Disclaimer: The opinions expressed here are my own, and are based on my understanding of the motivation(s) behind the NMC Bill.

In the previous article, I presented details regarding the ‘bridge course’. This article will examine the proposed National Licentiate Examination, and the issue of permitting medical professionals to practice medicine and surgery without qualifying the aforementioned Examination.

Background Information:

It is an established fact that all medical graduates are not comparable with respect to (minimum/ basic) knowledge and skills expected of a graduate doctor. This is the reason admission to certain institutions is highly sought after- the quality of training varies considerably between institutions within the same university.

Thus, while some MBBS graduates are well equipped to fulfill the needs and expectations from a graduate doctor, a large proportion (of MBBS graduates) are not.

There are several consequences of such disparities:

1. The quality of healthcare provided is not uniform, and results in preventable morbidity, mortality and resource utilization, often causing an additional burden on the system (to rectify errors previously committed)
2. The ill-equipped graduate doctors lack confidence in their abilities, and avoid involvement in healthcare provision till such confidence is established
3. Many of the ill-equipped graduate doctors seek ways to improve their knowledge and skills before joining a postgraduate course in a better institution:
   1. Internship in institutions with good teaching and sufficient clinical material
   2. Working in Primary Health Centres
      1. to gain clinical skills and exposure
      2. to acquire eligibility for state government quota in PG entrance exam
   3. Observership (paid/ unpaid) with reputed medical practitioners
   4. Self-study (theory), followed by any of the above
4. Some ill-equipped graduates abandon the idea of pursuing a post-graduate qualification, realizing that they would not pass the qualifying examination. A fraction of these proceed to engage in general practice; some take administrative roles in healthcare institutions; while others change career paths or otherwise abandon medical practice.
5. Prior to the introduction of NEET-PG, many of the ill-equipped graduate doctors would proceed to pursue post-graduate qualifications by paying large sums of money to gain a PG seat in private higher education institutions.

Cumulatively, these have resulted in a highly fragmented healthcare delivery system in which the client is deprived of assured minimum competence from a graduate doctor.

In simple terms, there is a difference between graduates from AIIMS (New Delhi), JIPMER, AFMC, Madras Medical College (and other ‘premier’ public sector institutions, for instance), and graduates from most other Government Medical Colleges. Similarly, there is a difference in quality between the graduates from CMC, Vellore; St. John’s, Bengaluru; KMC, Manipal; CMC, Ludhiana (and other ‘premier’ private sector institutions, for instance), and graduates from most other private medical colleges.

This should NOT be the case, considering the cost of medical education is almost uniform to medical students, regardless of the institution they train in (barring a few exceptions). Thus, when students pay similar fees for their training; and adhere to the same curriculum, they should have similar competences upon graduation, too.

The fact that a large proportion of MBBS graduates lack minimum knowledge and skills has allowed the proliferation of less qualified/ unqualified ‘medical practitioners’. They exploit the fact that neither do the real MBBS graduates pose a threat to them, nor does the unsuspecting public notice any difference.

Supporting evidence for the above:

• A Niti Ayog report states that a common licentiate exam would
  “ensure common standards of knowledge and skills for Doctors on a Nation-wide basis and would also constitute an objective benchmark to judge outcomes of the medical education process in any given institution.” (page 13)
• A National Knowledge Commission Working Group Report states that
  “we are producing poor quality professionals, who should not be permitted to be let loose on a trusting hapless public. It is the duty of the state to protect its citizenry and act as early as possible.” (page 33)

The emphasis of the Medical Council of India (MCI) on input (infrastructure, number of faculty/beds/patients, etc.) rather than output (quality of teaching/training, competences of graduates, etc.) has been pointed out as a major flaw in its functioning. 

Key Concerns:

I. National Licentiate Examination (aka NEXT)

The National Medical Commission Bill 2017 proposes a paradigm shift- from focusing on input, to output; from recognition, to rating. In keeping with this philosophy, it proposes that a National Licentiate Examination be conducted to determine eligibility

• to practice [15(1)]
• for admission to post-graduate courses [15(4)]

Supporting evidence:

Comments on the National Licentiate Examination

1. The intention behind the Licentiate Examination appears to be a desire to standardize medical training across the country. This should help eliminate discrimination between graduates of various institutions to a large degree, as well as restore confidence in the general public.
2. The Knowledge Commission’s Working Group on Medical Education suggested the following scheme:
   1. National Exit Exam immediately after Final MBBS university examinations, and before internship commences
   2. National Exit Exam
      1. to serve as PG entrance exam
      2. to be MCQ type, with questions regularly updated
   3. Internship to be
      1. used of skill acquisition
      2. assessed through log-book (formative); and OSCE (summative)
      3. Skill assessment through OSCE to be done 1 year after Exit Exam
   4. Scores obtained in the end-internship OSCE to be added to the Exit Exam
3. The NMC Bill 2017 does not specify if the scheme suggested by the National Knowledge Commission will be followed, or another scheme will be introduced.
4. In order for such a National Licentiate Examination to be conducted, competence based medical education will have to be implemented across the country.
5. A National Licentiate Examination will require that all universities synchronize (at least) the Final MBBS university examinations.
6. A list of essential skills, and standards for the same will have to developed to ensure uniformity and avoid ambiguity.
7. If a skill-based OSCE is conducted, it should follow training and certification of examiners for the task, and global best practice(s), to be meaningful.
8. Institutions will necessarily have to invest in skill-labs, and provide adequate training opportunities for their students to acquire the skills.
9. The three years’ time frame for introduction of a National Licentiate Examination may be too short to introduce the changes mentioned above, and conduct the examination as mandated by law.

Assumptions

1. The implementation of a National Licentiate Examination will ensure that all medical graduates possess at least the minimum knowledge and skills expected of them.
2. Institutions will be assessed and/or rated on the basis of students’ performance in the National Licentiate Examination.
3. If #2 is true, then institutions will be forced to provide better training to students so as to equip them to perform well in the Licentiate Examination

Additional Comments

1. There is a chance that skills assessment will become formulaic, and students will focus only on the tasks/skills that are assessed
2. Institutions may increase the fees to recover the costs of establishing skill labs. However, students will likely get better value for their money by means of better training.

II. Exemption from passing the National Licentiate Examination to practice medicine and surgery

One of the most talked about aspects of the NMC Bill 2017 is Section 33 (1):

The claim is that this Clause allows foreign medical graduates to practice medicine and surgery without passing the National Licentiate Examination.

I suspect that the true intention of the provision is different, and is in alignment with existing regulations. I would like to draw the attention of readers to Section 14 of the Indian Medical Council Act, 1956 (page 7):

Clause 1 (b) permits medical practitioners with foreign medical qualifications to work as legitimate medical practitioners as long as

• their work is limited to the institution (in India) to which they are attached
• they are engaged in
  • teaching
  • research
  • charitable work

Such medical practice has been conducted for decades, with prominent foreign doctors using this provision to participate in medical and surgical camps; teaching and research activities.

The existence of this provision dates back to 1956, and cannot be claimed to have provided foreign medical graduates a backdoor entry into medical practice in India. Even then, foreign medical graduates had to pass the screening exam conducted by the MCI, before receiving permission to practice medicine in India. This is a special provision, and is reserved for such use. The NMC Bill 2017 merely continues the existing provision forward.

When one considers that the original IMC Act, 1956 also had this seeming contradiction [on the one hand insisting that foreign graduates pass a screening test, and on the other, granting special permission to foreign medical practitioners to practice medicine (albeit with restrictions)], one wonders why the NMC Bill, 2017 is being criticized for having the same provisions:
After the NMC Bill 2017 comes into force, and the National Licentiate Examination becomes operational, new medical graduates- from inside India and abroad- will be required to pass the National Licentiate Examination to practice medicine and surgery (Section 32(2); and Section 33 (1)(a), page 15)

Further reading and references:

Report of the Working Group on Medical Education (available from:
http://knowledgecommissionarchive.nic.in/downloads/documents/wg_med.pdf)

Preliminary Report of Niti Ayog Committee on Reform of Indian Medical Council Act, 1956 (available from:
http://niti.gov.in/writereaddata/files/document_publication/MCI%20Report%20.pdf)

The National Medical Commission Bill 2017 (available from:
http://164.100.47.4/BillsTexts/LSBillTexts/Asintroduced/279_2017_Eng_LS.pdf)

The Indian Medical Council Act, 1956 (available from:
https://www.mciindia.org/documents/theIndianMedicalCouncilActs/Complete-Act-1.pdf)