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‘I forever bow down to you the loving motherland, the land of Indians where I have flourished in happiness. I bow down to a great, auspicious, and holy motherland for whose sake I sacrifice my life.

Each and every Indian, at some point in life, has certainly felt this great emotion of being absolutely grateful for the motherland, as expressed in this great shlok from the ancient Sanskrit literature. Then, why do we Medicos pose that one question to ourselves that ‘What is better for me, living in India or leaving India?’

Well, there are many reasons that this question comes in front of us as one of the most crucial decisions of life. The most important reason is the dream & desire of an individual to live a happy and prosperous life. It is especially more important for doctors as becoming a doctor comes with hard work, the devotion of extra youthful years to the studies, sacrificing significant family time, and a lot more. Therefore, moving abroad and starting a new life in a foreign land and culture is always going to be a big decision, particularly working in a field as complex, competitive and technically challenging as medicine. Through this article, I aspire to show all the shades of the green on all the sides of grass to facilitate this decision making process. So, taking such a decision involves multiple aspects like prospects of medical education and professional opportunities, cultural differences, financial stability, the standard of living, professional satisfaction, medico-legal vulnerability, social structure, respect from the society, and quality of life. Interestingly, the priorities of these parameters are different for different individuals. For example, for someone, the financial aspect may be the most important, whereas, for someone else, it’s the choice of medical speciality that is most important. The ‘quality of life’ as defined by the World Health Organization (WHO) includes ‘factors determining health, happiness, education, social and intellectual attainments, freedom of action, justice and freedom of expression’. However, such a definition will be useful when there is an absolute lack of clarity about what one wants in the future.Let us look at the existing facts. India produces around 30,000 medical graduates every year. According to a parliamentary report, around 1500-2000 Indian medical graduates leave the country every year. In a study conducted in 2018, it is observed that there are 221,838 doctors of Indian based in the United States of America (US) and they account for 18% of all doctors in the US and 25% of all International Medical Graduates employed in the US world. There are more than 50,000 Indian doctors serving the United Kingdom (UK) population, according to an association of Indian-origin doctors in Britain. In the UK, the Indian-trained doctors form the largest group of foreign-trained doctors.

The WHO has said in 2015 that a few hundred thousand doctors trained in India are employed overseas, with a higher proportion of these (around half) working in the US, followed by the UK, Canada, and Australia. In the US, nearly one in five doctors is Indian; in Australia too, one in five doctors is Indian; in Canada, one in 10 and in the UK, one in 10 as well. These data suggest that there is no doubt that a lot of Indian medical graduates choose to move out of the country for the rest of their life. On the other hand, let us also understand how the life of a doctor in India is. A few broad observations can be considered for understanding. In India, the practice of medicine is getting difficult with each passing day for multiple reasons. Medical education in India has become costlier than ever before. All the possible ways of practicing medicine in India, i.e. solo practice, group practice, government hospitals, trust hospitals, and corporate hospitals, all have one or the other major drawbacks. The working hours for doctors in India are almost always overtaking their hours for personal and family life. Certain bills and legislations are threatening the doctors continuously with widening their claws than ever before. Doctors have become soft targets for the public, government, and even certain sections of media. In certain situations of an inevitable bad outcome, doctors and their clinics are thrashed citing negligence. The violence against doctors is a black truth of today’s Indian medical practice. The Indian allopathic doctors are expected to compete with graduates of the alternative Indian systems of medicine like Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy, and even quacks. The medico-legal suits against doctors are constantly increasing in this country The image of doctors is fabricated as superrich, whereas the reality is only 5% of doctors fall into that category, and the rest all are either upper middle class or middleclass citizens. The life of a doctor is continuously under stress. In India, as a doctor, you get less rewarded for your work. We have come to an era where doctors, once treated as next to God in this country, are now sometimes called even selfish butchers. Doctors are under constant threat of losing their own lives either due to professional exposure or by the violent behavior of the patient and relatives.

Author Saranaya Nandakumar in his book ‘What’s Up, DOC?’ in 2004 captures the psychology of emigration about medical practice in India. But, certainly, the times are changing. In spite of all these limitations, the profession of a doctor still remains the number one choice for the fresh students in India. With the more active society and increasingly aware citizens, with the efforts of some sensitive sections of the public, government, and media, conditions are likely to improve for doctors in the future. Stringent legislation to support and protect doctors against violence are also in the pipeline. Though there is a lot of competition, the demand of the doctors in India is equally vast. Increasing the number of medical colleges across the country with an increasing number of seats for post-graduation is likely to provide more opportunities for different specialities in India. Larger budget allocation for the health sector in India is also likely to improve the working conditions for doctors in India. Research opportunities in the medical field are continuously expanding in India. After the pandemic of COVID-19, the majority of the common man have re-established their faith and trust in doctors in India. Indian doctors have started perceiving the respect of true warriors caring for patients’ lives even at the cost of their own life.

Thus, it is certain that there cannot be one uniform answer to this core question that I have begun with. Each individual who has faced this question in the past will have a unique story to tell. And the decision on either side of the question has been equally successful or equally not so successful for different people across the globe.

My life has been through the puzzle of this question as well. I have seen, have experienced, and have been a part of the medical education system and health system of countries like the US, Australia, New Zealand, and Japan.

There are vast differences in each of these systems. Neverthless, it would be unfair to answer this question based on just my experiences and observation. So, to do justice to the question, I have broadly analyzed the health systems of India and all the hotspot countries for Indian doctors to be in. There are multiple destinations that one can opt for.

I have chosen only a few most preferred ones to discuss over here. I will try to reflect the most neutral view of the overall scenario today. But, the rider will always prevail that ‘each individual has to analyze individual circumstances and has to make their own decision’. Whatever is presented here can only be a guide to one’s thought process in this direction.

The United Nations evaluated various countries in 2019 for their health care index as shown in the figure below. India ranks 33rd with average health care index, whereas Australia ranks 10th, the UK ranks 13th, New Zealand ranks 16th and the US ranks 30th. This basically is a guide to how advanced and efficient the health system a particular country has, providing opportunities for an individual to progress.

To understand the entire complex situation easily, I have narrated the scenario under different categories. Under each category, I have analyzed the narrative of living in India v/s leaving India. So, let us discuss each aspect one by one.

  • Prospects of medical education

The scenario in India as far as the selection of speciality for post-graduation is more or less very clear to everyone. The option of National Eligibility cum Entrance Testpostgraduate (NEET- PG) and other alternatives are known to all Indian medical graduates. When it comes to the US, the entry to medical education is through the United States Medical Licensing Examination (USMLE) which has different steps like step 1, step 2 CK, and step 2 CS. After cracking the examination, the entry to the post-graduate courses is through the National Residency Matching Program (NRMP), where US graduates and international medical graduates (IMG) all compete together with the overall USMLE score. The match also takes into account other multiple factors like college & country of graduation, research experience, scientific publications, letter of recommendation, citizenship, and visa status. It is generally perceived that it is easier for IMG to get into the specialities like internal medicine, family medicine, pediatrics then the specialities like general surgery, orthopaedics, obstetrics & gynaecology, ophthalmology, dermatology, and radiology. However, with an extremely good score and strong recommendations, there are students who have got into these specialities too.

The lateral entry to the system can be through graduate courses of Public Health which I will not recommend due to its lengthy and diverting path. Moving to the UK is a well-traveled path for Indian medical graduates. Indian medical colleges frequently utilize the same textbooks as British institutions, meaning students are equipped with transferable knowledge. The entry is through clearing the academic International English Language Testing System (IELTS) and/or Occupational English Test (OET) and the Professional and Linguistic Assessments Board (PLAB). The entry to postgraduate courses is very competitive and tough. But, with appropriate guidance and good preparation, one can certainly enter the UK medical education system. Once qualified, the UK may offer much safer placements, better financial dividends, and greater career development compared to most other Englishspeaking countries.

The pathway to post-graduation in Canada is through the National Assessment Collaboration Examination (NAC-OSCE) and the Medical Council of Canada Qualifying Examination (MCCQE). After clearing these exams, residency can be obtained through the Canadian Resident Matching Service (CaRMS). In Canada, each province and program has its own eligibility criteria and requirements. The option of lateral entry to the Canadian system is as a clinical assistant.

Australia and New Zealand are rated as the best countries to immigrate to for Indian doctors in a study conducted in 2017. Both these countries, with minor differences, allow Indian medical graduates to enter the health system through the competent authority pathway, standard pathway, and specialist pathway which also includes an area of need pathway. The Australian Medical Council (AMC) examination is required to practice medicine in Australia through the commonest AMC standard pathway. In the area of need pathway, short placements can be obtained without going through the long path of the AMC examination. But eventually, one has to clear these examinations, required training, and the respective board examinations to practice as a specialist.

The United Arab Emirates consisting of seven Emirates including Dubai requires one to pass the medical licensing examination which gives one-year practicing permit. The candidate will be granted the title based on the credentials and experience such as Consultant, Specialist, or GP. In this duration one can find a residency position or a job or one can open their own clinic/hospital. Thus, the dedication to sincerely prepare for competitive examinations and the patience for waiting to enter the system are the first basic requirements for anyone who is planning to migrate to any of these countries.

  • Cultural differences in clinical practice

In any English speaking country, there are multiple cultural differences that medical professionals from India encounter. It begins with the language barrier as none of the Indian graduates have English as their mother tongue. Though the medium of instruction in medical colleges in India is English, there are vast differences in spoken English in India versus other countries. The ascent, dialect, and the colloquial used in these countries vary. In India, communication with patients is largely in other regional languages, whereas in foreign countries, communication is in English. So, getting used to fluent spoken English is very essential. When patients are also from the non-English background, frequently, medical interpreters are used, which is a new thing to learn for Indian graduates.

The US has many Indian doctors already in the system. The patients are now aware of and quite accepting of Indian doctors. But, the patients expect a lot from the doctors. One needs to spend a lot more time with one patient than what is experienced in India. The counselling skill is very important for day to day practice. Counseling is done with factual figures and available evidence rather than individual opinions. The UK is considered a culturally very traditional country. One has to keep the cultural differences in mind while practicing. For example, practices relating to patients’ consent tend to work differently in the UK than they do in India. In the UK the concerns of patients themselves always take priority over their immediate relatives, in contrast to India where relatives’ choices have to be given importance too. Australia is a widely multi-ethnic country. In any health care facility, one is surely going to encounter patients from various ethnic origins. One needs to be truly sensitive and medically accommodative to ethnic and religious practices related to the individual. Australian accent is considered to be very fast. One has to get accustomed to listen to and to understand Australian spoken English. UAE has totally different cultural practices due to the predominant Islamic population. Indian doctors, abundant all over the Gulf, are respected by locals as well as expats. Another challenge could be really demanding patients and this may increase stress levels. So it is very important to be updated and do only the right things, as per the protocols.Other differences include the prevalence in these countries of care homes, intermediate care, and nursing homes as alternatives to home discharges and the significant differences in end-oflife care methodologies, both for resuscitation protocols and palliative care pathways. The bottom line is that wherever you plan to migrate, you need to be sensitive to and accommodative of cultural values and practices of different religions and ethnicities.

  • Financial aspect

The level of earning obviously remains one of the important points to consider. There is a perception that Indian doctors earn much less than their counterparts in developed countries. According to the survey by Indian Health Service, in the United States in 2020, the average salary of a specialist is around 100000 US dollars per year, ranging from 70000- 215000 US dollars depending upon the specialty. The range of salary for the UK is 60000- 100000 pounds. For Australia, it is 120000-250000 Australian dollars, for New Zealand, it is 155000- 219000 New Zealand dollars and for UAE, it is 471000- 243000 Arab Emirates Dirhams. These are very vague estimates and the yearly earning varies a lot depending upon multiple factors like experience in the area, additional qualification, type of practice, place of working and days, and hours of working. Let us not get mesmerized just by the numbers.

As Indians, we have a tendency to convert a particular currency in Rupees and then calculate the benefit. This is grossly a wrong method of comparison. One has to consider the living expenditure in a particular country, and in a particular suburb/ town/ city/ state/ province of that country. The cost of living widely varies in different regions of any country. From a purely financial perspective, the financial aspect takes into consideration not only income, but also the expenditure, financial goals to achieve, the assets, the liabilities, future financial planning, retirement plan, and so on.

  • Medico-legal vulnerability and sustainability

We all very well know that medical science is a complicated science. And human judgements that we make in the best interest of the patients may not always provide the best expected outcome for all the patients all the time. Unfortunately, most of the patients and relatives across the globe are not ready to understand this fact. The medicolegal suits are constantly increasing in India with huge fines as compensation if proven guilty. The lifetime of earning, reputation, and peace of life will all be at a stake with just one such case. But, there are insurance companies to pay and medico-legal lawyers to fight for doctors. And the numbers of such cases filed against individual doctors are still much lesser than that in the other Western countries.

In most of the advanced countries, patients are more likely to sue the doctor. Deviation from evidence-based practice or defined protocols, lethargy in paperwork, and casual attitude towards patient management are likely to increase the chances for the same. Yes, in these countries also, there are insurance and lawyers to help the doctors. But, it would be difficult to afford these particularly at the beginning of the career. In nutshell, if one is following the evidence-based practice and protocols with clear intentions and awareness, the chances of getting into a medico-legal mess are significantly low anywhere in the world.

  • Personal Life equations

When living in India as a medico, we surely come across a question to marry a partner of the same field or a different field. This is a topic in itself that needs a separate article to talk about. But, I have mentioned this issue here with a different perspective. In India, generally, you get the liberty to choose the life partner in a way that you desire. This liberty is there while leaving India too. But, there may be some restrictions in this matter when one starts thinking about marrying a person with additional country-specific advantages. In countries like the US, the choice of speciality is dependent upon one strong factor which is citizenship or permanent status of an individual. It is not rare for aspirants to get married to a person from a foreign country to change the status from an Indian citizen to permanent resident or citizen of that country, thereby increasing the chances of getting into residency in the speciality of choice and place. Of course, this is not a mandatory requirement to pursue a further career in foreign countries. On one side, this seems to be a completely laughable decision. And on the other side, there are numerous such successful examples. In my opinion, one should not make conscious efforts in this direction just to ensure that medical speciality of choice can be obtained. Remember, you are going to live with the partner and the speciality both for the lifetime, but your peace and happiness will depend more upon the choice of the former.

  • Social Structure

The Indian social structure is family-centric with relatives and friends being part of each and every phase of life. People keep meeting on numerous occasions and even on a daily basis. So, there is a lot of social interaction in Indian life. In the majority of developed countries, life is more of an individual-centric. People prefer to have their own personal and family life restricted to themselves. People don’t meet each other without prior plans and appointments. Social life in these countries is mainly about weekend gatherings or parties. Thus, social isolation is meant to be felt by Indians migrating to these countries.

  • Weather

The weather in India is mostly sunny and bright. It is said that the Sun & the sunlight give energy, enthusiasm, and positivity. Generally, people are not exposed to extremely cold weather and snow in India. So, it is essential for one to be aware of the different weather conditions in different countries. In the US, the weather varies depending upon the state. Some of the states are quite colder, some of them are quite windy, some are snowy and some are pleasant too. In most of the states, the summer is for a very short period.

Though the system has all temperature control measures in place, one needs to be prepared to face such weather. Canada has mostly colder weather with snow in a few months. The absence of sunlight for many days continuously can be dull and depressing sometimes. As Australia and New Zealand are located in the southern half of the globe, the seasons are reversed. The summer is extremely hot there, especially due to the deficient ozone layer, and the winter can become equally colder too. But, the Indians can get accustomed to such weather in these countries relatively easily. UAE is actually a country constructed in the desert. In peak summer the temperature goes up to 51 C with plenty of humidity. But, the country has an advanced air conditioning system making you feel pleasant everywhere.

To conclude, though there are wide variations in weather conditions in different countries, there are good conditioning systems in most of the countries. So, this issue should not be considered a major issue in decision making.

  • Quality of Life Life

in India is relatively flexible and comfortable. Help for household work and other day to day work can be hired due to the availability of enormous human resources. Multiple festivals round the year keep giving breaks to Indians. Even then, the working hours for doctors in India are significantly more than that for other countries. Doctors routinely work on Saturdays and many times on Sundays too. Additionally, the infrastructure and the public systems in place for day to day functioning are quite meagre limiting the ease of living. This may make life chaotic and crowded adding to the overall stress over a period of years. But, all is not so bad either. Doctors in India largely live a decent life with many of them having luxurious cars like Mercedes, BMW, or Audi, a lavish villa and a farmhouse or a holiday home.

Life in hotspot countries is more systematic and predictable. The working hours for doctors are relatively less and preset. Doctors are not expected to respond to patient calls or work-related calls after office hours. But due to complete responsibility, patients’ autonomy, stringent laws, and higher expectations, professional stress is likely to be more. On the other hand, Doctors get more personal time, family time, and leisure time in these countries.

The infrastructure is robust and the public systems are quite efficient to make one very happy and comfortable for day to day activities. It is not very difficult to have Lincoln, Lexus, Cadillac, Mercedes, or Jaguar cars and beachside bungalows or a grand mansion if one desires so. Whatever one says, the quality of life is a very subjective perception. One has to know what quality of life is desired, realistic, and fulfilling.

To summarize, let us not forget that every coin has two sides. When one is looking for some financial gains and better quality of life, possible extra stress, compromise on social life and leisure has to be considered. And while focusing on family and social life, one may lose the potential opportunities for professional and personal growth. The decision must not be guided by a comparative evaluation of what one truly wants versus what others around us have. It ultimately will be an individual who will have to take that call about what are the priorities. In the end, what matters the most is peace and happiness, wherever you go, whatever you do.

I would like to end by quoting another Sanskrit shlokas follows:

‘Knowledge is wealth in a foreign land, Intelligence is wealth in tough times, Righteousness is wealth in other world and verily, Good Character is wealth everywhere and at all times!’

I am sure with the power of knowledge, intelligence, righteousness, and good character; one can certainly have a prosperous, peaceful, and happy life, whether living in India or after leaving India!

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Author

– Dr. Ashish N. Shah

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