Perception of medical graduates towards government service, as a career option after graduation, in a medical college in the Bundelkhand region

INTRODUCTION

Most medical students after completing their graduation generally opt for post- graduation/ specialization and take several attempts to get the subject of their choice. According to the health ministry there are 1.18 lakh seats in MBBS and 74.3 thousand seats in post-graduation in various specialities in India.¹ So, even after best efforts every year approximately 44,000 students will not get a seat in post- graduation. So at the end of 5 years about 2.20 lakh graduates will be left with only a graduation degree. Moreover, there is a shortage of doctors in the government sector known as PHMS (Provincial Health and Medical Services), in our state. As a result, the primary care to the community is weakened. The primary hurdle in joining government service, as perceived by young doctors is working in rural areas, for which many may not be ready. These two issues are closely interlinked and addressing one would also solve the other. A cross-sectional survey from Orissa showed that the most preferred immediate career goal was post-graduation studies (45.9% of students in government medical colleges and 54% in private medical colleges) and only 17% of government students and 9% of private students showed willingness to work in rural areas, in the long run.² In another study participants included 203 medical students, only 33 (16.26%), were willing to work in rural area.³ A few studies however showed 64% medical students showed interest to work in rural area.⁴

As per the National Health Workforce Accounts Data (2020) portal, 0.73 doctors are available per 1000 population and 1.74 nurses per 1000 population in India.⁵ The situation is improving and the latest PIB release shows a doctor population of 1:811.⁶ But this qualified workforce would also tend to be more concentrated in urban areas and private sector. This shortage definitely affects the delivery of primary health care to the community. So this study was done to explore the perception of medical graduates towards government jobs and their readiness to join provincial health medical services straight after graduation along with its perceived advantages and disadvantages. This can help to determine the possible solutions, so that the medical graduates can select their field of working with confidence and the vacant posts can be filled. The study thus, wishes to address two important issues - the shortage of doctors in PHMS services and career options for medical graduates who do not get a seat or do not wish to do post- graduation courses.

METHODS

A cross sectional study was planned in Maharani Laxmi Bai Medical College, Jhansi and all recently passed medical graduates were requested to participate in it. The study was conducted between March 2024 to April 2024.

Inclusion criteria

All recently passed MBBS students who were doing their internship, and those working as non PGJRs and demonstrators were included in the study. A total of 80 medical graduates enrolled for the study.

Exclusion criteria

Those who did not give their consent for the study were excluded.

The participants were given a schedule which had closed and open ended questions pertaining to their socio-demographic details and also questions related to whether they wanted to join government service after graduation. They were told to give reasons for their answers and mention the advantages and disadvantages of joining government service. The schedule was finalized after discussion between all researchers and content validity was confirmed by consulting two experts in different departments within the college. The schedule was pre-tested by administering it to ten final year students. The schedule was given as a Google form and any queries the participants had during filling were resolved by the researchers present there. This study is part of a bigger study and ethical clearance was taken from the Institutional Ethical Committee (vide letter no 537/IEC/I/2022-2023). Results were tabulated and expressed in frequencies and percentages and the factors influencing the choice of participants were tested using Chi square tests.

RESULTS

The mean age of participants was 25.38±2.2 years, 60% were males, 37.5% were from a rural background, 60% had no doctor in the family.

The main reasons for choosing the medical professions were mentioned as serving humanity and interest in the profession (Figure 1).

On asking about their choice of working field 52.5% wanted to work in Public sector, 26.2% wanted to work in self-established clinics, 10% wanted to work as Teaching faculty. Rest were undecided. Only 18.8% had a family member in health services and 12.4% had friends/acquaintances in health services. 68.8% participants had no one in the health services and hence felt the need for guidance after completing graduation.

On questioning, 67 out of 80 (83.5%) affirmed having thought of joining a government job after MBBS and 81.3% answered they would join a government job immediately after internship if offered. The mean salary quoted by them was 1.02 lakhs (Range: 50,000-2,40,000)

One participant mentioned ‘transferring the benefits of Government policies to the general public’. Others mentioned their ‘liking for field work’, and ‘interaction with community’. Others expressed concern over healthcare in private facilities being expensive, and wanted to make health care affordable. Other work place related reasons given by participants were’ good equipment’-1,’less interpersonal struggle because of uniform pay scale’ and ‘sense of belonging to an institution’-1. Two other participants mentioned ‘good research facilities in government sector’ and ‘a chance of involvement in policy making as their reasons’.

16.5% (n=13) participants did not want to join health services. The reasons mentioned by them are mentioned in the Table 3.

* Three participants mentioned working in their own clinics or establishments and two participants wanted to do their post-graduation first, of which one wanted to go for job in Medical College.

The factors associated with the decision to join service are summarized in Table 4.

*Two participants’ father had passed away, one in each group, and were not used in the tabulation.

DISCUSSION

This study breaks the myth that all students want to do post-graduation/ specialization before starting to work. A large number of students (81%) affirmed that they would join a job if offered immediately after Internship. Similar findings were seen in a study from Andhra Pradesh in which 79.9% of respondents expressed willingness to work in rural areas. The commonest reason for willingness to work in rural areas was to gain experience (62.2%). And 81.4% of respondents believed that rural services should be made compulsory for doctors.⁷ This is in contrast to a study from medical college in Chattisgarh only 44% students were willing to serve in the rural area the main reason being reservation or added marks in postgraduate entrance examination by more than two-third respondents.⁸ This study however was done among students who still had a chance to change their perception. Present study was done among interns who had completed their curriculum and working in all departments. In a study from Maharashtra ,35.82% medical students were interested in working at rural areas.⁹

The participants in the present study clearly spelled out their reasons for willingness to join services job security, a sense of purpose, diverse exposure, fixed schedule, ready to work set up and good work-life balance. The reasons mentioned in a study by Yadav et al were contribute for betterment of State health system, build confidence as a clinician secure job, compulsory bond service, job satisfaction, and supportive people in rural areas.¹⁰

The most strongly associated factors found in the present study were mother’s education and father’s occupation. In the study from Maharashtra age, place of primary education, type of family and branch of medicine being practiced parental education, place of residence, type of college and year of undergraduation of medical students had significant association with their preference towards rural practice.⁹ Place of residence rural/urban did not have any association with choosing government service in the present study in contrast to the study by Yadav etal from Uttarakhand where four-fifth of study Participants (80%) belonging to rural areas showed interest to join rural health services compared to three-fifth(60%)among those belonging to urban area.¹⁰

The reasons for not joining were limited infrastructure in health facilities, delay in post-graduation, limited professional growth, less salary, connectivity with cities not good and isolation from family and relatives.¹⁰ Most of the students maintained that good housing, better salaries, and adequate facilities at the workplace would attract more students toward rural service.²

More importantly, the reasons for not joining can guide policy makers about the issues which need to be clarified and addressed so that more and more doctors are encouraged to join health services in government sector. Issues like frequent transfer, less earning, posted away from home, no scope for private practice and work place security were voiced by the doctors. In a study from Orissa 44.5% participants mentioned opportunities for career growth, followed by the possibilities for higher education (26.8%) as major the factors for preferring an urban posting in addition to higher pay scales and better working conditions.² These reasons are partly included in those mentioned by graduates in a study in Singapore which were limited professional opportunities, mundane case mix, lack of continuity of care, limited consultation time, and specialists’ negative attitudes towards family doctors.¹¹

The ‘Family Adoption Program’ which is a part of curriculum of medical students, and the compulsory bond for MBBS students can all play a facilitatory role in encouraging students to take up government service. Regarding the attitude towards compulsory service bond after MBBS one particular study only 17.8% were disinterested.¹² In another study two third of students agreed with the fact that rural service should be made compulsory after MBBS.¹³ This bond period will also help doctors become confident in dealing with the community and delivering primary care.

The present study had 80 participants from diverse backgrounds and residences all over the state as well as outside the state majority of whom were willing to strengthen the health system workforce. This opportunity to work after graduation will also put education during graduation in a proper perspective. This is so because there is an increasing trend among students to go for preparation for NEET-PG (National Eligibility Entrance Test for post-graduation) during their MBBS years. This shifts the focus from attending classes and learning, to 4.5 years of NEET PG preparation which although based on the same syllabus, are two different approaches of going through the undergraduate curriculum. Learning among graduates will improve and their confidence to do work will increase, if they were freed from the compulsion to do post- graduation and prepare for PG entrance. According to an article by Rao et al investments will be needed to improve the relevance, quantity, and quality of nursing, medical, and public health education in the country to improve the delivery of primary health care.¹⁴

Limitations

A single study may not be representative of all students elsewhere so studies at other medical colleges are required for policy makers to understand completely the trend and enable those students, who wish to work after graduation, an opportunity to do the same. The overwhelming positive response to joining government services seen in this study is definitely an eye opener and warrants serious discussion and more studies elsewhere.

CONCLUSION

Contrary to popular belief, this study breaks the myth that medical graduates want to opt for specialization and do not want to go for a job. 67 out of 80 participants showed readiness to join government job. Advantages and disadvantages of working in health services were mentioned by the participants, which can guide policy makers to make the workplace environment more conducive for them to join these services. Their joining would help fill the vacant posts and give health services to the community while at the same time reducing not only delay in treatment but also reducing the reliance on unauthorized practitioners. This will further the cause of universal health coverage to the community and strengthen health systems.

Recommendations

A systematic approach to addressing the concerns of young graduates is important. Making students at both graduate and post graduate level aware about the opportunities and scope of working in government sector, PHMS, will help them make an informed choice about their field of working. This can be done by annual sessions in Medical Colleges and Post Graduate Institutes followed by campus interviews like Engineering and management institutes.

An ‘annual recruitment policy’ based upon the number of vacancies, due to creation of new posts and retirement would regularize the joining process and help to deal with shortage of manpower. These vacancies could also include the retirements due in the upcoming year so that immediately after retirement the post is filled and the delivery of health services do not suffer.

Giving them good infrastructure and work place environment and strict measures for workplace safety, especially for remote areas so that they can give their best services.

Fixed number of years of rural service, lenient transfer policy, allowing home district posting after a certain number of years. No of years of rural service can be fixed as a matter of policy like in Banking sector.

Facilities for transport from the nearest city /township for those posted in remote areas (upto 50-60 km) for doctors.

Giving them a good and encouraging environment during their bond period after graduation/post-graduation will help increase the chances of their choosing government jobs after graduation and strengthen the workforce required to provide primary care to community.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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