Emergency medicine in India: Time for more than applause

As the COVID‐19 pandemic continues to rage across the United States and Europe, attention has been diverted from the toll the virus is taking in India. India is currently home to the second largest COVID‐19 outbreak in the world, with more than 10 million confirmed cases and over 150,000 confirmed deaths. ¹ Although officially reported numbers are down from a peak over the summer, many experts believe that the true number of coronavirus cases in India is much higher than reported. ² Throughout the pandemic there has a great deal of focus on the role that emergency medicine (EM) providers have played in the fight against COVID‐19, dutifully standing on the frontlines to provide compassionate care for patients while exposing themselves to a deadly virus. The frontline providers in India have shared in this sacrifice: more than 660 doctors in India have died while caring for patients with COVID‐19. ³ Despite their sacrifices, many of these doctors are denied formal recognition as trained EM physicians by the Indian government. While news media has been flush with heroic tributes to frontline providers, India's emergency physicians need more than appreciation. In a demoralizing fight against an invisible enemy, what many of these doctors truly need is recognition––recognition by India's government as validated, sanctioned, wholly competent, and legal practitioners.

Despite the need for a well‐trained EM workforce, infighting between stakeholders, the slow pace of program development, and onerous certification requirements have handcuffed the development of EM in India. As a result, much of the emergency care system in India remains in its infancy. In 2009 EM was formally recognized as an independent specialty by the Medical Council of India (MCI), and since that time EM training programs have been initiated in both public and private hospitals. Unfortunately, the scale of this government‐sponsored training is woefully inadequate to serve India's population. This year in India there are 196 recognized, government‐sponsored training seats available in EM to serve a population of 1.324 billion people. ⁴ , ⁵ For comparison, the United States has 2,278 training seats per year and 57,000 active board certified EM doctors for a population less than one‐quarter the size. ⁶ The gap is huge. To reach similar proportions, more than 130,000 trained emergency physicians are needed in India today to provide adequate access to emergency care.

Recognizing the insufficient numbers of graduates available from government‐sponsored training programs, many hospitals have developed their own educational programs to address the EM physician shortage. These programs, commonly referred to as masters in emergency medicine (MEM), have taken various forms, some in partnership with international universities, while others partner with local professional societies. Moving to fill the gap in EM training, MEM programs have flourished over the past decade, particularly in private‐sector hospitals. As a result, hundreds more doctors are trained in EM each year. Many of the doctors leading these programs have worked in the emergency department for their entire careers, simultaneously providing valuable education and training to students and providing lifesaving care to the people of India. Despite their expertise and commitment, graduates of these programs are not recognized by the Indian government as trained EM specialists. Aggressive campaigns in the Indian news media threatening the legitimacy of these programs have only further demoralized these frontline providers. As a result, graduates of these programs are faced with a choice: to serve in their home country where their validity as physicians and livelihood is under continuous threat or to leave. As a former member of the British Commonwealth, the Membership to the Royal College of Emergency Medicine examinations are given throughout India every year. Doctors who pass this examination can practice as recognized physicians in most commonwealth countries. Faced with a choice, each year many MEM graduates leave India, as bureaucratic pressure pushes them out, while better‐paying jobs and formal recognition in places like Australia and the United Kingdom pull them in. ⁷

Given the current deficit of EM physicians in India, solely relying on new trainees from recognized, government‐sponsored programs to solve the physician shortage is unreasonable. However, there are numerous steps that India could take to scale‐up capacity in emergency care. Significant international precedent exists for the grandfathering of physicians trained in different specialties. Judicious and deliberate use of grandfathering, in combination with additional experience requirements, will enhance emergency care capacity in India, while maintaining that only qualified doctors gain recognition.

Additionally, recognition of training pathways like MEM programs could prevent movement of India's EM physicians elsewhere. This second step has other potential benefits. More than 70% of India's population lives in a rural setting, yet access to trained health care providers in rural areas is limited. Approximately 77% of all qualified allopathic doctors in India live in cities, forcing many rural Indians to travel great distances for medical care. ⁸ By tying recognition for physicians trained in MEM programs to a requirement to spend time working in a rural posting, India could simultaneously address its shortage of rural health care providers while retaining manpower and scaling up its emergency care capacity.

Even before the pandemic, the need for emergency care in India was immense. Injury is the second most common cause of death in India after age 5, second only to ischemic heart disease. ⁹ It is estimated that in 2016, a total of 415 people died each day in India due to road traffic injuries. ¹⁰ While the arrival of several promising COIVD‐19 vaccines gives reason for hope, quantities are limited and much of the existing supply has already been purchased by wealthier countries. This, combined with the emergence of more contagious and potentially more deadly variants, suggests that the state of the pandemic in India will likely worsen. Increasing EM training pathways in India must be a national priority. As precariously positioned and underresourced as the Indian emergency medical system may be at present, it would no doubt collapse entirely without the tireless work of these unrecognized doctors. In the early days of the pandemic, people across India cheered for health care workers as they remained away from their homes and families to stand guard and care for patients on the frontlines. The time is now to formally recognize their contribution with more than a just round of applause.

CONFLICT OF INTEREST

All authors are teaching faculty in masters in emergency medicine (MEM) programs and are involved in regular teaching, curriculum development, and program implementation of MEM programs in India.

AUTHOR CONTRIBUTIONS

Kevin Davey, Katherine Douglass, Janice Blanchard, Ankur Verma, Sanjay Jaiswal, Wasil Sheikh, Meghna Halder, Kamal Palta, Narendra N. Jena, Venugopalan Poovathumparambil, Sajid Nomani, and Shweta Gidwani conceived and authored this piece. All authors contributed substantially to its creation and revision.