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Dilemma of Medical Graduates in Nepal

Discussion in 'Doctors Lounge' started by Angel, May 11, 2011.

  1. Angel xenoMED

    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.
  2. Elina Shakya New Member

    In last 15-20 years, the focus of medical education in Nepal has been on establishing medical colleges. However, in this new era, most medical graduates wish to join Post graduate programs as soon as possible. Nepal certainly does not have enough seats for post graduate programs. Thus, dilemma after medical school is highly expected. As highlighted in this article, there are basically three choices, to stay in Nepal, to go to neighboring countries or to fly all over to US.

    It has been precisely pointed out in this article, how important it is to have a career counseling for medical students and fresh medical graduates. There are individual preferences, social and financial situations, that affect the decisions of one over the other. Making an informed decision helps save time, money and energy. Most of us just depend on advices from our seniors. Some are determined to go to US. Some are against leaving their families.

    In my opinion, the medical education in Nepal is good, for those who take it seriously. There should be more clinical exposure during school. Those who got PG seats in Nepal are lucky. They get education, close to their family.

    Considering the current political and financial situation in Nepal, I think it is also important for some nepali medical graduates to fly abroad. They are expected to bring home, novel techniques and generous ideas. Our country needs a fast pace if we want to overcome our ' lag' behind the rest of the world. I believe this is possible with sincere efforts of residential nepalese plus non residential nepalese.

    I have always encouraged my juniors to go for what they really want to do. After all, there are inner voices inside everybody. The question is not whether you get what you want, the question is what if you get it !
    Angel likes this.
  3. Angel xenoMED

    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.
  4. Pal Member

    Nice article, भिर उढो जाने गोरुलाई हाई भन्न सकिन्छ काधा दिन सकिन्न its time for Nepalese graduate to make their vision wide.
  5. This article is truly elaborative and relevant.
    Currently, it seems that medical graduates have at any cost to enter into post-graduation (MD/MS)- either in the country or in the US. But it has not been sufficiently explored and informed about the opportunities in other field viz. public health, medical journalism, biomedical research, health administration etc. There must be few, if not all, graduates who are truly compatible in those fields. I think medical doctors can and should lead these areas for effective and smooth running of health dynamics and health politics. Had it covered these, this article would have been complete!!
  6. Embolus New Member

    मलाई यो लेखले एकदमै छोयो, मेरै लागि लेखेको जस्तो, शब्द शब्दमा कती धेरै अर्थ हरु छन भने, कतिपय लाई छोएर मात्रै रखिदिएको छ, पढ्ने मान्छे हरु ले पनि दिमाग लगाउन भनेर होला ।
    सुभासजी, तेई भएर होला हजुर ले भनेको कुरा लाई नखुलाएको, किन भने राम्रो लेखकले पाठक हरुलाई सोच्ने ठाउँ दिएको हुन्छन ।

    जेनीजी को अर्को कुन लेख आउछ, म कुरी बस्छु ।
  7. Embolus New Member


    दामी लाग्यो, दरो भन्नु भयो नि
  8. Jenny New Member

    Thank you all for such nice words. I am overwhelmed to know you found the article interesting. Dhanyabad Angel Dai :)
  9. Angel xenoMED

    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.
  10. Jenny New Member

    I want people to open their eyes before its tooooooo late.
  11. Angel xenoMED

    Great, I hope your effort to bring out this article would be beneficial to all.
  12. Subhas Bhetwal New Member

    Whenever I get some time, I've been exploring the different sections of xenoMED recently and this article came as an interesting finding. Dr Jenny has beautifully outlined some of the intimate feelings of a young medical graduate and the general dilemmas. The white apron excitement during the clinical year and writing Dr in front of your name....these some of the beautiful moments we all have had in our lives as medicos. But the charm soon fades away and you see some serious issues slowly creeping into your life. As usual it is what next? But this time the answer is not as simple as it used to be. When I reflect back to my own past, I can still feel the anxiety. Being a medical student in China and studying medicine there (esp in english medium) itself was full of uncertainties and challenges. There were times when we had no lecturers and had to look for them ourselves and sometimes in the middle of the semester we had to go on strike with the FAO (Foreign Affairs Office) just because the lecturer is not coming to the class as he hasn't been paid for months now!!

    That is all a memory now. We were tiny little voiceless medical students in China! But what I still find hard to accept is that we were treated worse in our own country. We had to compete for the internship and then pay for it. Before giving us a provisional registration, NMC under instructions from MOHP asked asked us to sign a formal agreement according to which we had to work in rural areas for a year after the completion of the internship. We signed and were ready for that. After the completion of internship we went to MOHP and asked for being allocated to the rural postings. But no one had any idea what to with us. They said that "Well, yeah...we know that we have made a policy but it is in the file. We need to see and let you know'.They scheduled us for a couple of rounds of meetings and came up with silly excuses like they didn't find the file or someone had gone abroad and we had to wait for guy's return. Later they started saying that Ministry of Finance wasn't ready to pay! We lost nearly two months in the process though some of our friends started working in the later phase of the series of meetings and negotiations. Finally the whole matter just dissolved. Nobody spoke about it. This was just to add my own reflection on the issue.

    I totally agree with Dr Jenney when you say "there is a tunnel vision in our existing medical education system....". We do have a tunnel vision. Let's think in terms of resources. The resources we need to produce a medical graduate is huge, for most of the medical graduates it is out-of-pocket expenses. After they have graduated, they should at least be in a position to find a place in the healthcare system and contribute to the overall health needs of the country. What we are not focusing is that medical graduates fall on the upper end of the spectrum of the skilled health workforce. Why don't we have a mechanism/a system which at least optimally makes use of the existing health resources. I think it is the role of the state to give right place to the right people in right time. That every medical graduate now has to strain one's nerves thinking about the post graduation, for me, is the failure of the state. We see the difference when we see the way resources are managed in other countries. Let's see Australia for instance in terms of the resource management, here most of the people who come out medical schools are not worried about the post graducation. We find GP's everywhere. They are the bulk of the workforce and they are only MBBS. They have specialists of course but people get to see specialist when they are in real need. GP's need to refer a patient to the specialist for them to be eligible to get an appointment. This is a country which has among the best health indicators in the world. And see our country, a huge bulk of the nation doesn't have a Skilled Birth Attendent when a woman delivers and while others are getting their common cold being treated by a chest specialist.It's unfortunate! MBBS doctor, patient don't beleive! They need to see a long list of qualifications before they decide to get inside the door. This is not their fault though. It is the weakness of the system. It is the weakness in the part of the policy makers. We can't stop the migration of the health resources it is another blow of globalization for the poor nations healthcare system. It is how the people of wealthy nations get better health at the expense of couple of maternal mortalities for each doctor migrating abroad. But we can at least do something to stop this being specialist/seeking specialist trend from advancing too far. We need to have ANM, TBA, SBA HA, and a huge no of GP's supervising them and few specialist who work in a tertiary setting to take the referrals. In that case even the limited number of specialist produced would serve their true purpose and the others GPs would also be satisfied with their jobs provided they are given enough opportunities for development and proper incentives for their work. This would give some good results for resource poor country like ours. Just a thought of mine!!
    avanish and Angel like this.
  13. Angel xenoMED

    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
  14. Subhas Bhetwal New Member

    Agree with Dr Angel! I think the medical community in Nepal needs to respond to this issue as well. We need to have a strong lobbying group within the medical community so that we can put some pressure on the policy makers and make them adopt policies which are evidence informed even if not evidence-based. I feel good about the research interest which I feel is fostering now. I don't have much idea about the role of others but Dr. Angel's commitment needs some sincere appreciation. I wish to join the force once I am back. Hamro Lagi Hami, fits for this issue as well. :)
  15. Angel xenoMED

    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.


    :)
  16. Jack Daniels New Member

    NIce Article Jenny.
  17. drgenius New Member

    nice presentation

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