Is the time ripe for MD in OPD practice?

The dissent was there - all the time. Now, it is reaching very uncomfortable proportions.

I am talking about the perpetual tussle between Governments and Doctors. Both are blaming each other for what they perceive as lack of accountability towards the society. While the doctors are sure that the successive Governments have fared miserably in managing healthcare in the nation, the Government always blames doctors for neglecting rural sector in extending healthcare. Apart from the direct onslaught, the Governments use surrogate tools on the entire medical community to hide their inept performance in healthcare.

The element of truth exists on either side. At current scenario, it is not easy for a doctor with mere MBBS degree to derive success and money through practice. The current medical education treats MBBS as a pre-requisite for writing PG Entrance exams rather than creating a doctor who can be benefit to primary healthcare in society. Mere MBBS has been de-glamorized beyond expectations!

Also, the quality of medical education has been deteriorating with successive years. The medical faculty who used to be the sources of inspiration for generations, has been slowly vanishing. Advent of Post-Graduate courses in every medical colleges have been eating up the hands-on opportunities from MBBS interns. The internship after MBBS is becoming more and more clerical and uninspiring. No wonder internship is no longer seen as preparation for future career as practitioner.

With this kind of natural history, doctors with mere MBBS qualification perceive themselves "not good enough" for practice. Also, the society expects every doctor to be a "super-specialist" and looks down upon someone who lacks specialty qualification. This is a very big moral let down for a fresh medical graduate who genuinely wishes to practice after MBBS. Overall, the scenario is not bright enough for primary healthcare.

The vacuum created in primary healthcare by inadequate number of MBBS doctors has been easily filled by quacks who either lack qualification or those with AYUSH qualification but shamelessly practice modern medicine in surrogacy. Since Governments have the onus of covering up their own lacunae, they openly support AYUSH quacks irrespective of what the law dictates! It's marriage of convenience between AYUSH quacks and inept Governments!

There is DNB in Family medicine, but appears ill-constructed and less advertised. Also, the centres that offer DNB family medicine do not do any justice for the candidates. Many of these institutes use such candidates as cheap labour rather than training them effectively to cater the needs of society. Also, the objectives and curriculum of this course do not seem to be functioning. Something more concrete and much bigger than this is the need of present times.

It is probably ripe time for MD in OPD practice. Those who wish to serve as family physicians in enforcing the primary healthcare should be given a proper training and support to counter blames from Governments as well as to fight quackery. The following suggestions can be considered. The medical community can feel free to add to these suggestions:

1. There should be 2 or 3 year course in MD in OPD practice. There should not be any entrance exam for this course. Those who are interested should be allowed to continue after completing interneship. These candidates should not be allowed to write any other PG entrance exams for 5 years after finishing the MD in OPD Practice course.

2. The fee structure should be minimal and the stipend should be equal to any other PG course. Private medical colleges should also follow the same principle. 

3. The training rotation should be exclusively in OPD with about 3 months posting in emergency to learn the principles of triage. These students should not be misused for ward duties, discharge summaries, emergency duties and so on. The broad specialties should have longer posting with few weeks each in specialty OPDs. The curriculum should be carefully designed by a panel of senior expert faculty from many specialties.

4. There should be 1-2 months posting in Laboratory to understand the functioning of basic autoanalysers, procurement of basic reagents, maintaining them, principles of biomedical waste management, and operating a simple laboratory which caters to basic set of investigations.

5. There should be another 1-2 months posting in pharmacy to understand procurement, stocking, arrangement and dispensing of medicines with basic principles of book keeping. It should be enough to manage a small pharmacy which dispenses important medications.

6. There should be periodic assessment rather than one tough exit exam. These assessments can be at every 6 months interval and should summate to the final results. There need not be a grand exit exam or viva voce.

7. The Government should mandate these doctors with MD in OPD practice to set up clinics only in rural areas. They should be provided interest-free loans to be repaid in 3 to 5 years to set up their clinics in rural areas. They should be given permission to set up their small laboratory which can perform basic set of investigations and should be given permission to dispense medications in the clinic without any need of additional license. This will ensure adequate financial compensation and will encourage more and more qualified doctors in rural areas. It should be ensured that two such clinics should be separated by at least 2-3 km to avoid clustering and to discourage unhealthy practices.

8. Periodic CMEs should be conducted in this area and every doctor should accumulate at least 6 CME credits every year to sustain the life of license.

Overall, the objectives of this course should be
a) create more competent and confident primary care physicians
b) check quackery
c) encourage doctors moving towards rural areas to deliver primary healthcare
d) elevate the overall quality of primary healthcare
e) reconstruct the skewed healthcare pyramid of this nation

Hence, this course should not be made painful by unnecessary hardships or tough training protocols or rigid exit exams. This course is a need of this nation and should have the objective of meeting the required needs rather than making life tough!

Constructive criticisms and suggestions are welcome. Those who have something pessimistic to say, please keep away. It is time for constructive action rather than cribbing, blaming and complaining.

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