‘We are considered outsiders’: FMGE students pay thousands for medical internship

NEW DELHI: While undergraduate medical education typically lasts five-and-a-half years, for Pavandeep Singh it has stretched to eight years with no income in sight.

Singh, who in the final year of MBBS came back to India from China in 2021, not only took six years to complete MBBS thanks to Covid, but also had to do a two-year internship in India, made mandatory for foreign medical graduates (FMGs) by the National Medical Commission.

Medical students affected by Covid-related travel restrictions and the Ukraine war were allowed to complete their compulsory internship in India, however, the council mandated a two-year internship after their MBBS, in place of the usual one year to make up for the loss of clinical training during online classes.

Unlike Indian medical students who are paid a stipend during their internship, foreign medical students are being asked to pay a heavy amount as internship fees instead. This is despite the NMC, in May, 2022, instructing state directorates of medical education to ensure that no internship fee is charged from any group of interns and to ensure that stipend and other facilities are provided to FMGs, on par with their Indian counterparts.

MBBS Internship: No stipends

That’s not how things worked out for Singh.

“In 2021, I got my first internship in a private medical college after paying Rs 50,000 and did not receive a single penny as stipend. For my second internship, I paid Rs 20,000 and received no stipend even though there are NMC guidelines that ensure stipends for FMGs,” said Singh who is currently in his second internship at Dr. BR Ambedkar State Institute of Medical Sciences, Mohali, Punjab. His internship will end in November.

In September 2023, Singh will complete eight years of medical education when most MBBS graduates in India move on to pursue postgraduate degrees or are eligible to practise with a permanent licence. Singh, now distraught about NMC’s “arbitrary” regulations, has spent over Rs 42 lakh on an MBBS course in China and internships without earning anything.

FMGE internship fees

FMGs, as per NMC regulations, are required to apply to the state medical council and go through a counselling process to be allotted an internship in a medical college. Based on their FMG Exam result, MBBS marks and Class 12 marks, age and domicile along with students’ preferences, medical colleges are allotted.

During the counselling, Surbhi Rana, an MBBS graduate from Homieĺ State Medical University in Brussels, Belgium, found that FMG students in Himachal Pradesh are also paying thousands in fees for internships. However, the amounts are collected under different heads.

“I have paid around Rs 48,000 to get an internship in Government Medical College (GMC) Chamba. Premier government colleges have different fees that they collect from FMG students. It is usually taken as Rogi Kalyan Samiti fee [Patient Welfare Committee] and not as FMG internship fee. For example, in Indira Gandhi Medical College and Hospital Shimla and Shri Lal Bahadur Shastri Government Hospital Nerchowk the fee is Rs 32,000, in Medical College Hamirpur the fee is Rs 30,000,” said Rana. “The highest FMG internship fee is taken by Tanda Medical College in Kangra district, Rs 1.9 lakh.”

A private medical college in Solan is charging Rs 1.2 lakh per student but the fee is charged under hostel accommodation, she further added.

In Tamil Nadu, the directorate of medical education allowed FMGs to join service in 2021 to compensate for the shortage of health workers as the number of Covid cases rose exponentially. The FMGs were allowed to join the compulsory internship in public medical colleges with a fee of Rs 2 lakh. A year later, the state’s health and family welfare minister Ma. Subramanian announced a 90% percent reduction to Rs 30,000.

After clearing the national-level screening test—Foreign Medical Graduate Exam (FMGE) – the graduates had to pay Rs 5.2 lakh for an internship. Of that, Rs 3.2 lakh was to be paid for obtaining a No Objection Certificate (NOC) from MGR Medical University and the remaining Rs 2 lakh as internship fee to government medical colleges. Similarly, the Kerala Directorate of Medical Education (DME) had also charged fees.

“In Tamil Nadu, the fee was as high as Rs 5 lakh and after the NMC rule came it must have stopped. In Karnataka and Maharashtra, medical colleges were asking for Rs 1.5 lakh and above to give internship opportunities,” said A Najeerul Ameen, president, All India Foreign Medical Graduate Association.

When Singh enquired about the NMC rule, the medical college administration gave “lack of budget” as the reason for charging fee. “They said that they had already flagged the issue of scarcity of funds to support FMGs with NMC. They also said that only those willing to pay should join. We had no option,” said Singh.

Dr. BR Ambedkar State Institute of Medical Sciences, where Singh is interning, was established in 2021 and currently holds classes for first and second-year MBBS students.

“There are always ways to evade a law. It is common for medical colleges to ask for a fee in the name of “development funds” or any other such title to support the medical college. A nominal fee has been the norm for a long time but if students are asked to pay Rs 50,000 and more, it is not acceptable,” explained Ameen.

Discrimination, protest at NMC

The two-year compulsory internship mandate does not apply to Indian medical students who also studied online during the pandemic. This prompted FMGs to protest at the NMC office in October 2022, demanding equal treatment.

“When we were protesting, the president of undergraduate programmes at the NMC, Aruna Vanikar, told us we are not qualified to practise medicine in India unless we complete this internship. When we asked why this rule was not applied to Indian graduates, she said that the students in India contributed during Covid-19 emergency. I, too, treated patients in the emergency ward during my first internship in Ludhiana. Why are we being treated so harshly?” asked Singh.

Vanikar did not respond to questions emailed to her.

According to Ameen, the policy is not discriminatory because it aims to solidify the foundation of a health worker who will treat real-life patients. “Online classes cannot help you understand the nuances of treating a patient. It is important that they learn by doing as others do. The two-year internship rule is to compensate for what they missed out during the pandemic and should not be seen as discriminatory.”

On November 18, 2021, NMC issued the notice that FMGs can do internships only at medical college hospitals and directed the colleges to set aside 7.5 percent seats, down from 10 percent. Internships at non-teaching hospitals were considered “invalid”.

Later, in May, NMC issued a list of 600 non-teaching hospitals where internship was allowed till May 2024. In Punjab and Haryana combined, there are 42 such non-teaching hospitals. In this circular, NMC directed the state medical council to not deny allotment of medical colleges for internship to FMGs on the basis of their domicile.

FMGE will be replaced with the National Exit Test (NExT) to be conducted for the first time in 2024. Medical graduates will have to clear both NExT Step 1 and Step 2 to obtain a licence to practise modern medicine in India.

‘Can’t go back’

While Singh is struggling to complete the two-year internship, his junior Gagandeep Singh, who came to India in his fourth year, is anxious about the “frequently changing” regulations of NMC.

NMC, in its latest notice, said that the two-year internship is applicable only to FMGs who were in the last year of their programme and returned to India due to Covid or war. “Other FMGs are required to acquire a valid offline medical qualification and qualify FMGE to undergo CRMI for a period of one year,” the notice said.

Also Read| The FMGE problem: Foreign medical graduates allege discrimination, seek reforms

“NMC is changing rules in such an arbitrary manner. I have completed MBBS in 2021 and then I qualified the FMGE. I am currently in the second year of internship following NMC rules from 2022. Even though I am compensating for the lack of clinical training, I will not qualify as per the new rule,” said Gagandeep, adding, “I have already taken all the formal documents related to my graduation from the university I studied in China. They follow their own regulations. Just because NMC made a rule today, the Chinese university will not reopen their admission and allow students to come back and complete studies offline.”

FMGs get a Permanent Registration (PR) after qualifying FMGE and the completion of a compulsory internship. The latest regulations make Gagandeep Singh ineligible to apply for a PR even after completing a two-year internship. His second internship in a government medical college will end in five months.

“In China, like every other university, mine also communicates through a social media app called V-Chat which was banned by our government. I cannot explain my dejection about my future,” he lamented, “FMGs are blatantly discriminated against. The authorities including our government, the NMC and even the Supreme Court have failed to address our issues. We are considered outsiders even though we are Indian. It hurts.”

*Names of all students changed to
protect their identities.