Why DM and MCh seats are lying vacant?

INTRODUCTION

Of the 5000 super specialty seats available in medical colleges across the country, as many as 1000 were lying vacant after the two rounds of counselling under the National Eligibility cum Entrance Test- Super Specialty (NEET-SS). With no takers for a few super specialty courses across the country, the National Board of Examinations in Medical Sciences (NBEMS) was forced to decrease the eligibility cut-offs for special counselling rounds to fill the vacant seats.¹ For the year 2023, the Medical Counselling Committee (MCC), in their wisdom, announced that NEET-SS 2023 candidates with zero percentile were also eligible to secure a super specialty seat if they opt for it. However, despite the cutoff being lowered, 700 seats remained vacant.²

There can be many reasons for a high demand for a few super specialties such as Urology, Nephrology and Cardiology but a decline in interest in Cardiovascular and Thoracic Surgery (CVTS), Paediatric Surgery and Plastic Surgery is of concern. The predominant cause for this is future financial stability. Most doctors opt for a specialization that pays well in the long run. Most students are not interested in those branches that have fewer patients and hospital dependent practice because of the enormous set-up cost.

MEDICAL TREATMENT REPLACING SURGERY

There are fewer super specialty candidates in some of the surgical branches as medical treatment has improved and patients can be treated with drugs and radiological interventions instead of surgery. Cardiothoracic surgery has suffered the most. Coronary artery bypass graft (CABG) surgery has decreased because more and more stenosed coronary arteries are being treated by coronary angioplasty. Vagotomy and gastrojejunostomy was often done for peptic ulcer disease but at present most patients are being treated by a change in the understanding of its pathophysiology and hence improved medical treatment. Similarly, the number of patients requiring transurethral resection of the prostate (TURP) has decreased because there are better drugs to treat the symptoms.

PREFERENCE FOR INDEPENDENT PRACTICES

In CVTS, a doctor cannot function independently. She/he always needs to work with a team of doctors, technicians, nurses and back and front office staff. A super specialist will need a lot of infrastructural cost to set-up a private practice and so she/he is invariably dependent on a hospital––government or corporate. New medical branches such as neuroanaesthesia, specializations under oncology, organ transplants, critical care, head and neck surgery are also not in demand as compared to surgical gastroenterology, urology, medicine, etc. These specialties require a dedicated team other than the surgeon himself and a lot of input cost on infrastructure to assure a good outcome. Hence, people are gradually losing interest in these fields. However, there is a new interest for specialization in spine surgery, which beats this trend.

PREFERENCE FOR SPECIALTIES THAT ARE PHYSICALLY LESS DEMANDING

Work–life balance is the buzz word among young doctors today. When they are about to enter a super specialty training programme they are either getting married or have a young family which justifiably demands their attention. That is the reason why while choosing a specialty the crem-de-la crem of the fresh medical graduates choose Radiology, Dermatology and Pathology. There are no emergency calls after scheduled hospital hours and family time remains sacrosanct. This trend continues in their choice for super specialty. This is the reason behind the lower demand for Paediatric Surgery and CVTS. They are physically more demanding and taxing than other streams.

SUPER SPECIALTIES THAT CANNOT BE ENCROACHED BY OTHERS

With a dismal specialist–population ratio such as in India this should theoretically not be a problem. However, the problem of patient numbers in certain specialties is undeniable and when even these are encroached upon by other super specialties this becomes a discouraging sign for future aspirants. In case of paediatric surgery, other than a few dedicated procedures, there is constant competition from general surgeons, urologists, etc. for many of their patients. Plastic surgeons find dermatologists, general surgeons and even dentists doing hair transplantation and liposuction, breast surgeons, gynaecologists and endocrine surgeons doing aesthetic breast surgeries, even beauticians and quacks playing with lasers, and head and neck surgeons doing reconstructive surgery. This crazy market reality discourages many would be aspirants.

AVOID HIGH-RISK AND LITIGATION PRONE SPECIALTIES

In the present litigious society with great mistrust between patients and doctors, aided by misreporting, one has to always be aware of the potential threat of being sued. Certain super specialties such as Paediatric Surgery, Plastic Surgery and CVTS are high-risk super specialties where patient’s expectation are often far beyond the possibilities of science. Some doctors are prepared to go the extra mile and converse, reassure, treat, document and follow up impeccably but mishaps still occur and result in litigation. Many super specialty aspirants are not prepared to opt for these high-risk options and choose to remain away from them.

FINANCE IS IMPORTANT

How much one spends in super specialty education and how much one earns out of it once in practice are important factors in the choice of super specialty. Is there value for money, the super specialty aspirant is asking. High fees that private medical colleges demand for super specialty education is a big deterrent and the majority of the seats that are lying vacant are in private colleges. The fees, on an average are about ₹50 lakh (5 million) per annum amounting to ₹1.5 crore (15 million) for the 3-year course. When seats in few government colleges offering these courses are also lying vacant despite the low fee structure, these private seats have no hope of attracting students. This amount of investment in an uncertain future work environment for a person who has a young family is taxing, if he is not from a very affluent background.

Compounding this issue is the small stipend paid to them. Some colleges do not even provide a proper stipend. Some students have alleged that the stipend is provided only on paper, but nothing is credited to the student’s account!

STATE BONDS ARE A DETERRENT

The seat in a government medical college comes with a compulsory post-qualification working bond. Many students are not opting for higher studies because they are trying to escape the ‘seat-leaving bond’ policy.³ They do not want to get into the bond trap of the state government. The state bond is a serious problem as financial penalties are high. State bonds have proven to be a huge deterrent for young postgraduates.

LACK OF JOB OPPORTUNITIES AND LIMITED FINANCIAL GROWTH

Many super specialty streams offer the opportunity only to become a faculty member or get into research. Unfortunately, both have lost their charm today. There is limited financial growth in these profiles, and this has affected students’ outlook towards them. It is not uncommon to come across vacant faculty positions in even premier medical institutions such as the All India Institute of Medical Sciences, New Delhi, King George Medical University, Lucknow and Maulana Azad Medical College, New Delhi. Hence, the faculty status of newer medical institutions can easily be gauged. If after completing the grueling super specialty course the candidate is not absorbed in a faculty position her future employment prospects remain uncertain.⁴

The most successful impact of the liberalized education policy has been the promotion of engineering and medical colleges, which used to be the privilege of a few. The colleges mushroomed, but building infrastructure and manning them with qualified professionals are two different things altogether. While freshly qualified super specialists, with a dream in their eyes to excel in teaching are working for pitiable amounts in corporate hospitals, the faculty position in most of these newly inaugurated medical institutions are lying vacant.⁵

CHOICE OF END-BRANCH

General Surgery is an open branch and to establish a good practice one needs a super specialization in one of the super specialties such as Urology, Gastrointestinal surgery, Endocrine surgery, etc. So, seats in the end-branches such as orthopaedics, ophthalmology or otorhinolaryngology get filled earlier than general surgery. Similarly, plastic surgery is an open branch and one must undergo further training in hand surgery, aesthetic surgery, craniofacial surgery, etc. to establish a super specialty practice. This increases the learning period and further postpones the start of clinical practice. This too is a deterrent to choosing these branches.⁶

A POSSIBLE APPROACH

We feel that a person, who intends to practice his super speciality can do the common initial 2 years of training with his General Surgery colleagues and then skip the third year and proceed to a 3 year super specialty programme. She does not get a MS General Surgery degree but a MCh degree much like the 5-year programme of the National Board of Examination in Medical Sciences. The 2 years of grooming in General Surgery is enough for all surgical super specialties. This has the added advantage as she will not be competing with his General Surgery colleagues for general surgical patients. Vacant faculty positions in teaching hospitals should be routinely filled and super-specialists should be offered attachment in district hospitals which do not have them in their regular staff already. Though there is a theoretical remedy of reduction in the super specialty seats to avoid them remaining vacant, the number of seats is and will always be decided by the government. With the super specialist–patient ratio being so low, and patients still travelling long distances for super specialty care, it is unlikely the government will reduce the number of super specialty seats.