The National Medical Commission (NMC) Bill seems to be a disaster in the making

Recently in a national orthopaedic conference in Australia, there was a keynote address about the status of women, the LGBT community in Orthopaedic surgery and the issues of bullying, harassment and equality of rights and privileges while maintaining the peak of professionalism. One of the important statements that the speaker made was, “We have to do enough, and more importantly appear to be constantly doing enough, to monitor and regulate ourselves on the fronts of quality, human rights and ethics; because if we are not visibly doing enough, someone else will do it for us and that imposition will not be pleasant.”

This statement should stick to our minds for a long time to come. We should be visibly doing enough to keep ourselves clean and at par with the contemporary norms of quality and ethics, otherwise the authorities will police us. The Medical Council of India (MCI) obviously didn’t do this. They have clearly and shamelessly failed at the core issues of maintaining ethics and transparency in administration of medical training, distribution of resources for the same, regulating the practitioners to the professional levels expected by the society and guide the government in public health and human resources development policies. This indefensible failure has resulted in the government bringing in the NMC Bill. Although I agree a change, a good old full overhaul might well be necessary, the NMC bill has been complicated with poor design, exclusion of the stakeholders and most importantly things that have a potential to take things from bad to far worse in the way of corruption, quality of health care and ethics. These issues have potential to further erode the public’s trust in the healthcare system and create a status of confusion in the healthcare sector of India that will lead things to a status of disrepair which might take decades to recover if it ever does that.

Esoterica apart, let’s talk about the core issues in very objective manner.

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The NMC will be formed with ‘select’ members on the panel.

We are Indians. We know how things work when people in such powerful positions are ‘selected’. This might lead to sycophancy, corruption and nepotism in selection of the NMC panel. The panel members will only technically have to be responsible to the political ‘selectors’. In a correct model, such a Council should have representatives from all the stakeholders and the stakeholders in public healthcare delivery system in a large country like India are, but not limited to:

-Medical Practitioners

-Medical Academics

-Medical Scientists (Research and Quality Control)

-Economics (Government’s representative)

-Health Insurance bodies

-Medical Indemnity Insurance providers

-Education experts

-Population and demographics experts

This will be a good bunch to plan the approach, extent, resource allocation and policies pertaining to medical education, ethics, registration and quality control, while they are also responsible to their areas of representation, meaning they feel their responsibility to uphold the betterment of their cause, not just pleasing the political selectors.

The National Medical Council may encompass all the medical and paramedic specialties, streams, systems and have separate registration mechanisms with grievance redressal mechanisms under one banner but the system streams have to stay distinctly separate from each other.

This brings us to the next level of this contentious issue: Allowing ‘Ayush’ healthcare providers to practice ‘Allopathy’ after doing a certain ‘Bridging Course’.

First, there is no such thing as ‘Allopathy’. The term ‘Allopathy’ was coined as an insult in the early days of European medicine and it literally translates to ‘The other suffering’. This was meant to say the disease is a suffering and the treatment (back in the day) was so bad, it was a suffering in itself. What you call ‘Allopathy’, goes by the name ‘Modern medicine’ or merely ‘Medicine’ these days. Also, I will be clear about this bridge-mixing the healthcare streams right away- this is an idea as bad as bad can be. I will talk about the issues and the common arguments for/against this. May be we can even have some speculative answers that show us light for the future:

1. “The MBBS doctors don’t work in rural and remote areas and allowing the ‘alternative therapy’ practitioners to practice as doctors will help this.”

Have you ever wondered why the MBBS doctors won’t work in rural and remote areas? Do you have any plausible reason why the ‘bridged’ practitioners WILL work in the rural and remote areas after they are bridged across?

I have worked for a few months in Valsad- a District hospital but still fairly ‘remote and rural’ in the terms of comparison, say with Ahmedabad or Baroda. The pay scale in government hospitals are low even in remote and rural locations. There are no ‘incentives’ the government provides for people to choose the location the government obviously does identify as rural and remote. A doctor in a career will obviously compare what their professional reimbursements are to their equivalent in a city private practice or similar realistic option they could go for alternatively. If they are not getting paid competitively, they won’t keep that job.

The next issue is infrastructure and equipment. Doctors want to be able to use their skills to the best possible extent to help a patient. This needs not just a brain and two hands, but equipment, support staff, laboratory, X-ray and imaging, operating theatres, procedure rooms, access to continuing medical education through library and medical data access, and finally, a reciprocating professional support system through a robust bilateral referrals system. When you don’t have these, it results in lack of job satisfaction and professional depravity and if you just throw some more money to incentivize this, it won’t work and it won’t attract the best candidate for the work in any case.

Finally someone who has picked a peak profession like medicine also expects some work-life balance and a respectable lifestyle. If you expect doctors who are mostly trained in large city universities to relocate to small and rural centres, there has to be some support system in the form of residence, relocation support etc, even if temporary for them to sort out long term plans on the job. The ‘Government Quarters’ are seldom available to new doctors coming to town and if they are, they are not of a quality the young professionals expect for themselves.

Various governments have tried in different ways to force young doctors to go work in rural areas through compulsory rotations, financial bonds etc and nothing of these have worked. Nobody has actually tried to lure doctors into the rural practice.

Getting to the ‘bridging’ part, why does the Govt believe that the bridged alternative practitioners will work in these rural and remote areas only after being certified? Why won’t they want to live and earn in the cities like the Doctors do? There is practically no system in India that can ensure that certain doctors will only have certain practice privileges in certain locations. For example, in Australia each doctor gets a ‘medical care provider reference number’ and this number is unique to each doctor for each hospital/ consulting location they work at. They can provide some services at some locations but not at the other location at times. There is no mention of such an arrangement in the ‘Bridging’ plan. Even if this is considered, it is an extensive data management process to enforce this in India where not all the hospitals and consulting clinics are registered and monitored by national hospitals accreditation board and most billing is out-of-pocket, not through insurance.

2. Medical doctors are sold to the Pharmaceutical industry, are corrupt and indulge in financially motivated malpractice.

I am not even going to deny this. Although I firmly believe that more doctors are honest and ethical practitioners than not, arguing against this point only makes the case of the opposition stronger. I accept your point that the lack of integrity exists in India and is undeniable.

What I will say to this is though, the ‘Bridged’ alternative practitioners are also product of the same society. Why wouldn’t they indulge in the same vices? Once they are licensed to practice as ‘Doctors’ why won’t the ‘Pharma’ industry woo them with the same ulterior motives? Why do you think they are not already doing this? As often said in their defence, these alternative practitioners are already prescribing modern medicines too quite regularly, and hence they are already within the reach of the ‘big pharma’ manipulators too.

Bridging the alternative practitioners won’t improve ethics within the medical practice. It will only further collude the field, make tracking of malpractice, suggesting improvements and imposing industrial reforms more difficult and almost impossible. And as a reason to justify the bridge course, the argument falls flat.

3. The MBBS doctors are too arrogant in their system and see the alternative therapies as inferior

We believe in our system and we respect the fact that those who have learned and are practicing the alternative therapies also believe in their system. Although, seeing that in a large treed the ‘alternative practitioners’ want to find ways to practice modern medicine while not many modern medicine practitioners are keen on practicing alternative therapies or Ayush, I actually doubt the alternative practitioners have respect for the system they have been forced to learn, in a vast majority of cases.

Modern medicine is the only system that has an ongoing self vigilance through scientific methods. All drugs, surgical procedures, therapies, diagnostics, pathology, even understanding of anatomy and physiology are constantly being tested with prevalent scientific methods, changing the ideas of past and proposing fresh. Such a constant scientific vigilance is lacking in all the ‘alternative therapies’. There is a lot of ‘Research’ in the alternative therapies but most of it is in the pattern of navel gazing and self-approval, not a very widely vigilant process. You say Metal on Metal hip replacements failed? You say Statins were doubted? Guess who researched and published those doubts?? Modern medicine scientific processes did.

When was the last time you heard that an Ayurvedic/Homeopathic/Unani/Naturopathic therapeutic method was debunked and suggested to be removed by their own respective scientific research?

4. The MBBS doctors just want to save their turf while the Ayush doctors are already partially trained in medicine.

It is right in a way but it’s not just that.

Even if I don’t think the alternative therapies are an inferior science, even if I accept them as a legit alternative to medical therapy, all I want to say is, they are different. The very philosophy that the whole system of medicine stands on is distinctly different for each of these alternative therapies and they are all quite different from modern medicine.

While they sure teach Anatomy and Physiology in the Ayush courses as well because these facts can’t be altered by esoteric and philosophic differences, the very attitude and depth with which these subjects are taught have to be significantly different. Why and how would someone teach Anatomy the same way to an MBBS student and a Homeopathy student when they well know with one, the student might one day grow up to be a cardiac or a neurosurgeon and will need exact minutia of this information always refreshed while the other student is just learning this for a term exam and is not going to ever have to cut into a person in his natural progression of career?

Did you all have an ‘optional’ language in high school? Do you remember some subjects were taught at a ‘higher level’ or a ‘lower level’? That is the distinction between the teachings of the same subject between systems.

The very understanding and thinking about how and why illness occurs and how it should be managed are radically different between modern medicine, Ayurveda and Homeopathy. One talks of molecular and cellular level activities, the other talks about balance of natural humors, while the third thinks of stimulus and response mechanisms in contentious ways. How can you just ‘bridge information’ between these systems of healthcare when their very central philosophies of development of illness, pathogenesis and therapeutics are so different they can’t stay in the same postcode??

Then some say the Homeopathy and Ayurvedic colleges have been teaching Modern Medicine pathology, therapeutics etc too, and I ask WHY? Again, don’t they just trust their system in its entirety? And if they don’t, why don’t they drop that course, sit the NEET once more and try to become a Doctor practising modern medicine? We’d love to have someone with a skeptic mind who wants to question things being taught to them and would like to make inquiries outside of the context in the modern medicine practice, because that is what we do.

5. If people of Ayush specialties want to learn modern medicine, the knowledge should not be harnessed or limited. They should have access to it.

Yes, everyone should have access to knowledge. They should feel free to learn modern medicine if they so like, but as things stand, the resources we have for imparting such knowledge are unfortunately limited. Hence, we have created multilayered guards against entry into such privilege. The NEET, the merit, the quotas, the capitation fees and private college fees.

Allowing ‘bridging’ across from alternative medicine to MBBS will completely violate the idea of access through merit (even with reservation and quotas as they are).

Often people with higher ‘scores’ in their respective streams who can’t get MBBS will get into Dentistry, Pharmacy, Physiotherapy, Nursing etc before or around the same scores where some would take ‘Alternative therapies’. Such bridging courses will be unjust to those who took other ‘non-bridgable’ alternative career when MBBS was not available at their score.

This will create a corrupt private university market out there that will admit students into ‘alternative therapies’ courses as a backdoor entry to MBBS. This will risk the overall quality of healthcare and also result in inflation in alternative therapy courses, universities and capitation fees. This is bad health education resource management.

What India needs is more actual government medical colleges at a lower cost to meet demands, not more ‘alternative’ streams towards being a doctor and paying multiple layers of fees along the way. This will bring a large number of financially hungry, dubiously trained, medically confused and difficult to regulate ‘medical’ doctors who will be a huge risk to the public health.

If Bridging is actually to be contemplated, it will have to start with a massive reform at the level of universities. All the universities in the country will have to be categorised to match levels. Level-A universities will recognise the course material of another Level-A university as compatible and so on. This may lead to all the subject modules being categorised to the quality of teaching and then people who qualify to get admission into MBBS course in a university through NEET but have done another relevant course in the past from a comparable university can get advance standing in the course and may finish their course sooner. This is the acceptable way of ‘bridging’ or establishing a cumulative learning material.

If it comes to this, it will become very apparent very quickly that courses like Dentistry, Physiotherapy, Pharmacy, Nursing, even Veterinary Science will find it easier to make significant advanced standing when changing up to an MBBS because the very central philosophy, the modern scientific methods, facts and attitudes of these streams are closer to the MBBS of modern medicine than the Alternative Therapies are.

6. The ‘bridging courses’ will make medical treatment cheaper

Nobody seems to have taken the financial stakeholders of healthcare delivery into account in these discussions. The health-insurance permeation is fortunately increasing. More and more people are covered through private health insurance, employee health schemes, compensation claims, accident and third-party insurances etc. This is a good thing because it separates healthcare financials from the emotions and the outcomes.

The insurances are basically cumulative risk management plans that share the financial risk through premiums.

The government says they will ‘allow the bridged practitioners to work as doctors’, but have they taken the view of the Insurance stakeholders?

Are they willing to take the risk of these practitioners coming in the market? Will the private health insurance companies pay these ‘bridged’ doctors the same fees for their services that they do the modern practitioners? If they take this additional ‘risk’ by accepting their practices, will this lead to rise in premiums and cost of all health insurances? By how much?

Although I am not a voter in India, I am a supporter of the current moderate right-wing government in India and yet I am harshly critical of this NMC bill, mostly in the spirit of what I said at the very beginning of the article: If we don’t regulate our own, someone else will.

(Disclaimer: I have trained both undergraduate and post-graduate medical qualifications from India, have worked in large apex government hospital, remote district government hospitals. Now I work overseas and have no financial interest in healthcare in India, although I have interest in wellbeing of India and Indians.)

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