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 Table of Contents  
MEDICINE AND SOCIETY
Year : 2022  |  Volume : 3  |  Issue : 2  |  Page : 170-173

Career opportunities in rural healthcare for young doctors: Opportunities and challenges


Department of Surgery, ASHWINI - Gudalur Adivasi Hospital, Gudalur, Tamil Nadu, India

Date of Submission10-Jul-2022
Date of Decision12-Aug-2022
Date of Acceptance13-Aug-2022
Date of Web Publication29-Aug-2022

Correspondence Address:
Dr. Royson Dsouza
Ashiwni Gudalur Adivasi Hospital, Gudalur, The Nilgiris - 643 212, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JME.JME_89_22

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How to cite this article:
Dsouza R, Menon N. Career opportunities in rural healthcare for young doctors: Opportunities and challenges. J Med Evid 2022;3:170-3

How to cite this URL:
Dsouza R, Menon N. Career opportunities in rural healthcare for young doctors: Opportunities and challenges. J Med Evid [serial online] 2022 [cited 2022 Nov 27];3:170-3. Available from: http://www.journaljme.org/text.asp?2022/3/2/170/354997




  Introduction Top


About 70% of our country's population live in villages. More than 80% of Indian doctors work in urban or semi-urban hospitals, leading to appalling inequity in access to healthcare for rural Indians. The Government of India responded to this crisis by allowing numerous new medical colleges, many in the private sector, and by increasing the number of undergraduate seats in government medical colleges. This was intended to nudge the new doctors to work in rural areas, as urban and semi-urban areas are already saturated with doctors. Unfortunately, something else is happening.

Most of the new doctors are crowding the urban and semi-urban areas, where they are more of a liability to even the existing healthcare system. A graduate medical doctor without specialisation is seen as someone with no value in an urban setting, is put into a rat race and is forced to specialise, superspecialise and subspecialise further. The competition to grab the few patients who seek care there leads to shameful practices like referral fees, branding and marketing to bring in more patients. This awful situation unfolds even when vast swathes of rural India suffer without qualified medical professionals.

The current medical education system fails to introduce the trainees to the charm and great opportunities that exist for a meaningful and dignified career in rural India. The authors of this paper have worked in remote parts of rural India and have wonderful insights to share about their experiences. One such experience is shared in the paper. This paper is written to enlighten the medical trainees of our country about these realities.


  Dr. Royson Dsouza-ASHWINI Gudalur Adivasi Hospital Top


Throughout my undergraduate training at St. John's Medical College, Bengaluru, there was an emphasis on serving the underprivileged. However, not once during my MBBS did I imagine working in a rural hospital. After graduating, the popular option amongst the studious ones was to pay off the rural bond, join a coaching centre and crack the PG entrance. Why would I think of taking the path less travelled that would slow my career down? Besides, my perception of working in a resource-limited, remote rural hospital was quite different. The rural hospital was somehow synonymous with inferior patient care, lack of mentorship, without chances for recent advances or research on a background of a lonely and boring life. Little did I know that I was going to be blown off my feet and my life would change forever.

January 2014 was my first visit to Gudalur, a small town located at the foothills of the Nilgiris and at the junction of the three Southern States (Karnataka, Tamil Nadu and Kerala). There is a popular belief about a sensation of well-being in Gudalur, which has no scientific evidence, but you see it on the faces of the people here. This first visit was by chance as it was for a research project and I had to spend a week training one of the Adivasi staff at the hospital to create ear moulds for fitting hearing aids. During this time, I had an opportunity to spend time at the outpatient clinic, follow the doctors during their ward rounds and observe some surgeries. I realised that working in a rural hospital meant using all my knowledge from MBBS and internship to diagnose and treat patients. This was unlike the tertiary care system of having to make the patients jump over from one speciality to the other or rely too much on the investigations and miss the bigger picture, the patient! That week was such an eye-opener and that is when I decided to do my rural bond.

While working in Gudalur, our day would start with grand rounds which were full of discussions and healthy arguments regarding patient care. There was no hierarchy, intimidation or humiliation, unlike in our medical colleges. The entire team of doctors and nurses would have just one point to prove to help the patient. When the world around us is busy compartmentalising medicine into super- and subspecialities, working in a rural hospital made me an all-rounder. One of the first patients I got to manage was brought in after being mauled by a bear. He had a trimalleolar fracture of the ankle and multiple lacerations over the bilateral gluteal region. He was calm as a rock with a heart rate of 70, whereas mine was at 140. When I started debriding the wound under 0.5 ml of pentazocine, his heart rate went to 80 while he continued to look at me with those calm eyes. I was amazed by this incredible pain tolerance our patients had. Our outpatient department is right next to the labour room and not once have I heard any screams, neither the mother nor the staff. On my 1st week of on-call, a well-looking 5-year-old boy was carried in by his 60-year-old grandmother after he suffered an injury to the right leg. The boy was in no pain but could not walk. The X-ray revealed a comminuted fracture of both the bones. After sharing the X-ray images on our orthopaedic WhatsApp group, I wrote the referral letter to the nearest tertiary care centre that was 4 h away, while waiting for the opinion from our orthopaedicians. I was first told not to worry, put an above-knee slab, watch for compartment syndrome and convert the slab to a cast after the oedema subsides. In 2 months, the fracture had united perfectly; the bone had remodelled beautifully and more importantly, the boy was walking cheerfully.

In the 2 years of my rural bond, I was exposed to a spectrum of medical, surgical, paediatric, obstetric and gynaecological conditions. I was trained to perform upper gastrointestinal endoscopy, basic ultrasonography, a variety of general surgical procedures, caesarean sections, closed reduction of fractures and spinal anaesthesia. I had the opportunity to look at the grassroots level of healthcare during the community visits. The evenings were full of sports and fun activities which slowly changed into studies for PG entrance exams. I was advised to study to be a good and competent doctor in my 1st year and do the PG entrance books in the 2nd year. It was fascinating to learn how interesting the less chosen books such as Ganong, Robins, Katzung and Keith L More were when you read them to improve your knowledge.

I was fortunate to work under one of the best clinicians who would then be my lifetime mentor. Dr. Nandakumar Menon was a surgeon by degree but a perfect all-rounder by profession. Having imbibed a great deal of knowledge and life lessons, I chose to be a surgeon. My strongest reason to choose surgery was that I could be an all-rounder when and if I worked in a secondary care hospital. I believe that with our MBBS level of training, a majority of medical, paediatric, psychiatric and dermatological conditions can be managed in a resource-limited setting, but that is not true for surgery. Hence, in my opinion, a surgeon would be a lot more productive in a rural hospital.

I went on to do MS general surgery and am ever grateful for getting selected to Christian Medical College, Vellore. Unlike most institutions in India, the training in CMC, Vellore, is focused on producing competent surgeons capable of performing surgeries independently and in a resource-constrained setup. Thanks to my 2 years in Gudalur, I was able to cope with the busy post-graduate life with ease. After completion, I chose to come back to Gudalur and to the community which made me who I am today. Working as a surgeon in a rural hospital has its challenges. The patient's fitness for surgery and if the surgery is the right one for the patient needs to be decided properly. Anticipating intraoperative and post-operative complications and precautions to prevent them need to be assessed in a broader aspect compared to a well-equipped tertiary care centre. Despite these odds, the work is very fulfilling and gratifying. Today, my outpatient clinic is a combination of patients with both surgical and medical illnesses. The most important quality to be an all-rounder is the willingness to learn. I teach surgery to my junior medical officers and they teach me how to interpret an electrocardiogram. A typical day in the operating room consists of surgeries such as hernias, lumpectomies of breasts, circumcision and hysterectomies with a gynaecology colleague. Laparoscopic appendicectomy is the most common emergency surgery. To continue my learning curve, I often get to do laparoscopic cholecystectomies, cystoscopy and ureteric stenting, thyroidectomies and endovenous laser ablation of varicose veins under the direct supervision of my teachers. I have also been able to publish a number of research articles showcasing the good work that can be done in resource-limited settings. Being a surgeon does not stop me from fulfilling my primary role as a doctor. This includes conducting field visits to the community for screening of tuberculosis, malnutrition, cancers, etc., and COVID vaccination campaigns.


  Perception of Working in a Rural Healthcare Setting Top


Although 70% of our country's population reside in rural areas, the drive to cater to their healthcare needs is seldom seen in our young doctors.[1],[2] Working in resource-limited rural healthcare settings is unfortunately seen as the 'path less travelled' and is unpopular in young minds.[3] The norm is to enrol in the coaching centres for a minimum period of 1 year and to crack the post-graduate entrance exam which is undoubtedly set to assess only the memory of the students rather than their work experience. Thus, working in a rural healthcare setting is perceived as a 'slowdown' in the career of doctors.

Rural healthcare is invariably perceived as one offering inferior care with inadequate resources and technology.[4] The apprehension of not practicing advanced medicine, lack of newer diagnostic modalities and second opinions from higher specialities are thought to be inadequate patient care.[5] Young doctors choosing hospitals for good pay will not consider rural healthcare settings.[6] Similarly, rural life is perceived as a life of loneliness and boredom without opportunities for entertainment and sports.


  Breaking the Myths Associated with Rural Healthcare Top


Not a life of sacrifice but of blessing

Life in rural healthcare is often portrayed as one full of sacrifices and challenges but in fact, could be a blessing and fulfilment. It provides young doctors a chance to apply most of what they have studied during their MBBS curriculum in the management of patients. Lack of advanced diagnostic tests can be sought as an opportunity to improve one's reasoning and arrive at the correct diagnosis, which is more rewarding than the former. This emphasises the need for thorough history taking and complete physical examination which improves the clinical acumen of the doctors. With one's knowledge from MBBS, a majority of medical, paediatric, obstetric, psychiatric and dermatological disorders can be competently managed. This opportunity is available in only a rural healthcare setup that is not overcrowded with multiple specialists like its urban counterparts.

A chance to be an all-rounder

Working in a rural healthcare setting provides young doctors a chance to be all-rounders. This includes seeing and managing a spectrum of medical conditions in the outpatient clinics, inpatient management, emergency and critical care.[5] There is also an opportunity to acquire skills such as ultrasonography, diagnostic upper gastrointestinal endoscopy, reduction of fractures, conducting deliveries and learning basic obstetric and general surgical procedures. The skills acquired during one's stint in a rural healthcare setup will result in making one a more competent and confident doctor during post-graduate training and thereafter.

Mentorship and career choices

A large number of rural healthcare centres are established and run by some of the finest minds in our country. Unlike many of their materialistic counterparts in Tier 1 cities, their passion for selfless work to restore the social imbalance in health is commendable. Choosing such places to work provides a great opportunity to get a first-hand experience from the pioneers themselves. This can change one's entire outlook on what is to be a doctor. Young doctors may then be able to make a better choice in choosing the post-graduate course that is based on strong values and experiences.

A chance to make a difference and away from the rat race

Working in remote, resource-limited rural healthcare settings will provide a chance to impact the lives of thousands. Timely intervention results in successful outcomes in all infectious and non-communicable diseases.[7],[8] This will minimise the complications due to the same and referral to tertiary care centres causing a large economic burden on the patients.[9] A rural healthcare professional has a chance to be a beacon of light in providing health education and preventive medicine and improve the knowledge, attitude and practices related to health in the community.

More productive at a young age

Due to a moral obligation, many young doctors may decide to serve in a rural healthcare setup but only after having a fulfilling career. It may not be easy to step away from established practice and with familial responsibilities to take on a more challenging rural healthcare. One may be too qualified to be productive enough for a rural healthcare setup that requires all-rounders and multi-taskers. Furthermore, the adventures that rural life offers in terms of hiking, trekking, farming, etc., are more enjoyable at a younger age.

A chance to have a good life

Rural life has its charm. It is a life free from pollution, noise and traffic. It is an opportunity to breathe fresh air, drink clean water and enjoy nature. We as doctors unlike most other professions have a chance to work in these beautiful places and enjoy life while still restoring social equilibrium.

Barriers for young doctors to choosing rural healthcare as a career option and solutions to overcome these barriers

Like many things in life, we may not be happy with something that we have not had a chance to explore. Similarly, most young doctors have pre-conceived notions about rural healthcare without even experiencing it. Only a handful of institutions in our country make rural bonds an option for their students.[1],[10] A majority of these young doctors complete their obligation and come out with fruitful experiences and a few even return to their rural healthcare centres after post-graduation. On the other hand, doctors without a chance to explore life in a rural healthcare setting see no other option but to get into the rat race of specialisation and super specialisation. Young doctors should realise that spending at least a year or two after MBBS in a rural healthcare setting is not a slowdown in their career. Hence, they should give themselves a chance to experience healthcare at the grassroots level. Rural healthcare may not be everyone's cup of tea, but unless one is willing to explore that possibility, one will never know.

Post-graduate training in India today is focused on producing just the senior residents instead of competent and confident doctors.[11] This is more so for the surgical specialities where the chance to independently perform even the basic surgical procedures is given only during senior residency. Therefore, the doctors who just come off training may not be confident enough to work in resource-limited rural healthcare settings, especially if they do not have a senior for a backup.[5],[6]

Working in a rural healthcare setting may be considered no opportunity for personal growth in terms of wealth.[5] Richness depends completely on one's perception of it. There are many rural healthcare centres that pay adequately well. A lot of daily expenditure in urban areas such as travel, food and fuel can be saved in rural areas. To keep in touch with recent advances and academics, technology has developed to make most of these available on online platforms.[12] To enhance the hands-on surgical experience in advanced and complex operations, regular visits by specialists from tertiary care centres who are willing to train can be arranged.


  Conclusion Top


Working in a remote, resource-limited, rural healthcare setting may not be every doctor's cup of tea. However, it is definitely a career that is worth exploring, even if it is for a short duration. The authors of this manuscript are testimonials for this fulfilling work and hope to have broken some of the myths regarding rural healthcare.

Acknowledgements

  1. Dr. Anand Bharatan, Sri Ramakrishna Hospital, Coimbatore
  2. Docnet India Organization
  3. Rural Sensitisation Program
  4. Rural Hospital Network (ruralhospitalnetwork.org).


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sharma DC. India still struggles with rural doctor shortages. Lancet 2015;386:2381-2.  Back to cited text no. 1
    
2.
'Young Doctors Don't Want to Go to Rural Areas Because They Feel ill-Equipped'. Hindustan Times; 2016. Available from: https://www.hindustantimes.com/analysis/young-doctors-don-t-want-to-go-to-rural-areas-because-they-feel-ill-equipped/story-w4lHPNBcz9 X975nJ3HEp2M.html. [Last accessed on 2022 Jan 12].  Back to cited text no. 2
    
3.
Why Are Budding Doctors Hesitant to Work in Rural Areas? Research Matters; 2019. Available from: https://researchmatters.in/news/why-are-budding-doctors-hesitant-work-rural-areas. [Last accessed on 2022 Jan 12].  Back to cited text no. 3
    
4.
Anticona Huaynate CF, Pajuelo Travezaño MJ, Correa M, Mayta Malpartida H, Oberhelman R, Murphy LL, et al. Diagnostics barriers and innovations in rural areas: Insights from junior medical doctors on the frontlines of rural care in Peru. BMC Health Serv Res 2015;15:454.  Back to cited text no. 4
    
5.
Goel S, Angeli F, Dhirar N, Sangwan G, Thakur K, Ruwaard D. Factors affecting medical students' interests in working in rural areas in North India – A qualitative inquiry. PLoS One 2019;14:e0210251.  Back to cited text no. 5
    
6.
Saini NK, Sharma R, Roy R, Verma R. What impedes working in rural areas? A study of aspiring doctors in the National Capital Region, India. Rural Remote Health 2012;12:1967.  Back to cited text no. 6
    
7.
Kollef MH. Should we be debating the importance of timely adequate antimicrobial therapy? Clin Infect Dis 2010;50:617-8.  Back to cited text no. 7
    
8.
Non Communicable Diseases. Available from: https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases. [Last accessed on 2022 Jan 12].  Back to cited text no. 8
    
9.
Rural Hospitals Overview – Rural Health Information Hub. Available from: https://www.ruralhealthinfo.org/topics/hospitals. [Last accessed on 2022 Jan 12].  Back to cited text no. 9
    
10.
To Tackle Shortage of Doctors in Rural Areas, Centre and MCI Approve Two-Year PG Courses after MBBS. The Indian Express; 2020. Available from: https://indianexpress.com/article/india/to-tackle-shortage-of-doctors-in-rural-areas-centre-mci-approve-two-year-pg-courses-after-mbbs-6563982/. [Last accessed on 2022 Jan 12].  Back to cited text no. 10
    
11.
The Problems of Medical Education in India – Should the Medical Council of India (MCI) be Scrapped? ClearIAS; 2018. Available from: https://www.clearias.com/medical-council-of-india-mci/. [Last accessed on 2022 Jan 12].  Back to cited text no. 11
    
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