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| GENERAL ARTICLE |
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| Year : 2016 | Volume
: 29
| Issue : 1 | Page : 42-46 |
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India's foreign medical graduates: an opportunity to correct India's physician shortage
Sharma Anjali1, Zodpey Sanjay1, Batra Bipin2
1 Public Health Foundation of India, New Delhi, India
2 National Board of Examinations, New Delhi, India
| Date of Web Publication | 18-Mar-2016 |
Correspondence Address:
Sharma Anjali
Plot 47, Sector 44 (Opposite PF Office), Institutional Area, Gurgaon - 122 002, Haryana
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/1357-6283.178932
Background: India's current estimated doctor-population ratio of 1:1700 against targeted ratio of 1: 1000 shows a clear shortage. A mismatch in number of medical aspirants and available seats, intense competition and unaffordable costs of medical education prompt many Indian students to pursue training opportunities abroad. Many later return to India, and these foreign medical graduates (FMGs) must pass a qualification test which is a required to practice medicine in India. This review undertakes a situational analysis of FMGs in India and suggests a roadmap to better utilize this resource pool of physicians. Methods: A thorough literature search was carried out using Google Scholar, PubMed and websites of the Central Board of Secondary Education and Medical Council of India. Foreign Medical Graduate Examination (FMGE) data was obtained from India's National Board of Examinations. Results: From 2002 to 2014, growth was seen in the number of FMGs who took the FMGE, with more having trained in China than any other country. However, typically only 25% of FMGs pass the FMGE. In 2013, 9,700 FMGs were unable to pass the FMGE to enter practice in India. At least 7,500 FMG physicians are unable to become licensed each year for failure to pass the FMGE, including those who retake and again fail the exam. Discussion: There are possible solutions. Additional training and hands-on apprenticeships can be introduced to help FMGs build their skills to then be able to pass the FMGE. FMGs can now learn by participating as observers in the established programs. Opportunities also exist for FMGs to work outside of clinical care, including in research, hospital administration and public health. As of now, FMGs are an untapped resource and lost opportunity to a country with shortages of physicians. Keywords: Bachelor of Medicine and Bachelor of Surgery, Foreign Medical Graduate, Foreign Medical Graduate Examination, India, Medical education
How to cite this article:
Anjali S, Sanjay Z, Bipin B. India's foreign medical graduates: an opportunity to correct India's physician shortage. Educ Health 2016;29:42-6 |
| Background | |  |
As a country, India has to her credit the largest number of medical colleges in the world. The Medical Council of India (MCI) lists398 medical colleges with 52,105 MBBS (Bachelor of Medicine and Bachelor of Surgery) registered seats for new students each year.[1] India's medical education system has come a long way from the mere 23 medical colleges operating before independence in 1947. Growth in private medical colleges has also occurred in the past two decades, and in the past decade nearly 70% of the medical colleges established have been private.[2] Although significant progress has been made in number of medical training institutions, India still faces physician supply issues. The current estimated physician to population ratio in India is 1:1700, against the targeted ratio of 1:1000, showing a continued shortage.[3] India also has a physician distribution challenge, with close to 70%of physicians concentrated in urban areas. This leaves the density of physicians in rural India at 3 per 10,000 population versus 13 per 10,000 in urban areas.[4]
With too few physicians and India's high disease burden and need for more well trained physicians, it's medical education system faces important challenges in meeting this need. These challenges include issues in the student admissions processes, the way education is imparted, curriculum content, and how students are assessed, among other issues.[5]
In the admissions process, each year around 30 medical entrance examinations are conducted at the national level, such as through the All India Pre-Medical/Pre-Dental Entrance Test (AIPMT) and All India Institute of Medical Sciences entrance examination and at the state level. A total of 616,982 candidates registered in 2014 for the AIPMT exam, which is the most often taken entrance exam for the MBBS course [6],[7] [Table 1]. Out of the 398 medical colleges in India, 215 are private, with a capacity for 27,170 new students each year, and 183 are government medical colleges, with seats for 24,935 students. The admission process for private medical colleges differs across states and colleges. Under the Non-resident Indian Quota, up to 15% of seats in private medical colleges maybe filled by non-residents of India, 42% of seats are to be filled in by State Pre-Medical Test (PMT), and the remaining seats may be filled as the colleges wish.[8] Tuition fees at private medical college range from 35-50 lakhs (US$ 55,000 to 79,000) for the entire MBBS course, excluding internship. With high competition for seats and the high cost of education in private schools, many aspiring doctors from India are forced to seek their medical education abroad. There are also Indian students who believe a foreign degree will provide better career options later when the return to India to practice. | Table 1: Number of applicants for All India Pre Medical Test/National Eligibility cum Entrance Test UG for last 4 years
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In recent years, several important issues hamper the ability of graduates who have trained abroad to become licensed to practice in India. This paper explores these issues facing Indian physicians trained abroad.
Foreign medical graduate examination
A foreign medical graduate (FMG) in India, as for many countries, is a physician who has graduated from a medical school outside of the country where he or she intends to later practice. In order to enter the Indian health system, these physicians must pass the Foreign Medical Graduate Examination (FMGE) screening test conducted by the National Board of Examinations (NBE). The NBE was established in 1975 for the purpose of standardizing post-graduate medical education in India. Since 1982, the NBE has functioned as an independent, autonomous body for the field of medical sciences broadly. Its principal goal is to improve the quality of medical education by elevating the level of education and establishing threshold standards for post-graduate medical examinations. As per the FMGE screening test 2002 regulations, “An Indian citizen possessing a primary medical qualification awarded by any medical institution outside India who is desirous of getting provisional or permanent registration with the MCI or any State Medical Council on or after 15.03.2002 shall have to qualify a screening test conducted by the prescribed authority for that purpose as per the provisions of section 13 of the Act.”[9] There are no restrictions on number of times an applicant can try to pass the screening test. The criteria for FMG and licensure exam is (1) he/she is a citizen of India or Overseas Citizen of India. (2) The candidate should possess a primary medical qualification, which is to be confirmed by the Indian Embassy for the country where the degree is earned. Five English speaking countries are exempted from this act.[10] This review undertakes situational analysis of FMGs in India and offers suggestions for how to utilize this resource of physicians willing to return to India more effectively.
| Methods | | |
A thorough literature search was carried out using search engines like Google Scholar and PubMed. A set of single and combined keywords was used, which included foreign medical graduates, medicine; education; international medical graduate; clinical; healthcare and public health. Data for the number of FMGs who took and passed the FMGE since 2002 was obtained from the NBE. We also undertook a review of the websites of the Central Board of Secondary Education and MCI to estimate the competition for medical seats in India. Various blogs and newspaper articles related to the medical education system and FMGs were also searched.
| FMG Statistics | | |
The practice of Indians studying medicine abroad began in Russia a few decades back, and gained momentum in the past six years with newer destinations like China, Nepal and Ukraine. Each year, it is estimated that more than 5,000 students leave India for medical education elsewhere, with China being the most popular destination followed by Russia, Ukraine, Nepal and Kazakhstan. The total number of candidates for the FMGE trained in China from 2010 through 2014 is 18,297and the number is increasing [Graph 1].
The number for FMGs sitting for the screening test has increased from 2002 through 2014 [Graph 2]. However, the percentage of FMGs who pass has hovered around 25%. In 2012-2013, 3,664 of the 13,953 FMGs (26%) who sat for the Test passed. According to NBE statistics, of 13,953 FMGs who sat for the FMGE that year, 8,063 had trained in China, 1,739 in Russia and 861 in Ukraine. Since the test is held twice a year with no restriction on the number of attempts an individual may make, many take the exam several times.
What makes destinations like China, Russia and Nepal attractive for aspiring doctors is their low cost, good education and ease of admission. The difference in the cost of a medical education in private colleges in India is about double that in these other countries. Over 52 Chinese universities offer positions to Indian students. An entire medical education can be completed in China for ₹15-25 lakh ($US 24,000-40,000), less than half what it would cost in a private medical college in India, excluding the expense for room and board.[11] Another factor that makes China popular for Indian students is that the medium of instruction is English, unlike that in Russian universities. Also, there are minimum entry requirements in either Chinese or Russian universities.[12]
Failing expectations
FMGs returning to India face a harsh reality. Those unable to pass the FMGE mandated by the MCI are either un-employed or under-employed.[13] Over 10,000 FMGs were unable to enter the Indian health system in the 2012-2013 year [Graph 2]. Among the reasons for low pass rates are differences in the curriculum followed by Indian MBBS training institutions and medical colleges overseas; in some countries the curriculum is taught in non-English languages rather than in English used in Indian institutions; lack of peer mentoring and adequate educational standards in some international schools; and students taught outside of India receive inadequate training in India's particular health problems, which are tested in the FMGE. Further, with the lower entrance requirements in foreign schools that are preferred by Indian students, some FMGs who seek licensure in India will have a harder time achieving competence.[14] A 2014 expert committee report on screening test highlights the negative role of agencies engaged by overseas institutions towards admissions.[15] With these various challenges facing FMGs, test preparation courses often cannot help them pass the FMGE.
On average, at least 7,500 FMGs are added to the pool of unlicensed doctors in India every year. Even FMGs who pass the screening test can wait as much as six months or more for the MCI to issue an eligibility certificate.[16] Until they receive a certificate, FMGs cannot apply, register, or take an examination for postgraduate seats or start a residency. Moreover, the competence of FMGs as physicians is questioned by some, so they can face barriers in the job market. Their English language skills for practice can be weak,[17] their international schools can be of questionable quality, and they can have difficulty adapting to Indian healthcare system. There are fewer quality concerns for graduates of countries like Nepal and Mauritius, as medical education there is in English and modelled after the Indian system. In 2012, the FMGE pass rate was highest for students from Nepal (34%), followed by students from Bangladesh (30%), Russia 28% and China (27%).[16]
Migration of medical graduates from India
With 1.24 billion people, India's health care system is over-burdened and is struggling to respond to healthcare needs of the population. Growing physician emigration further contributes to the existing shortage of doctors. Migration seems to be substantially higher for graduates from the best medical colleges: 54% of graduates of India's premier medical college between 1989 and 2000 left the country, with most of them leaving to the USA.[17] Financial insecurity in India, political instability, sparse opportunities for continued education, low compensation and rigorous workload for physicians lead to the emigration of medical graduates.[18]
There is high demand for trained medical graduates in developed nations including the United States (US), United Kingdom, Canada and Australia as these countries consistently train fewer physicians than their populations need. Currently, the US trains only three quarters of the physicians it requires to fill its entry level residency positions. The other quarter of residents employed by its hospitals is composed of US citizens and immigrants trained in other countries. Studies forecast 20% physician shortages in the developed world by about the year 2025, representing 40 times the current yearly immigration rate.[18] This dependence on foreign physicians puts a tremendous strain on the healthcare systems of developing nations like India. At present, India has no mechanism to track the outflow of its medical graduates. The current guidelines of MCI does not require graduates to obtain any official approval before migrating abroad. While India faces an ongoing shortage of trained medical manpower, along with trained doctors emigrating to other nations, FMGs can at least partially ameliorate this situation.
The path ahead
India's FMGs have made a sufficient contribution to the number of medical graduates enlisting with medical councils. In ten years, a total of 19,733 FMGs have registered with MCI and State Medical Councils, almost equalling the output of 20 medical colleges with 100 graduates each. But the question is -what happens to those 75%of physicians who are not able to clear the FMGE.
The existing FMGE has 300 multiple choice questions, including 100 from pre and para-clinical sciences and 200 from clinical sciences. Each item is a single correct response type with four distractors and no negative marking. The items used are memory recall and the benchmark course curriculum is the MBBS course in India (Graduate Medical Regulations).[19],[20] An expert committee report on screening test in October 2014 recommended introduction of clinical skills testing as an essential component in assessing physicians' qualifications. Since physicians deal with the human lives, the FMGE cannot be eliminated without risking quality. There are some possible solutions. The entry pathway to medical institutions abroad can be strengthened, perhaps by introducing the AIPMT Ranking/National Eligibility Entrance Test (NEET) Ranking as a criterion. Second, a refresher or a primer course for these candidates can be introduced before they appear in the FMGE to accustom them to important issues in health in Indian. Third, a top-up training course can be introduced for one year for those graduates who are unable to pass the test after three or more attempts. Fourth, FMGs could appear for the FMGE after spending a specified amount of time in clinical settings in India as observers or in clerkship programmes as apprentices. As apprentices, graduates can rotate through various medical specialties in public facilities and assist in delivering care under the supervision of practising physicians. Also, just as some have proposed that MBBS students who graduate from domestic institutions must serve a year rural positing at a Primary Health Centre (PHC) before applying for post-graduate medical courses [21] similarly foreign graduates can also have a requirement to work in PHCs, perhaps for two years, before be allowed to practise elsewhere. This will also aid in lessening the urban-rural divide in physician supply. A centrally coordinated network or association of FMGs can provide comprehensive study material based on the topics covered under the FMGE and offered through distance education. It can provide further handholding support to FMGs through mock tests, providing important information on commonly asked questions about the licencing process, and counselling about overseas colleges and universities. This platform can also assist FMGs in honing competencies like language skills, which are often a barrier to passing the FMGE. Such various measures can help FMGs build their knowledge, skills and competencies to help then pass the FMGE. It would be also be important to evaluate FMGs who succeed in gaining entry to practice in India to track their performance and skills and see how well they adapt to the local culture and health problems of the patients they see.
To address FMGs who cannot pass the FMGE or find employment after passing it, alternate types of work can be created beyond clinical care, perhaps in public health, hospital administration and research. FMGs could enrol in any of the 31 institutions that offer 850 positions each year in Master of Public Health (MPH) courses. Opportunities for MPH graduates in India include the areas of health policy and management, disease prevention and control, health promotion and communication, occupational/environment health, reproductive health, and others.[22] To open this public health career pathway, public health programs will need to recognize the international medical degree as an academic qualification for entry. FMGs can also pursue the opportunities created through the recent growth in positions in hospital and health administration and health research.
| Conclusions | | |
India is struggling with a shortage and maldistribution of physicians. FMGs are an obvious and potentially important resource pool but are yet to be tapped. If mechanisms can be created to allow FMGs to become licensed in India, they can make a significant contribution to health care in India, including in decreasing the rural physician shortage. Any solutions for better using the FMG pool that are seen to jeopardize the quality of India's physicians might be sharply opposed, but they are too important a resource to leave unused any longer, and they are anxious now to serve the country.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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