While it was clearly a tongue-in-cheek, what the aphorism perhaps meant to convey was that those who regulate the section of the society that people turn to when they are most vulnerable are entitled to a degree of trust that bordered on Divine! And that was the sentiment that governed the process of medical regulation! While the General Medical Council in recent decades has lost a lot of its sheen, it would not be erroneous to state that it still enjoys a very high public esteem and its decisions are generally respected.
The Medical Council of India was set up on identical principles. It borrowed its philosophy heavily from the General Medical Council and at least in the initial years, even the wordings of the two statutes were very similar. The first president of the Medical Council of India, Dr Bidhan Chandra Roy, apart from being a legendary physician, was a national statesman and a very active freedom fighter pre-independence. I would stand corrected but I believe he is the only Indian physician to have been conferred the Bharat Ratna.
Dr Roy strove to maintain the highest ethical and academic standards. It was only in the 1970’s that people began to note that there were some very serious problems that had crept into the hallowed portals of medical regulation in India. Patently the MCI was not performing even its most fundamental function i.e. maintenance of Indian Medical Register which apart from being very inaccessible, was hopelessly outdated. Physicians who had passed away decades earlier were still enrolled.
Ethical transgressions were simply being overlooked which was seriously jeopardising the reputation of the profession. No curriculum revision was being effected despite substantial advances in the field of medicine. Regular checks on the standards of the medical schools were not being carried out with a degree of diligence. And to cap it all, we witnessed a grotesque spectacle of a senior physician from Lucknow widely known for not having an ethical bone in his body being appointed as the President of the Medical Council of India. In order to grab the headlines, his first action was to de-recognise the British specialist qualifications the only effect of which was to inconvenience hundreds of Indian physicians who wished to return to India after specialising in the United Kingdom.
Matters proceeded from bad to worse with the passage of time .The nadir was when a sitting president of the MCI was shown on the television screens in handcuffs being dragged to the prison after being arrested on charges of making money for extending recognition to newly formed medical schools. As an Indian, it was a matter of intense shame for the entire medical profession.
In effect, I am stating that with these credentials, it was time for the MCI to be disbanded! And personally I am glad that it was! Therefore I am not in full agreement with the Indian Medical Association’s blanket rejection of the National Medical Commission which is being formulated to replace it. I have read the Bill several times and while I do have some major queries, I find some very positive features in the proposals.
I shall attempt to outline my assessment.
As I have adumbrated earlier, I think this move needs to be commended. By disbanding the MCI, we may still be in a position to retrieve the lost reputation of our profession.
The National Medical Commission as proposed would comprise 25 nominated members by the government each of whom would be expected to function for 4 years. I am a bit unclear as to the degree of autonomy that would be enjoyed by the proposed Commission and its nominees and perhaps the government would clarify on this in due course. It is important that the Commission should function as an autonomous body free of direct governmental control as happens in several countries that I have worked in.
The proposed NMC would comprise four Boards viz Undergraduate Medical Education Board, Postgraduate Medical Education Board, Medical Assessment and Rating Board and Ethics/Medical Registration Board. Again I see this as a big improvement over the modus operandi of the defunct MCI.
At the moment there is some confusion over the manner of curriculum revision that is being proposed and an elaboration on this count would be helpful. Those of us who have served on the faculty of medical schools in the West, myself included, would know that the medical graduates from India are generally very sound in terms of their theoretical orientation but somewhat shaky on the practical front. This can be attributed to both the curriculum that is being followed as well as the manner of instruction which lacks coordination between different disciplines in many medical schools. This is a big problem that needs to be addressed; curriculum revision is long overdue-and it needs to be done on a massive scale. And if the proposed Commission can bring it about, it would be entitled to our sincere gratitude.
I would also have liked the Bill to have addressed some other outstanding concerns which are related to the manpower. Primary healthcare provision is the main lacunae in our entire setup. There are only a handful of medical schools that have taken up the challenge of setting up postgraduate training courses in Family Medicine. If we are to gear up our healthcare system to the needs of our fellow citizens, then we cannot afford to ignore this aspect. I have myself published several columns in different fora (including this very portal) on the subject.
Change in the status of State Medical Councils
The state medical councils would be replaced by an advisory board with several of its powers curtailed. Medical negligence and ethical concerns would be dealt with centrally. In principle, I agree with this move although I am a bit concerned that this might lead to bureaucratic delays. I hope the government would affect a measure to present protracted legal procedures.
Fee Structure of the Private Medical Colleges
There are proposed measures to control the fees of half the candidates in private medical colleges. My initial reading did raise some concerns in my mind about the quality control that is so essential but I suspect the exit exam proposed would take care of this.
Exit Licentiate Exams for both Indian and foreign medical graduates to be taken in tandem with the postgraduate entrance exams:
One of the very major problems of medical education in India is the enormous variability that exists within different medical schools. I have myself worked in 11 different countries both developing and developed and am in a position to state that while some of the Indian medical schools maintain a standard comparable to the West, there are others that should have been re-recognised long ago as they do not conform to the most elementary denominational standards.
I, therefore, welcome this measure and sincerely hope that the government would take cues from the National Board in the United States that follows this practice. I personally do not have any sympathy for the substandard MBBS holders who would not be able to procure an automatic medical license as used to be the case; we have tolerated many of them far too long. This measure would ensure effective quality control and bring about uniformity.
Bridge Course for Non-doctors
I must admit that the way this provision has been worded in the Bill does give room for some concerns and a clarification would be in order. I am quite comfortable with dental surgeons with proper instructions being permitted to practise general medicine but I do worry somewhat at the prospect of community health workers being provided limited powers of clinical practise. I appreciate that this is being done to address the manpower shortage but I have known serious problems in countries where somewhat similar provisions have been enacted. China is a case in point. Those who have followed my columns on this portal would know that I have been an admirer of the Cuba healthcare system and the way it was built up post-revolution in 1959 when only a handful of physicians were left in Cuba. Instead of the mad scramble for specialisation and super-specialisation, the Cuban government concentrated on building up preventive and primary healthcare. Even today, there are very few specialists in Cuba yet it has the very best healthcare statistics in the world and even the most casual visitor to the country would not fail to notice that infectious diseases and malnutrition disorders are unknown in that country-and it is a developing nation whose healthcare expenditure is comparable to the developing nations.
What I am stating is that while there is a legitimate and perhaps a laudable role for paramedics to be trained for preventive healthcare provision, I have some worries about them being entrusted with clinical care. I would much rather have active Family Medicine departments in every medical school and a massive overhaul of preventive healthcare system instead of the mad scramble for AIIMS in every nook and corner because that is what the country needs.
I am sure the government was made aware of these concerns and I do believe there is a rational explanation but it somehow does not come across in the Bill-at least to myself.
I would also have liked the Bill to take steps to reverse the lunatic decision to de-recognise the British postgraduate qualifications as they are only hurting the Indian physicians who wish to relocate to India which would in turn address some manpower issues. Another revolutionary step that the NMC Bill could have taken is to do away with the time honoured tradition of entertaining ‘Certificates of Good Standing’ from different licensing authorities as valid evidence of a physician’s ethical standing. The fact remains that many of these licensing authorities do not only disregard the most elementary ethical parameters, but also flout the most fundamental principles of natural justice as elaborated in the Universal Declaration of Human Rights. The College of Physicians and Surgeons of British Columbia in Canada, a statutory regulatory body, was recently presented a letter of diplomatic protest by the Ministry of External Affairs through the Consul General Abilasha Joshi for its treatment of an Indian citizen on express instructions of late Mrs Sushma Swaraj. It had erased the Indian citizen without even apprising him of the charges against him after his altercation with the Deputy Registrar Harrigan who had racially abused him. We cannot accept the version of such a body without independent corroboration. And the Medical Board of Victoria again was found to act against a physician on the basis of a fraudulent document. This case was again brought to the notice of Mrs Swaraj who acted very promptly. A revolutionary step would be to de-recognise the medical regulators who fail to observe the ethical obligations and shame them by disseminating their absence of commitment to ethics.
I would like the National Medical Commission to at least attempt to live up to the standards that Bernard Shaw observed. And I would sincerely hope that the government would address the concerns that I have adumbrated here which I believe are shared by many.
Editor’s Note: President Ram Nath Kovind has given his assent to the National Medical Commission Bill 2019. The move came after Parliament passed the bill in the just-concluded session. The Bill seeks to repeal the Indian Medical Council Act, 1956. Union Health Minister Dr Harsh Vardhan has said now the rules will be framed and the NMC will be constituted within six months.