Summary

Dr. Soham D Bhaduri opines on Niti Aayog and the Health Ministry's new proposal to address the physician shortage in India, bridge courses that will enable dentists to practice as general medicine doctors.

A recent proposal to allow dentists to become full-fledged general practitioners through a Bachelor of Dental Surgery (BDS) to MBBS bridge course has received the nod of the NITI Aayog and the Prime Minister Office (PMO), and is the latest entry to the list of a number of such courses proposed over the years which have faced criticism from medical professionals and policy experts. While the three-year long course is aimed at tackling the shortage of doctors in the country, it is important that some recurrent misconceptions surrounding it are addressed.

The bridge course is based on the premise that the BDS (4-year course) and MBBS (4.5 year course) curricula are identical in their first three academic years, which is but over-stretching the truth. Though subjects like pharmacology, medicine, and surgery are covered in BDS, there is in it throughout a conspicuous (and much warranted) emphasis on areas of direct relevance to dentistry, like oral cavity, head and neck – in contrast to MBBS course which covers these subjects in greater holistic detail. The final year of BDS deals exclusively with oral medicine and surgery and has nothing in common with its MBBS counterpart.

Also, bridge course graduates are being confounded with mid-level healthcare providers (MLHP), who are found in many nations including China, UK, and US and provide healthcare mainly in under-served areas. MLHPs are trained in primary care through short term, 3-3.5 year courses and do not replace doctors but work under their broad supervision. Also, training them is less expensive and they are less costly to employ. None of these apply to BDS-bridge course graduates, who will be equivalent to MBBS doctors. Producing an MBBS doctor costs about Rs. 37 lakhs per academic year to the government. Assuming that it costs only half this amount for a dentist, which is a highly conservative estimate, a 7 year BDS-MBBS course would cost about Rs. 1.9 crore, which is more expensive than producing an MBBS doctor (1.7 crore). The bridge course would thus be a circuitous and costlier way of producing what would eventually function as a basic doctor. Further, one cannot expect a BDS-bridge course graduate to be paid less than an MBBS doctor, after 7 years of study and clearing two entrance exams.

While rural doctor shortage and a poor doctor-population (D-P) ratio (1:1655) are being advanced to justify the bridge course, the fact is that the public health system is in no position to effectively utilize even the services of the existing lot of MBBS doctors. The government employs only 1 out of 8 active and qualified doctors in the country, nearly 27,000 doctors in primary health centres – and while nearly 8000 posts remain vacant, they can easily be filled with MBBS graduates on simplifying procedures for permanent recruitment and providing reasonably good working conditions. Also, more worrying than the shortage of doctors is their skewed distribution in favour of urban areas. When even many AYUSH doctors remain reluctant to set up rural practices, it is unlikely that a BDS-bridge course graduate after 7 years of study would prefer otherwise. Producing a fresh cadre of doctors without addressing the problem of maldistribution can worsen the problem.

Interestingly, it has not been explicitly stated that BDS-bridge course graduates will help fill unfilled government vacancies in rural areas. It seems unlikely given our public health spending trends that they will be employed, on a pay-scale similar to their MBBS counterparts, one each in the 1.5 lakh health and wellness centres under Ayushman Bharat – since this would mean more than doubling the existing government doctor workforce (nearly 1 lakh).

The bridge course seems to be aimed merely at fulfilling the ideal D-P ratio (1:1000) in a less cost-intensive manner by using existing dentists rather than training doctors anew – without regard to where (rural or urban) or in what sector (public or private) they are employed. It demonstrates faith in the ‘overflow principle’, which assumes that producing more doctors will automatically channel more doctors into under-served areas without requiring active measures towards ensuring their fair distribution. It should not be surprising if most BDS-bridge course graduates cram into urban areas and private set-ups.

The field of dentistry has its own importance and individuality. Unemployment concerns in the field need to be addressed through measures such as increasing government posts, spreading awareness about dental care in rural areas, and attending to demand-supply considerations. Making dentistry a stepping stone to becoming a general practitioner is in the least an unsound idea, if not degrading and patronizing at the same time.

Dr Soham D. Bhaduri is Editor, The Indian Practitioner, a healthcare commentator, and a medical doctor based in Mumbai.