Dilemma of Medical Graduates in Nepal

I am sharing one of the very pertinent article by Dr. Jenny Lamichhane in our present context published in Journal of Nepal Health Research Council in October, 2010.




Dilemma of Medical Graduates in Nepal
- Dr. Jenny Lamichhane, Nepal Medical College and Teaching Hospital, Jorpati, Kathmandu, Nepal.


ABSTRACT
The medical education system is in infancy in Nepal. There are many constrains at various levels. The numbers of medical colleges are increasing every year without considering for its quality by the concerned authorities. Nepal Medical Council is the authorized body to look for medical professionals in the country. Even though, efforts have been made from various sectors but are insufficient.

This article will mainly focus on the life of a medical graduate in Nepal. It will give an idea of how these graduates have to undergo various problems regarding their career, family, profession and social lives, right after their graduation.

Keywords: career, dilemma, medical education, graduate, Nepal, profession

Introduction
The World Health Organization states that “the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being..."1 Accordingly, free health care has become one of the key slogan amongst most of the political parties and even government of Nepal has started this service for years. The success of such work depends upon multiple factors such as human resources, economy, infrastructures, incentives and many more.

The medical education system is slowly taking its shape, even though there are many constrains at various levels.2, 3 This article will mainly focus on the life of a medical graduate in Nepal. It will give an idea of how these graduates have to undergo various problems regarding their career, family, profession and social lives, right after graduation. However, the xenoMED has come out with a very useful interactive program “beyond Internship” which gives an idea about what to do after internship.4

Internship
After hard work of 4.5 years in more than 15 major and minor subjects, a medical student becomes an intern. With all the theoretical and practical knowledge gained during MBBS study, it is the time to apply this in the real life. On the top of that; having a title (Dr.) in front of a name, make them feel proud. With fewer responsibilities, they even wish this period would never end and becomes the golden moments of their lives. This is the time where a young graduate make up their mind as which specialty would be most suitable for them.

Nepal Medical Council (NMC) defines the criteria for the rotatory internship.5 However, the academic activities and supervision as defined by NMC has not been maintained. The job of an intern has mostly been limited to admitting and discharging patients, less supervised dressing and minor procedures, only. Therefore, after 3-4 months it becomes less charming in 12 months period.6, 7

Medical Officer
As soon as they come out at the end of one year of rotatory internship, there are many thoughts in mind; confusions, anxiety, stress, emotional disturbances and goose bumps experienced. Due to this, they sometimes tend to get lost, completely. The graduates who are scholarship holder of Ministry of Education have to undergo compulsory two year government services. It provides them some time to think and shape their career and avoid from being stressed out of what to do after internship. But for rest of the others, it’s a daunting task to make a clearer picture of what would happen next. This perplexity has created chaos resulting further confusion and hence, they know what not to study but they don’t know what to study.

Earlier there was a trend to work as a medical officer for many years and then apply for a post graduate program. But nowadays, scenario has changed. As soon as they become a medical officer (MO), they immediately want to join a PG program. For MO working in the rural parts of Nepal, it is very difficult for them to work as there is a lack of adequate infrastructure with limited laboratory facilities and availability of drugs. Few of them may be financially sound but they may not have job satisfaction and are usually deprived of supervision by seniors and latest development of medical fields.

Whereas the same graduate who works in the medical college or tertiary level; they work in one department under supervision unlike government scholarship holders who have to look after all the specialty without guidance. This is the reason why a MO who is posted in the periphery in limited facilities are hand cuffed and their performance goes down. Therefore, even though a doctor is present in the remote places cannot perform at its best and virtually the incentive (financial or non-financial) is inadequate at all levels.

Post Graduate Entrance Preparation
This has become one of the biggest hurdles in the current scenario. The number of newly graduates and the pool of old graduates are increasing every year but the number of post graduate (PG) seats are relatively unchanged over the years. This scenario has created a chaos in the PG entrance examination, be it Institute of Medicine (IOM) or any other like Kathmandu University (KU) PG seats. The issue of bribing and mismanagement has polluted these institutes, lately.8-10 The majority of MO cannot get PG seats and work as senior medical officers for years. All this leads to go for two options; either to stay in Nepal or abroad.

The post graduate opportunities are available in IOM, BP Koirala Institute of Health Science (BPKIHS), National Academy of Medical Sciences (NAMS) and KU affiliated medical colleges. All of these have their own set of eligibility criteria, no uniformity, some need working experience and some doesn’t. Because of increasing demand for PG seats, there have been reports of illegal activities in these places.8, 9 In this chaos, only those who have sound financial background and links are getting seats, but deserving are not, in most of the instances.

Some of the self-finance PG seats are so high that it is beyond affordable for most of the graduates and some time these seats are sold under heavy amount, mostly financially sound go for it. With this scenario if anyone is thinking to earn money, it’s not the right place; those aspiring people should join another profession, because it becomes very hard to return back the financial investments in their life time.

The recent trends have increased to go for All India Institutes of Medical Sciences (AIIMS) and Post Graduate Institute (PGI) Chandigarh, India, partly because they are renowned and those who don’t want to go beyond neighboring countries. There are many Nepalese medical graduates who prepare its entrance through coaching classes in Delhi, India. The number of these graduates making their position in AIIMS and PGI are increasing every year as compared to the past.

The trend for going to United States Medical Licensing Examination (USMLE)11 for USA has got pulsatile nature. In some year the number of graduates getting residency increases and some year decreases, accordingly number of applicants are increasing and decreasing from Nepal. This is costly, time consuming and requires hard work, dedication, devotion, passion and perseverance. And even if you complete all the phases, you are not sure whether you will get residency or not which has become one of the drawbacks of USMLE.

The issues such as considering finance, job satisfaction, and exposure to modern technologies and peer pressure to some extent are some of the reason for which there is increasing inclination towards USMLE. Dedicating years of preparation and hard work to get through the USMLE, not knowing whether they will get a residency at the end, may lead to frustration especially when leaving behind family and country. Those who love staying in the community, family, relatives and happy the way Nepal is; then USMLE is not for them.

The entrance examination is not required for countries like China, Bangladesh, and Philippines. However, it will not be the same, and may be these rules might change as with Pakistan which conducts entrance examination unlike previously. The UK, Australia and other countries have their own specific format of examination which starts from their medical licensing examination.

Post-Graduation
The IOM has got longest history of medical education in Nepal,2, 12 followed by BPKIHS, KUMS and NAMS.12-14 There is a need of increasing human resources in the specialties like dermatology, psychiatry, anesthesia, radiology, MDGP and many have not yet been considered important in the country. None of these institutions have worked according to the changing trend and need of the country but the conventional way. Had that been, then there would not have been shortage of human resources in these critical areas. Neither young graduate made first choice as their career option in these fields. There is a need of change in the medical curriculum, government policy and thinking at the gross root level.

Whereas in the subjects like internal medicine, surgery, pediatrics and gynecology and obstetrics have got relatively better scenario than others in terms of human resources. But there has been increasing trend of going for sub-specialty after PG particularly in internal medicine and surgery for DM and MCh respectively, without which future will not be possible in these fields in the coming years.

Because of lack of opportunities, PG candidate compromises with the subject they are least interested in. This might lead to poor performance in the workplace affecting health service delivery in long run. There is very less number of residency seats than the graduates which may lead to chaos in the coming days. It has also been witnessed by recent scandals.8, 9

The PG education has more number of hours in non-academic than academic activities. It is new in Nepal; therefore the system has not been yet completely settled. It will take more than a decade when there will be quality education at this level. Because of this reason NMC is trying to come out with entrance examination for PG graduate from abroad. It has already got Nepal Medical Licensing Examination (NMCLE) for MBBS graduates.

Due to the increasing pressure for PG and chaos in the country many graduates have started going to the neighboring countries like China, Philippines, Bangladesh, Pakistan and others. But there are very few universities recognized by NMC. Knowingly and unknowingly few graduates even go to unrecognized universities; facing many problems, later on.

Therefore, there is a need of a proper career counseling programs so that there will be a clear vision of the future and minimize the state of dilemma soon after internship. Career counseling also helps best use of time and knowledge in a more productive manner. There has to be a system to stop brain drain.

Way Forward
The young graduate and even medical students should be well aware of all the options and opportunities beyond a medical college. There is a tunnel vision in our existing medical education system, unlike in other countries where there are councilors who guide them for their future career. In this scenario, seniors and some organizations like xenoMED4 would be a great help who provides platform for guidance and sharing each other’s experiences.

The government has to come out with a clear policy and regulation to maintain quality of medical education in the country. There has to be a need based production of human resource for health. The government scholarship holder should be given special training of minimum six months in the tertiary level before posting them in the periphery and the mechanisms to provide them continue medical education. The number of post graduates seats has to be increased. A modern medical curriculum has to be made to address existing challenges in health rather than copying and pasting other countries guidelines. The specialists in medical education have to be strengthened in the chaos of mushrooming of medical colleges in Nepal.

The monitoring and evaluation system for NMC, medical colleges and universities has to be started by the government to ensure that they are performing at their best without any irregularities. The concepts of single entrance test for MBBS and PG should be started.

The protection of health professionals and institutions has to be insured, along with better incentives to check brain drain. The concept of free health care cannot be achieved fully, unless existing medical education system is improved. No one wishes to leave the country and family, unless there are opportunities and secure future within.

References

1. Health and human rights. World Health Organization; 2005 [cited 2010 Jun, 07]; Available from: URL:http://www.who.int/hhr/en/
2. Dixit H. Development of medical education in Nepal. Kathmandu Univ Med J (KUMJ). 2009 Jan- Mar;7(25):8-10.
3. Karki DB. Quo Vadis--post graduate medical education in Nepal? Kathmandu Univ Med J (KUMJ). 2003 Jan-Mar;1(1):2.
4. xenoMED Nepal. 2005 [cited 2010 Jun 07]; Available from: URL:http://www.xenomed.com
5. Nepal Medical Council. 2005 [cited 2010 Jun 7]; Available from: URL:http://www.nmc.org.np
6. Chaudhary D. Internship: in retrospect. Kathmandu Univ Med J (KUMJ). 2004 Apr-Jun;2(2):168-9.
7. Dangol B. Internship: a closer look at its prospects. Kathmandu Univ Med J (KUMJ). 2008 Jan-Mar;6(1):141-3.
8. Sharma SP. Nepal’s premier medical school closes over alleged bribery for exam papers. BMJ. 2010;340:c1707.
9. Sharma SP. Politics and corruption mar health care in Nepal. Lancet. 2010 Jun 12;375(9731):2063-4.
10. Pradhyapak. Institutionalization of corruption in KU. [online]: Kathmandu University & Change; 2007 Dec 24 [cited 2010 Jun 7]; Available from: URL:http://changeinku.blogspot.com/2007/12/institutionalization-of-corruption-in.html
11. Cramblett HG. The United States Medical Licensing Examination (USMLE): background and structure of the examination. Fed Bull. 1990 Jul;77(7):205-10.
12. Dixit H, Marahatta SB. Medical education and training in Nepal: SWOT analysis. Kathmandu Univ Med J (KUMJ). 2008 Jul-Sep;6(23):412-20.
13. Karki DB, Dixit H. An overview of undergraduate and postgraduate medical education in Nepal and elsewhere. Kathmandu Univ Med J (KUMJ). 2004 Jan-Mar;2(1):69-74.
14. Marahatta SB, Dixit H. Students' perception regarding medical education in Nepal. Kathmandu Univ Med J (KUMJ). 2008 Apr-Jun;6(2):273-83.

Absolutely, the system has not well developed, that doesn't mean we don't have any roles. We can educate our peer, share our experience, show them more options and opportunities and advocate for improving scenario.

Particularly, I do echo your voice...

We tend to go for what others are doing or imposing, but we seldom look inside ourselves, what exactly we want out of our lives. Those are the most successful and satisfied human being in this world who follow their intuition and do the things they like the most.

After all no matter how much credential we add, at the end of the day its all about happiness, satisfaction and being worthy. All other things are just temporary which doesn’t bring happiness but momentary.

To all - follow your heart, if it is not clear then get information about all the options and go for the best suited one.

Hello Jenny,

First time I went through your article it was so nice, I went twice and tried to look for things that had been missing. It was well written, incorporating important aspects of graduates. As other said, we would love to have more thought provoking issue from you.

Great, I hope your effort to bring out this article would be beneficial to all.

Subhas,

Its a wonderful perspective on your part, specifically the hard time you went through during and after your internship. The vivid picture of what you have described about your experience in MoHP is something that everyone encounters in most of the ministeries, agencies and councils for professional work.

This is also my personal experience working and spending hours of discussion with people from a small hospital to big, Medical college to Universities, Nepal Medical Council to Ministry, National Planning Commission to even head of the state, small donnors to large scale external development partners to even WHO, is No body wants to take a risk. They don't want to put themselves into the controversies. Everyone is trying to save their position, thats all.

Neither they wish to bring innovate, creativity in their work nor they want to go out of box. Very few people think about others but negligible number bring that into action. That doesn't mean there aren't enough nice people, some of whom I really appreciate their efforts but even if they are in the position, there voice is not heard.

Health Policy and Management is one of the biggest issue in our country. Even though we hire experts from abroad, and have policy and guideline but that is not implemented. I have gone through so many documents, its rigorously discussed and beautifully written and carefully prepared. But only thing - its not implemented at all. Because of unstable government, political turmoil and changing government with different political ideology. Even if the predecessor has envisioned very useful plan for the country, the successors do not follow them because of their political ideology and wrong person in right position in wrong time. And sometime one get position, even if s/he is not capable and not even expert on that field.

However, I am very much optimist that it will not be the same scenario. I'm talking about 10-15 years down the line, we will have more expert professionals who will take the lead. We will have more concerned consumer and more educated population.

For which even if there is no opportunity, no recognition, one has to trained in various fields, specialty to fill the gap and build the nation. We seriously need health policy and management expert, not so called but trained.

Regards

Thanks Subhas and you or any interested are always welcome to foster scientific work in Nepal. New scientist are emerging and critical mass is forming to shape the future, that is only possible from research and publication.

Hopefully we will have improved scenario in 15-20 years down the line.