India, the land of diversity. One country holding several “countries” – where heterogeneity and wide disparity are the rule, not the exception. The same is true for practicing medicine. There is a wide variation of practice patterns, quality of care, physician training, infrastructure, and capacity for patients to pay. As a physician who trained in the US and then returned to India, this experience provides a unique lens through which I appreciate the Indian Healthcare system. Here is a brief introduction to the Indian Healthcare system as well as a guide to help an American doctor practice abroad in India.
Importantly, the Medical Council of India was replaced by the National Medical Commission (NMC) on September 24, 2020. The National Medical Commission is now the governing body for the medical profession. The NMC has yet to share its website and outline formal guidelines. When it does, we will update this post. In the meantime, we outline the process that was most recently in place.
Indian HealthCare System
The Indian constitution mandates the government provide all citizens with the “right to health” and each state is required to provide free universal access to healthcare. There are private and public health insurance schemes, though on the whole, the healthcare system is underfunded. Private health insurance accounts for approximately 4% of total healthcare expenditure and tends to be available in bigger cities, typically only covering inpatient expenses with minimal or no outpatient coverage. The majority of medical care is still paid out of pocket. The Central Government Health Scheme and Employee’s State Insurance scheme provide medical coverage for many government employees and factory workers, enabling access to health care at nominal costs. Ayushman Bharat, the universal healthcare scheme, is still in the process of being rolled out and is not yet optimized.
Indian cities are divided into three tiers based on population density. Tier 1 cities have the highest populations, higher cost of living, and more developed healthcare and education infrastructure, while Tier 3 cities have smaller populations and are less developed. Tier 1 cities – like New Delhi and Mumbai – have access to the latest medicines and technologies and provide care on par with global standards. Tier 1 and a few Tier 2 cities, like Goa and Agra, also have a thriving private sector. The Private sector ranges from small clinics (run by an individual doctor), “nursing homes” which are essentially 10-50 bed hospitals staffed by one or two doctors providing care in one or two specialties, to 100-500 bed corporate hospitals offering all diagnostic and therapeutic facilities, and access to a wide range of specialists. Complicated patients are referred to a higher level of care in the closest metropolitan area.
Premier institutions – like All India Institute of Medical Science, Post Graduate Institute of Medical Education and Research Chandigarh, or Sanjay Gandhi Post Graduate Institute Lucknow – provide quality tertiary clinical care to millions of patients while also advancing their academic missions. In contrast, most other government facilities are short-staffed with limited supplies. In government facilities an individual could wait several months to a year to obtain a MRI or schedule an elective surgery.
The Medical Council of India was replaced by National Medical Commission (NMC) on September 24, 2020. The NMC is the new governing body which will set standards for medical education, grant Indian medical qualifications, determine validity of foreign medical qualifications, and grant and maintain registration for physicians. The NMC is proposed to consist of four governing boards: the Under-Graduate Medical Education Board, Post-Graduate Medical Education Board, Medical Assessment and Rating Board, and the Ethics and Medical Registration Board.
The MCI previously recognized basic medical qualifications obtained in India and international institutions as well as postgraduate medical education obtained in India and at foreign institutions. Specifically, they recognized American Board of Medical Specialties certification in pediatrics, psychiatry & neurology, orthopedic surgery, dermatology, radiology, urology, OB/GYN, internal medicine, pathology, ophthalmology, ENT, anesthesiology, plastic surgery, neurological surgery, Physician Medicine & Rehabilitation, preventive medicine, and thoracic surgery. With these qualifications, you do not need to take further exams, making it easier for American doctors to practice abroad in India. The National Medical Commission is yet to layout formal guidelines on registration – when it does, we will update this post with the links.
Previously, you could register directly with the MCI or register with your state’s medical council by providing identity documents and proof of credentials. All state registrations are automatically uploaded onto the national register, hence you don’t need to do both. They will verify your identity documentation and credentials.
Some states like Haryana mandate a state registration to practice medicine in their state, while other states will allow you to practice with a MCI registration number.
If you completed medical school (MBBS) in India, you will already have permanent registration in the state from where you graduated.
After obtaining permanent registration, you can add additional qualifications including residency and subspecialty fellowship training for a nominal cost and without much hassle. Once the NMC website is up, we will post the appropriate links. Non-ABIM /non-ACGME accredited certifications may not make it to the final state registration certificate. For example, my state registration certificate states: MBBS, Diplomate Internal Medicine ABIM, Diplomate Nephrology ABIM. The Delhi and Haryana medical councils refused to list my kidney transplantation fellowship since it was a one-year American Society of Transplantation accredited fellowship and not an ABIM or ACGME accredited fellowship.
Finding a Job
You can find a job by making a list of all of the hospitals and/or clinics in the city of your choice and emailing or calling the human resources teams for openings in your specialty. You can search job boards like Monster India or Naukri and reach out to colleagues practicing in your desired locale. There are a small number of recruiting agencies that have recently appeared though it is tough to verify their authenticity.
The Indian job market typically does not provide advanced job contracts such as signing up for a position 6 months prior to arriving in India. Instead, the on-boarding process for most hospitals is relatively simple and quick – “we have an opening – you can join tomorrow”. Similarly, you can resign from a position by giving one month’s notice. Consider connecting with local colleagues 5-6 months in advance to see if there’s an opening and consider making a trip to meet as many people as you can in person to assess the job market and to look for a home. That being said, your job will likely only get finalized when you are physically in India, so don’t get too stressed with planning and organization before your move. Take a leap of faith and make the plunge!
Salary & Work Culture
The pay is much lower than what you would get in the US (don’t even try comparing!) and it takes a lot of hard work to achieve the standard of life that you become accustomed to in the US. Expect full working days on Saturdays and even half-days on some Sundays if you would like to earn a “decent” salary.
There is fierce competition in Tier 1 and Tier 2 cities. It will take a long time, perhaps 5-10 years, to establish yourself and be known professionally. In a tier 2 or tier 3 city, such as Bhopal, Indore, Meerut or Mathura, you have a chance to be known professionally and be more successful within a matter of 2-3 years.
Be prepared to update your knowledge and skill set when you make the move. Many medications have different names and different combination formulations – it will likely take a couple months to get up to speed. There are many smart phone apps that can help with this.
Consider completing subspecialty training in the US prior to returning, as procedural subspecialties like cardiology, GI, nephrology and non-procedural subspecialties like endocrinology and rheumatology are in demand.
Indian Citizens and Overseas Citizens of India (OCI) can practice medicine in India on a permanent, long term basis. The MCI previously offered Non-Indian citizens and Non-OCIs an opportunity to practice temporarily in India though we await the NMC’s formal guidelines.
The Indian healthcare system is not easy to adjust to. There is no standardization of work, pay, or turf. As an “American-trained” doctor practicing in India don’t expect a red-carpet welcome. You may face a bit of hostility since you haven’t been in the trenches of the Indian healthcare system. Most people don’t understand the meaning of “Board Certified” – all they understand is MD/DM/MCH.
Be clear on your reason for moving to India. You will need to hold on to these reasons when you breathe in the pollution, drive through the potholes, and work long hours. If you move to India just to give it a try, chances are things will not work out. The beginning is tough and the best parts come after a long slog. Many physicians end up returning to the US.
Despite the struggles, the community of American doctors practicing abroad in India is growing rapidly. Those who are determined will pave their own path – where there’s a will, there’s a way!
Personally, it has been a little over three years since I returned to India and knowing what I know now, I would still make this decision to return again. My six-year stay in the US, spanning internal medicine residency, nephrology fellowship, and kidney transplant fellowship was very satisfying and gave me a lifetime of skills, knowledge, memories, and friends.
Dr. Sagar Gupta is an American trained doctor practicing in India. He is a nephrologist who did his MBBS from Maulana Azad Medical College, New Delhi. After completing his internal medicine residency and nephrology and kidney transplant fellowships in the US, he returned to India to practice in New Delhi in 2017. Currently he is the Consultant and Head of Department, Nephrology & Kidney Transplantation, Metro Hospital, Faridabad.
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