The National Medical Commission (NMC)’s recent move advising states and union territories to do away with the ‘seat-leaving bond’ policy in medical colleges comes as a significant relief for postgraduate (PG) medical students. This recommendation, issued on January 19, 2024, by the NMC's Anti-Ragging Committee, is deemed crucial considering distressing incidents such as suicides, stress, and depression reported among PG medical students across various institutions.
In a missive directed to the principal secretary of health and medical education of all states and union territories, Dr Aruna V Vanikar, President of the Under Graduate Medical Education Board (UGMEB) of the NMC, highlighted the commission's awareness of the “alarming levels of stress, anxiety, and depression” encountered by medical students, particularly PG students, in various institutions, as stated in media reports.
According to sources, this decision stems from a review of seven case studies brought before the NMC between 2020 and 2023, with three cases originating from Madhya Pradesh and one from Telangana. Additionally, EdexLive initiated a Google form-based survey on January 10, 2024, aiming to explore the concerns of PG medical students regarding the bond policy issue.
Survey statistics
It is observed that the PG medical students contemplate resigning and forfeiting their positions due to the arduous and exhausting work environment, compounded by reported instances of harassment, humiliation, and ridicule, even in the presence of patients.
Leaving the PG seat
As per the findings by EdexLive, approximately 54% of PG medical students have contemplated relinquishing their positions, albeit hindered by the penalty associated with the bond policy. The motivations prompting this consideration include:
Work pressure
Toxicity
Stress
Exploitation
Humiliation
Politics at the hands of the higher officials.
However, their aspirations were stymied by the penalties imposed under the bond policy. Furthermore, many of these medical students revealed that they hailed from economically disadvantaged backgrounds. Conversely, a portion of the PGs expressed an unwavering commitment to their vocation, citing their dreams and the perseverance they had invested in reaching this point. They found inspiration in their familial support networks and camaraderie with roommates.
One respondent, reflecting on their journey, shared a poignant anecdote: “I cherished the moments spent in the operating theatre (OT) alongside my colleagues, where we collectively endeavoured to save lives. Witnessing patients leave the hospital with their loved ones, their smiles a testament to our efforts, has been immensely rewarding. Despite personal challenges, the encouragement and gratitude from patients and their families served as my driving force. They bestowed upon me the title of ‘daughter’ and instilled in me the determination to continue giving my best, even when faced with adversity.”
Toxicity at work
Toxic work environments was a significant factor prompting PGs to consider leaving their positions. EdexLive investigated the work dynamics and found that 78% of medicos reported facing toxicity at their workplaces.
One participant, speaking anonymously, lamented, “We (PGs) are never treated as humans. We are treated like slaves, and superiors enjoy making fun of us and insulting us every time.”
Another student expressed a desire to quit due to stress and mistreatment by seniors but cited financial constraints, stating, “I desperately want to leave the seat just because of the stress and torture by seniors. However, I can’t afford ₹50 lakhs to leave my seat. Additionally, being transgender, it becomes very difficult to survive without the stipend.”
A couple of toxic instances experienced by the medicos include:
Excessive overtime hours
Political manoeuvring by seniors and verbal abuse
Unequal distribution of workload, favouring certain individuals
Instances of sexual harassment from male assistants
Inadequate resources and equipment, despite high expectations when it comes to performance
Regular transfers to remote and inaccessible locations
Lack of sufficient time for meals and rest
Stressful duties
Furthermore, according to the survey responses, 69% of medicos reported working over 12 hours per day. In terms of stress levels related to their duties, 46% admitted experiencing stress two to three times a week due to their assigned tasks.
Further exploration reveals that these duties are just a few among many others that contribute to the stress experienced by the medicos:
Other responses indicate that there is no fixed schedule in place, as work hours are flexible and often extend beyond the norm, with no provision for leaves, weekends off, or holidays.
When EdexLive probed further to understand how PGs cope with these overwhelming emotions, one shocking revelation emerged: a few medicos resort to taking sleeping pills.
Others mentioned using sleep, coffee, chatting with friends, listening to music, and other activities as their means of relaxation.
Mental health
In summary, the mental well-being of medical students is severely compromised. In addition to toxic work environments, stress, harassment, and humiliation, attacks by patients further exacerbate the mental strain experienced by these medical professionals. The escalating trend of attacks on doctors and PG residents in India demands urgent attention.
Incidents of such assaults have been reported in states including Tamil Nadu, Kerala, Telangana, Punjab, Maharashtra, and elsewhere. Despite their desire to leave, medicos are often deterred by the penalties associated with resignation, as revealed by survey responses.
Penalty for seat leaving
It is evident that medicos face immense stress and anxiety due to their demanding work duties and the substantial penalty imposed if they choose to leave their PG seat prematurely. Many survey responses highlighted the significant hurdle posed by the hefty penalty. However, it is important to note that each state has its own criteria and bond policy, which candidates agree to upon admission to various medical colleges in India.
The penalties levied by medical colleges across states are not uniform. They vary depending on various factors such as seat quota, institution type, and regulations set forth by the state government’s health department in government medical colleges, and by institute management in deemed universities. Our research indicates that penalties can range from Rs 10 lakh to Rs 1 crore or more.
As per our research, here are the details of bond penalties charged by states:
Andhra Pradesh: ₹30 lakh to ₹50 lakh
Assam: ₹20 lakh to ₹25 lakh
Bihar: ₹25 lakh
Chhattisgarh: ₹50 lakh
Goa: ₹50 lakh
Gujarat: ₹50 lakh
Haryana: ₹7.5 lakh
Himachal Pradesh: ₹25 to 40 lakh
Jharkhand: ₹10 to 20 lakh
Karnataka: ₹50 lakh
Kerala: ₹50 lakh
Madhya Pradesh: ₹10 to 50 lakh
Maharashtra: ₹40 to 50 lakh
Manipur: ₹10 to 20 lakh
Meghalaya: ₹20 lakh
Odisha: ₹10 to 40 lakh
Punjab: ₹75 lakh
Rajasthan: ₹10 lakh
Tamil Nadu: ₹40 lakh
Telangana: ₹50 lakh
Tripura: ₹20 to 25 lakh
Uttar Pradesh: ₹20 lakh to 1 crore
West Bengal: ₹30 lakh
Delhi: ₹10 lakh
Graduates respond
On the condition of anonymity, medicos voiced their grievances and questioned the punitive measures imposed on medical students and doctors.
A medical graduate from Punjab expressed his sense of entrapment in a course he never intended to pursue. He recounts, “In 2022, due to abrupt changes in counselling, I ended up enrolling in ophthalmology though what interested me was medicine or surgery. Now, I find myself stuck in this course with no avenue for transition.”
“When I attempted to withdraw from the course, the college administration demanded a three-year fee amounting to over Rs 18 lakh. Coming from a middle-class background, how am I expected to afford such a hefty penalty?” he laments.
Similarly, another PG student, in their second year, disclosed to EdexLive their apprehensions about quitting due to the looming penalties.
“Why are all the penalties targeted at medical students and doctors? Are we not entitled to the freedom to change our specialisation or institution?” they vehemently question.
Meanwhile, a graduate from a medical college in Kerala alleges suffering from nasal irritation allergy after prolonged exposure to formalin during duty hours. Formalin, widely used as a preservative and steriliser in medical laboratories and vaccines, has triggered distressing symptoms for the medico. “Having joined PG this year, I started experiencing perpetual nasal discharge, headaches, and throat irritation after two months of formalin exposure,” the graduate revealed.
The graduate further elaborated on the escalation of symptoms, including breathing difficulties, dizziness, and tremors, which they attribute to Benign Paroxysmal Positional Vertigo (BPPV). Expressing regret over the choice of specialisation, the graduate shares the dilemma, “Now, I am unable to drop out, despite my reluctance to pursue an MD, as the Kerala government imposes a Rs 50 lakh penalty.”
Does the NMC know?
Moreover, the medico claims that an RTI filed revealed the National Medical Commission’s lack of awareness regarding seat leaving penalties. EdexLive obtained screenshots of the correspondence.
In response to the request filed on January 3, 2024, seeking details on PG seat leaving penalties across states and the rationale behind their non-uniformity, the NMC replied, “No information is available in PGMEB (Post-Graduate Medical Education Board), NMC. Please obtain information from concerned state govt/college/university directly.”
Private colleges vs government colleges
However, the scenario differs significantly in private medical colleges. According to regulations, medical graduates enrolled in private medical colleges are not obligated to sign bonds or face hefty penalties for abandoning their seats.
In a landmark ruling in November 2022, the Supreme Court prohibited private medical colleges from enforcing bond agreements or imposing exorbitant fines for breaches, as per media reports.
A respondent of the survey, a medico pursuing a Diplomate of National Board (DNB) in Anaesthesia at a private college in Kerala, revealed that she relinquished her seat four months into the programme and was required to pay a penalty of Rs 1.25 lakh.
A poignant question arises among students from government medical colleges in Kerala: “Why do different colleges within the same state have varying rules?”
Moreover, the student suffering from nasal irritation queried, “Why am I, suffering from allergic reactions due to the department’s primary chemical, unable to resign when the government demands Rs 50 lakh, plus stipend, for vacating an MD seat, while different rules apply to colleges within the same state (Kerala)?”
However, the concern transcends Kerala, resonating with medicos across India regarding the bond policy.
Expert views
Commenting on the National Medical Commission’s (NMC) recent relaxation regarding the abolition of the bond policy, Dr B Karunakar Reddy, Vice-Chancellor of Kaloji Narayana Rao University of Health Sciences (KNRUHS), Telangana, expressed his reservations regarding doing away with the bond policy entirely, considering it a short-sighted decision which overlooks long-term consequences. Additionally, NMC has not clarified whether extra seats will be sanctioned if the candidates vacate the seat in the first year, he said.
Dr Reddy elaborated on the NMC’s stance during a meeting, noting that the notice serves as an advisory, leaving the decision to implement it to the state governments. He emphasised concerns about potential seat wastage, highlighting the dual nature of the bond policy where its absence leads to vacant seats due to students pursuing higher education abroad and discontinuing the course here, while its enforcement ensures commitment to completing the chosen course. He reminisced about the inception of the bond policy in the 90s, initially with penalties of Rs two lakh or more, which increased under the observation of the then-united Andhra Pradesh High Court to prevent the wastage of seats as students began vacating seats. Dr Reddy argued that government resources are being wasted without the bond policy, asserting that completion of the course renders the bond null and void.
Reflecting on historical and contemporary trends, Dr Reddy noted a significant increase in students leaving seats prematurely, especially to pursue studies abroad, resulting in numerous vacant positions.
“In 1982, when there were 70 or 80 seats, four or five students opted for further study abroad. On the contrary, in today’s times, hundreds of students are leaving their seats before completion as there is no bond in place for them. I noticed students leave their seats after three months of joining the course. And I had students who left the seat three months before the final exams commenced as they decided to study abroad in the United States (US), United Kingdom (UK), and other countries,” shared the VC.
He lamented the detrimental impact on various courses due to the absence of a bond.
“Those who leave a seat, step out with a few months of PG experience that will benefit them in their further study abroad. But what about the seats vacated by them?” questioned the VC. He added, “I have noticed hundreds of BSc Nursing students discontinuing the course after joining as there is no bond. Since there is no bond, many tend to leave BSc Nursing, paramedical, physio, and other courses. As a result, every year many seats remain vacant.”
To address these challenges, Dr Reddy proposed reducing bonds for non-clinical subjects for those who want to discontinue. Gandhi, on the other hand, suggested assigning duties based on students’ backgrounds to ensure equitable distribution of the workforce across rural and urban areas.
Further, Gandhi advocated for a uniform policy and suggested reducing bond penalties to Rs 10 lakh while emphasising the importance of assigning duties based on students' backgrounds to meet healthcare demands effectively.
“Since many aspire to work in cities, duties should be assigned based on their background. For instance, rural background residents should be posted in rural regions and those from cities should be assigned duties for a year in rural areas and another year in cities,” suggested Gandhi.
Recalling the past
The issue of the bond policy isn’t recent; it’s been ongoing for months or even years. For instance, in November 2022, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences (PGIMS), Rohtak, Haryana protested, demanding a rollback of the Rs 40 lakh penalty. In response, the Haryana Chief Minister announced a reduction to Rs 30 lakh and a five-year service term. The strike lasted over a month.
Similarly, Tamil Nadu also saw significant protests against the bond policy. In September 2023, PG medical students in Tamil Nadu urged the government to reduce the bond term to two years, abolish it altogether, or allow service continuation after two years.
The Tamil Nadu Medical Students’ Association (TNMSA) and Tamil Nadu Resident Doctors’ Association (TNRDA) played key roles in achieving a government order that reduced the bond policy. This government order was issued on October 27.
