The social determinants of a physician’s path

Poverty is known to be an important determinant of a person’s health and longevity. A person’s zip code is more relevant than genetic code. Does a physician’s zip code – that is where they were born and raised – have an effect on where they practice? Specifically, do rural born and raised physicians return to their rural roots? The story of Prashant, a physician raised in rural Bihar, India, is instructive.

When I first met Prashant, he was a second-year medical student in Patna Medical College and Hospital. Patna is the capital of Bihar, and Bihar is one of the poorest states in India.

Prashant brimmed with idealism and vigor. “I’ll practice in Purnea one day and serve the poor villagers,” he told me in broken English.

Prashant comes from a family of Bihari farmers who are also affluent landowners. He grew up near Purnea, a fourth-tier town in Bihar surrounded by villages. Visiting these villages is like stepping into a time machine – you can see people traveling by bullock carts but using mobile phones.

Prashant spent much of his childhood reading books, tending to his land and, when there was no load shedding (power outage), watching MTV. He has an incredible work ethic and mercilessly devours medical textbooks.

I met Prashant again when he was a medical house officer. He was still brimming with idealism, though he had started drinking frequently and began enjoying the good life. Prashant wanted to be an anesthetist. A few years later I attended Prashant’s wedding. He had an arranged marriage with the daughter of one of Patna’s leading surgeons. The wedding was a lavish affair in a five-star hotel – Johnny Walker Red Label literally flowed from the fountains.

Prashant seemed more self-assured. He spoke English more confidently, with occasional traces of his rural lineage.

” Bhaiyya (older brother), what is the scope of anesthetics in the U.S.?” Prashant asked.

“What happened to serving your community in Purnea?” I cheekily reminded him.

” Bhaiyya, she doesn’t want to live in Purnea,” said Prashant glancing at his wife, lovingly. Prashant’s wife had a privileged upbringing in Patna. She had a degree in fashion design from New Delhi, where she wished to return.

“There are no good schools in Purnea,” offered his wife, pragmatically.

Prashant had undergone an under-recognized phenomenon in medical education – social class shift, his marriage was the final affirmation of the shift from a rural lad to a doctor on the brink of minting it. When he spoke to his parents there was a new hint of condescension – the slight annoyance with their educational chasm.

Prashant’s past was pesky and a foreign land. His wanted his future to be in another foreign land. You can understand the lad’s perspective. After all the hours of hard work he put in, he wanted something more than the jejune multiplex Purnea offered. However, his wife brought up an issue which partly explains why doctors aren’t thronging rural India – a genuine concern about the educational prospects of their children.

Years ago, my father visited his friend, a physician in Bhagalpur – a small town on the banks of the Ganges. When old friends meet they talk about memories and regrets. My father, after medical school, moved to Britain. He missed India. He missed Bhagalpur. His friend emigrated with my father to Britain but returned to India after his postgraduate training.

He had fewer regrets than my father. His only discomfort with returning to Bhagalpur was that he had to send his children to boarding school in Darjeeling, a hill station in West Bengal, for a proper education. He saw his children only twice a year. He was, therefore, envious of my parents. Ironically, my parents had sent me to a boarding school, too, but for very different reasons.

Medicine is still a middle-class profession in India, and despite the glamour of some celebrity doctors, most physicians have simple tastes in life – they rarely have the time to indulge in flamboyance. However, there are certain things all doctors want – stability, security and a decent education for their children.

Unlike professions such as finance, where the action is in metropolitan cities such as Mumbai, in medicine, the need is concentrated around the nearly two-thirds of the population who live in rural India. How should the government entice doctors to practice in places such as Purnea?

It is unreasonable to expect that a doctor raised in cosmopolitan New Delhi will migrate to rural Bihar to serve poor people. That happens mostly in Bollywood movies, and that too only after they’ve fallen in love with the local village girl.

A more pragmatic approach is for the government to designate towns such as Purnea, which skirt rural India, as “areas of need.” The government can do a few things to retain doctors in areas of need. First, they can reserve seats in medical school for those like Prashant born and raised in rural India with the condition they return to the area of need – that is the Indian Medical Council grants medical licenses restricted by geography. Second, seats in medical and engineering colleges, such as the Indian Institute of Technology, can be reserved for the children of doctors who practice in areas of need. Let’s call this the “rural doctors’ quota.”

Finally, the government could open medical schools for the sole purpose of producing doctors for rural India. Given the insane competition for medical school, I think there’ll be a fight to get into any medical school even if that means you can only ever work in places such as Purnea and its surrounding villages.

Prashant now works in a top private hospital in New Delhi, making more money than he has time to spend. He doesn’t even have time to drink alcohol. He has two children, still young. His wife, weary of Delhi’s high paced life, wants to send them to a boarding school when they’re older for a proper education.

Saurabh Jha is a radiologist and can be reached on Twitter @RogueRad.  A version of this article originally appeared in the Health Care Blog.

Image credit: Shutterstock.com

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