Teaching Shops Of Medicine

For a teaching hospital, Divya Jyoti Institute of Medical Sciences and Research (DJIMSR) in Ghaziabad, UP, was surprisingly devoid of human life on this morning. It had none of the familiar squash of Indian hospitals: sick people, stressed relatives, long and messy queues, the mingled smell of sweat and chemicals. We did have a hint that a ghostly entity awaited us. “Aage sirf jangal hai,” a man we asked for directions had said earlier. Only a jungle ahead. We kept going anyway, along a broad road that started cutting through fields, until we caught our first glimpse of the building. It looked like it had been abandoned mid-construction and has been crumbling since.

Before the guards began shouting at us, we jogged through. Every ward was locked. There was no electricity, no equipment—just a few stretchers inside locked wards, furniture piled on top of them. No ceilings, no glass panes. It was like being inside a big, concrete pipe-organ—the wind whistled through, blowing dust around.

DJIMSR had applied to the Medical Council of India (MCI) to start an MBBS course this September. Records show the hospital was set up in 2010; it had first applied for permission to start a college in 2012. They were denied permission every year, including in 2016. In August, the Supreme Court-appointed Over­sight Committee (OC) headed by Justice R.M. Lodha also turned it down. The DJIMSR website shows a host of facilities, but lists no phone numbers. When Outlook visited the chairman’s office, we were told he was not available. They never got back. The telephone number medical superintendent Manoj Govil had submitted to the MCI turned out to be a wrong number. The principal listed in the MCI forms told us he no longer works there.

DJIMSR is just one among hundreds of private ‘medical colleges and hospitals’ that exist out there—claiming, almost magically, to operate. Don’t ask about infrastructure, faculty or patients. But do ask how they manoeuvre the system to open ‘medical colleges’ and churn out batches of young doctors. Out of 10 lakh registered doctors from 400 colleges in India, thousands have got their degrees from institutes that function as little more than teaching shops. The traditional picture of medical education—a robust hospital with a large clientele, organically developing an associated medical college—does not apply automatically now. Today, colleges are set up almost immediately after hospitals are opened. They may have no patients for students to practise on. But if you have the money, a piece of paper certifying you as an MBBS awaits you at the end of five years .

This May, the Supreme Court had come down heavily on the MCI—the apex body responsible for regulating medical colle­ges—and declared that under it, the system fails “to produce a competent basic doctor”. That’s when it set up the three-member OC, to go through MCI recommendations. Just as well, for this is an entity famed for its corruption, with over 3,000 cases pending against it around India. And yet, the granting of permission to medical colleges isn’t vulnerable to corruption alone. Criteria of judgem­ent differ; it’s a delicate balance bet­ween quality and availability.

Proof of this deeper tension came when the OC, in a decision that surprised many, overturned the MCI ban on 63 colleges, opening up nearly 8,000 seats (see ‘It’s Inspector vs Inspector’). And it did so on the basis of self-assessments by colleges and their web­sites. “What colleges show us is the Taj Mahal,” says MCI head Jay­sh­ree Mehta. “When we go there, it might be locked up.” But Justice Lodha insi­sts there’s “no compromise” on quality. What governs this move towards partial relaxation is, of course, the acute shortage of doctors in India. The doctor-population ratio in India stands at 1:1674 whereas the WHO norm is 1:1000. While 8,000 young students may be moving fast to fill these new seats, they also risk being suddenly cast adrift—these colleges can lose their permissions anytime after October if a spot-check by the OC finds them lacking.

Take a case where the OC overturned an MCI ban: NC Medical College and Hospital in Panipat, Haryana. With MBBS classes slated to begin this month, there is a lot more life here. It has a building with running electricity and equipment. Nurses sit around chatting. It has one thing in common with DJIMSR, though: no patients, no doctors in sight. After a flurry of activity in the administrative block, the chairman and principal meet the Out­look team but refuse to take questions. The principal says they are busy preparing for a ‘surprise check’ (sic) by the affiliating unive­rsity (PBDSUHS, Rohtak) the following day. How does she know in advance? She doesn’t answer.

They are hiring, big time. Some 100 young men are filling up forms to join as tutors or junior residents. Many from Kerala, Telan­gana and Haryana itself—rec­ent graduates from universities in Russia, Ukraine and China—are signing up for Rs 50,000-60,000 a month. “There aren’t many people who live around here,” says a young doctor, exp­laining the absence of patients. “But since we’re on the highway, we may get accident cases.” Why come all the way from Andhra Pradesh? “Work here will be less stressful. We are anyway preparing for our PG ent­rance test. We’ll stay here for a while and see if it works out.”

In Israna village nearby, some are happy that healthcare is now nearer home. Others are unimpressed. “We can tell if it is a good hospital based on how many patients go there. Whenever I went there, it was pretty empty,” says Ram Kumar, a grocer. One might imagine a private hospital is expensive for villagers, but they all say tests—from X-rays to ultrasounds—and treatment are mostly free. The college has filled all 150 of its new MBBS seats. A week after Outlook’s visit, the college has a new principal. Dr Mukesh Yadav says the hospital had been running losses in crores and the OC’s perm­ission came as a surprise. “We are working on a war footing to improve morale,” he says. “To attract faculty to this remote area, we offer higher salaries, good facilities. We organise buses to bring poor patients.”

Last year, Dr Raj Bahadur received an SMS he wasn’t expecting. The message said a college in Andhra Pradesh was inviting him to engage classes for two days, as a professor. On offer: Rs 4 lakh. Bahadur is the vice-chancellor of the Baba Farid University of Health Sciences in Faridkot, Punjab. “It came from an unkn­own number, and had no contact details.  It must have been an agent who was sending out bulk messages to doctors listed on a database, hoping to trap some,” he says.

This practice has caught on. ‘Doc­tor-hop­ping’, they call it—doctors fly in and out of medical colleges around India, posing as staff and faculty. They are paid well and disappear after their cameo appearance. A retired government orthopaedic surgeon says, “I can actually moonlight and earn 10 times the salary I get every month.” A sharp MCI inspector can see through it, though. An MCI report on a college had these words: “The resident doctor claimed he had been working there eight months. But he was unable to name a single colleague.”

The shortage of faculty in India’s medical colleges—over 35 per cent—stares at the authorities like the symptom of an acute disease. A report of the National Commis­sion for Macro­econo­mics and Health says, “Even state governments feel compelled to indulge in irregular practices­—mass transfer of teachers of different speci­alties from one college to another on a temporary basis—at the time of inspection. Keeping fake rolls of teachers and showing expenditure under the salary head is common.”

Students at a medical college in Karnataka, recall how their cam­pus would come abuzz every time on insp­ection day. The college always seemed to know in advance. “We’d see seniors and old friends...they candidly say they’d come for inspections. The college usually calls in local graduates or those preparing for their PG,” says an ex-student, who is now preparing for his own PG exams. After his MBBS, he had worked at a hospital in Kerala, where he saw another version of the game. “I worked in the casualty ward but they paid me Rs 30,000 in cash for three days to pose as a faculty member. I wasn’t keen but was persuaded by colleagues,” he confides.

Dr Imtiaz ul Haq, the principal, has been an MCI assessor himself for many years. He supports the idea of inspections. Asked about what former students say, he answers, “I have been in charge here since 2013. Maybe these dishonest practices were happening earlier, not in my time.”

As president of the Punjab Medical Council, Dr Gurinder Singh Grewal found a high traffic of doctors bet­ween his state and Himachal Pradesh. Cross-checking TDS papers against the time doctors were registered in Punjab, Grewal was able to weed out hundreds of doctors who had been popping up in Himachal colleges around the time of inspections. Several show up on the rolls of Maharishi Markandeshwar University (MMU) in Solan, for example. “Unless they have a helicopter, there is no way they could be running clinics here yet teaching there. If you start searching for thieves here, you almost end up finding RDX. That’s how corrupt this field is,” he says.

As per the Indian Medical Council Act, a doctor can practise anywhere in India. State councils like Punjab’s also ask doctors to register themselves in any new state they work in, to ensure that doctors don’t fly through hospitals and colleges for brief periods. As per the MCI rules, a doctor can’t be on the faculty of more than one college in the same year. If caught, they risk losing their place in the Indian Medical Register. (Shrewd doctors have, of course, found ways to work around this.)

At MMU, dean Dr Kiranjeet Kaur, also principal since 2014, has been served a notice by the Punjab Medical Council for not having registered herself in Himachal. “Himachal Pradesh is not a big state, so we can’t get all the faculty we need here,” she says. “Most of our doctors eventually get admitted to the medical council here. If not, it still doesn’t make them culprits. I don’t think there’s any hard and fast rule.”

The parliamentary standing committee on health and family welfare puts its finger on a key enabling factor. Its 2016 report said, “Medical colleges have prior information of inspection dates and are thus able to keep ready the required number of ghost faculty and fake patients.” They called it out for being among the “worst kind of gross unethical practices.” Hospitals and attac­hed colleges are required to maintain a certain ratio of students to doctors and pat­ients. “Our college would go pati­ent-shopping, looking for ‘interesting’ cases, who’d be brought to campus during MCI inspections. On these days, where there was usually enough room to play football, there would not be space to even drop a pin,” says the doctor from Karnataka.

Students from Bangalore to Hapur talk of a similar mode of operation. Nearby villagers are often lured with free medical camps. Bulletin boards at NC Medical College in Panipat display newspaper reports on their free health camps. The Karnataka graduate adds: “In my five-plus years at the college, I never saw a single patient in the burns ward. The ICU has a capacity of eight beds but it would be full only during inspections. As interns we even picked them up ourselves from government colleges. Contractors also helped bring patients in buses.”

But a fake patient is not fully packaged until she is also accompanied by a full case file of her medical history. MCI assessors often check these. The Karnataka graduate recalls, “Only a few interns would be posted on duty, the rest of us stayed back writing up fake case files. Ten of us would write nearly five files a day. Just imagine, in a month we create case files for at least 1,500 patients, who simply didn’t exist. The assistant professors would give us the diagnosis and we would work backwards to write imaginary case histories that fitted the diagnosis. We wrote fake details on everything from height to bowel movements.”

Again, it does not always work. Seasoned inspectors check for freshness of paper, similarity in ink and handwriting, says an assessor from a private medical college in Bangalore. “When I am on inspections, I might see records for supplies showing a large number of items. But if I suddenly call for, say, ‘Paraffin block number 1357’, they would not be able to produce this immediately if they’d fudged their books.” she says.

India’s demand-supply dynamic in medical education is heavily skewed. The gover­nment and medical fraternity see this as  a key factor that spurs on the competitive market of corruption. A health ministry official explains that creating more medical seats and fast is priority. At present, there is a bottleneck between undergraduate and postgraduate levels, with only 25,000 PG seats available against 55,000 UG seats. “Supply is of a pyramidal nature. This means thousands of students will just not get seats. We need to increase seats—and through private medical colleges. Then even cost of education will reduce,” he says.

This urgency is what has changed the policy perspective. The traditional ‘inspector raj’ model of the MCI is being challenged by almost everybody, including the health ministry, NITI Aayog, the standing committee and the OC. MCI inspections are tedious; checks for ‘minimum standard requirements’ run to things as minute as the thickness of partition walls, distance between two beds, the number of books and journals in the library or if the lecture hall is set in a gallery formation or not. The standing committee says such rigidity, in fact, motivates colleges to cheat. “Despite all these tight controls, can anyone say from their heart that the quality of medical education has improved?” asks the official.

A rush for quantity is risky turf. A draft bill prepared by NITI Aayog in August to rep­lace the Indian Medical Council Act, 1956—currently inv­iting comme­nts—says there should be no ceiling or regulation of fees, for-profit organisations should be allowed to set up medical colleges and the practice of shutting down colleges that fall short of requireme­nts should give way to a market-oriented policy in which all colleges would merely get a rating. Students with money will be free to sign up even at the worst college. “Deviation from standards need not necessarily result in derecognition,” says NITI Aayog.

 Medical education operates on a peculiar business model. Colleges charge a bomb for admission, but function as teaching shops, offering little to the student exc­­ept the cer­tificate. And yet, they offer free or subsidised healthcare to the few poor and rural patients who come in, as Outlook observed in the colleges visited. Herein lies a hint. One would imagine the money for faculty, staff and infrastructure comes from a bustling hospital spanning 20 acres—the minimum prescribed norm. But a pharma specialist in Bangalore expla­INS: “The hospital is never the money-maker. They start colleges because it is from here that they expect money to fund everything else.” The possibility of earning crores via illegal capitation fees explains their impatience to start a college even when the hospital may not have pati­ents for students to learn on.

“When we graduated, we came out of the college worse than when we went in,” says the graduate from Karnataka. “Where we studied would not even qualify as a nursing college.” For a young student preparing for a life in healthcare to say this should alarm us to the imm­inent and long-term danger to public health. It may be easy to pin blame on single institutions or individuals for this spectre of total systemic collapse, but the reality is that this situation was brought about by failure at several levels over decades, especially by governments at the Centre and in states. Somewhere, the system needs to find a way “to produce a competent basic doctor”.

By Anoo Bhuyan in Ghaziabad & Panipat