|Year : 2017 | Volume
| Issue : 2 | Page : 31-35
A study on the possible reasons for attrition of junior doctors in India
Gayathri Chandrasekhar, Uma Warrier
Department of Management, Jain University, Bengaluru, Karnataka, India
|Date of Web Publication
T-11, Golden Orchid Apartments, 10/8 Kasturba Road, Bangalore - 560 001, Karnataka
Source of Support: None, Conflict of Interest: None
As populations, life expectancy, and health care need grow, countries all over the world are grappling to match the need for trained medical professionals – mainly physicians and nurses. Health care has become one of India's largest sectors – both in terms of revenue and employment. India is leading the globe with regard to medical tourism. Today, the health-care organizations need to deliver care in a new quality-focused, value-based, consumer-centric environment. Health-care workers comprise doctors, nurses, and support staff such as laboratory technicians. Workforce in the health-care industry is growing very rapidly. Growth also comes with its set of challenges such as recruitment, retention, training attrition, and governance. This has put the focus on the human resource-related aspects of the health-care workers. Attrition is among the top concerns. This article focuses on the attrition of junior doctors who are one of the key people under health-care workforce and is based on a review of literature, supported by empirical information based on online survey.
Keywords: Attrition of health-care workforce, attrition of junior residents, junior residents, resident doctors
|How to cite this article:
Chandrasekhar G, Warrier U. A study on the possible reasons for attrition of junior doctors in India. Int J Health Syst Disaster Manage 2017;5:31-5
|How to cite this URL:
Chandrasekhar G, Warrier U. A study on the possible reasons for attrition of junior doctors in India. Int J Health Syst Disaster Manage [serial online] 2017 [cited 2024 Mar 1];5:31-5. Available from: https://www.ijhsdm.org/text.asp?2017/5/2/31/213883
The Indian health-care industry is expected to register a compound annual growth rate of 22.9% during 2015–2020 to the US $280 million. Consequently, the workforce is expected to double to 7.4 million in 2022, from 3.6 million in 2013. In such a scenario, attrition will severely harm the industry by causing cyclical workforce shortages as well as impact quality of services, revenue, and delivery of each organization. This article aims to look at the top reasons for attrition in junior doctors (who form a key segment of the health-care workforce) and recommend means of attrition control.
| About Junior Doctors
Junior doctors comprise people who have just completed their MBBS degree and currently collecting work experience along with writing for the postgraduate (PG) entrance examinations (these examinations are tough and not cleared in the first attempt by many young doctors) and those who have cleared the PG examination and are in the process of studying and garnering experience to become an expert in their respective fields. They need to complete their experience under the guidance of a senior specialist. The second set of doctors is also called as PG residents/resident doctors. After 3 years of studies and work experience, they have to give their examinations, passing which they are allowed to continue with their medical practice. The law also entails them to work under supervision until he/she has completed a minimum of 3 years of hands-on training (the primary residence). Post this, they are trained to undertake medical decisions of patients.
| The Medical Hierarchy – doctors
- ↓ Medical director
- ↓Head of department (HOD)
- ↓ Attending physician or hospitalist
- ↓ Fellow
- ↓ Chief resident
- ↓ Senior resident (usually 3rd-year resident)
- ↓ Junior resident (usually 2nd-year resident)
- ↓ Intern (1st-year resident)
- ↓ Medical student.
Attending physicians are the senior doctors directly responsible for patient's medical decision-making and treatment. Fellows are doctors who have chosen to pursue advanced training in a particular field and do not have much direct contact with the patients. Next, in the hierarchy level are the resident doctors in their various levels of residency.
| About Attrition
Grobler et al. have given a good definition of attrition as that can be described as the total movement of employees in and out on organization. Attrition in HR field refers to the gradual loss of employees over a stipulated period of time. High attrition is a problem for companies, especially for service-intensive ones as it has a direct impact on revenue. Attrition is a metric that is closely measured and checked by the HR team.
| Objectives of the Research
Faced with a global shortage of skilled health workers due to attrition, the Indian hospitals are constantly under pressure to build and maintain an optimum knowledge workforce in health care for delivering quality health-care services. The purpose of article is first to understand the current status of attrition in India and second to highlight factors that are leading to attrition and lastly to look at possible means of reducing the attrition of junior doctors.
| Research Methodology
Descriptive research design was adopted for the review. Secondary sources from journals, articles, and press clippings were studied using key words. The study also used exclusion and inclusion criteria to select the article. Extensive review of literature was done on the health sector, health workforce, junior doctors, and junior residents. An online survey was also done using Twitter to understand the top reasons for attrition from doctors across Karnataka. The critical review and results of the survey helped in setting the objective for the study.
Let us look at some of the statistics of junior doctors in India today:
- PGIMER, Chandigarh, has an attrition rate of 12%–14% of junior doctors within the first 3 months of joining across 350 seats in a year spread across two sessions – January and July 
- Attrition rate of health-care sector in Coimbatore for the year 2015–2016 is at 35%
- The Delhi government hires around 200 doctors each year on short-term contracts of which around 50 resign before the completion of their contracts 
- There is a high attrition rate of doctors from government hospitals 
- The highest vacancy of senior resident doctors (PG pursuing doctors in their 2nd year) is at AIIMS Rishikesh and for junior resident doctors (PG pursuing doctors in the 1st year) is at AIIMS Bhubaneswar, where only 6 are in place against the required of 301. AIIMS is one of the most prestigious medical institutions in India
- Indian doctors are moving abroad. He is practicing his trade in other lands. The UK and US are the top two destinations for the foreign-trained doctors.
A literature review provided insight into the current status of health workforce on India. Most of the articles mention about increasing supply of skilled health workforce but have less emphasis to control attrition. Few studies highlighted the challenges of attrition and emigration that helps in retention and controlling further shortage of junior doctors. All these articles/journals/press articles' studies highlighted these reasons for attrition – long working hours, compensation, organizational hierarchy, lack of PG seats, infrastructure, and the difficult admission process for PG process.
An online survey was also conducted on Twitter wherein the respondents were given a 120-word questionnaire on Twitter asking them to mention three reasons (in order of highest to low) that in their opinion are the reasons for attrition of junior doctors. The respondents were chosen randomly (doctors who had active Twitter accounts). This survey was done across a span of 2 weeks. This also indicated long working hours, salary, and organizational hierarchy as the top reasons [Table 1].
Based on the sampling procedure and size adopted in the online survey, the results obtained are not claimed to be representative for the entire health workforce of a country. The data from the survey were a preliminary study undertaken, and the researcher aims to study this in detail as per of her research.
| Reasons for Attrition
Many writers attribute the primary cause of attrition to long, harsh working hours coupled with medical hierarchy. Although the junior doctors are “doctors” in the true sense of the word, i.e., they treat patients and they are also students, they have to give examinations at the end of their residency tenure. This requires them to devote equal time to both work and study. However, long working hours prevent them from this. It is not about just working for long hours but also the hard work that goes into it. It is a well-known fact that resident doctors are the ones who do most of the work in the hospitals (public and private). Most of the teaching hospitals expect the doctors to work for at least 18 h. In public hospitals, it is the resident doctors who work 24 × 7. Senior consultant doctors are only supposed to monitor resident doctors and ensure that everything is going right or they change the prescriptions if necessary. The major workload is divided among resident doctors. In private hospitals, it is a similar story. The residency scheme as advocated by the Ministry of Health states that junior residents must not work for more than 48 h/week and not more than 12 h at a stretch subject to the condition that the working hours will be flexible as may be decided by the medical superintendents concerned keeping in view the workload and availability of doctors for clinical work. However, this is not followed by many. This is because of a lot of reasons such as shortage of staff and doctor–patient ratio.
Furthermore, the medical hierarchy system confers a lot of powers on the HODs, leaving room for misuse. Residency has to be done under the instruction of the HODs concerned. For example, a resident doctor specializing in cardiology will be doing under the HOD, Cardiology. Junior doctors pursuing their postgraduation course and their final assessment are in the hands of these authorities, i.e., HODs. Therefore, no one normally risks their career. The majority of residents are academic residents who are afraid to do anything. This sword of fear of displeasing anyone in the old scheme of things can result in their failure in examinations. Protests are rare and doctors just look at passing through this stage. The passing rates in these PG examinations are extremely low, and hence, they tolerate the same. Second, with limited availability of seats and difficulty of the same, it makes them also worried. Furthermore, PG courses are expensive and/or coupled with contracts and bonds with penalty clauses and fines in lakhs of rupees which are impossible to pay back.
Salary is another concern for these junior doctors. Despite these long working hours, their satisfaction of the compensation front is another top reason people quit. There is a huge disparity in the salaries of public and private hospitals. Furthermore, it also differs from state to state. Medical education being a state subject, the pay scale of 1st-, 2nd- and 3rd-year PG students in medical colleges (i.e., resident doctors) is decided by individual states in the country. The salary in the government sector is highest in Delhi. This aspect of long and hard working conditions coupled with salary is also the major reasons for strikes by junior doctors in India. In 2015, resident doctors of Karnataka working in government hospitals went on strike with regard to compensation-related issues. The major demands were for increased stipends, addressing disparity in dearness allowance, reduced working hours, and getting a weekly off.
There are other reasons for attrition too – such as better training infrastructure, professional development adoption of newer technologies, work-life balance, and high-stress levels. The other factors were getting a specialization subject of choice/good institution  (in India, there is a huge gap between the number of MBBS seats and PG seats availability  which results in people constantly applying for the same) and residency closer to hometown, etc., Nandkumar in his book “What's up Doc” analyzes these factors in relation to the phenomenon of “brain drain.” He argues that the perception of greener pasture in the form of attractive pay packages, better training infrastructure, better education system who are aspiring for higher education, organized and corruption-free government system, and a sense of achievement influences the decision of junior doctors to quit in larger numbers.
Compensation is one of the critical aspects to control attrition. This covers many aspects such as being paid on time and disparity across sector. Organizations and public bodies must collaborate and work toward a uniform and reasonable compensation. This is imperative from all the three angles – employee (doctor) satisfaction, quality of service to the society (particularly for government hospitals), and also from a revenue perspective (for private hospitals). Karnataka government recently passed a notification of minimum wages to junior doctors in private hospitals. The 7th pay commission also attempted to work on this for government junior doctors. Organizational hierarchy is more of an organization-based affair in the private industry. The hospitals must focus on HR initiatives to work on the reasons for attrition with regard to their organization goals of increasing revenues. In a service intensive industry as this, people-related aspects such as retention, rewards and recognition, manager governance, and approachability are very important for revenue generation. On the public side, there are laws and practices issued by the government which needs to be adhered to strictly by all hospitals. Above all directives, suggestions and other suggestions of the public bodies and policy-makers must be looked into.
Availability of PG seats is another serious concern to be looked into. It is the scarcity that affects attrition of doctors who are unable to plan their PG studies. It is not just the limited number of seats also the tough competitive process to get admission to it. The surplus of medical graduates and shortage of PGs with plenty of hospitals available for training is indeed a problem. After the 4th year of MBBS, the students have work on clinical experience and preparation for examinations. Those who do not make it that year try again next year which ends up in the cycle of unplanned attrition. According to the Medical Council of India annually presents 52,965 and 22,850 graduate and PG medical seats, respectively, in India to medical aspirants. The difference between these two numbers is huge. In contrast, the US has 19,000 undergraduate and 32,000 PG medical seats. The UK too has similar ratio. This means that even after desperately enrolling themselves at coaching classes and devoting years preparing for PG entrance tests, getting a PG seat remains a dream for many deserving medical graduates in India; some of them just migrate abroad for getting a PG degree. In the Union Budget of 2017, plans were to increase 5000 PG medical seats annually. The move will help bridge the gap between the undergraduate and PG seats in the country. To overcome the scarcity of doctors in the country, the government is planning to double the availability of undergraduate and PG seats to meet a target of 80,000 MBBS and 45,000 PG seats in India by 2021. The Ministry of Health is targeting additional 38,431 seats in the MBBS and 22,806 seats in the PG streams by 2021, representing a whopping rise of 92.45% and 102.75%, respectively, over the current availability. When there are more number of PG residents, the attrition rate can come down. A move like this helps the industry and the country. This can also help reduce strikes by the junior doctors.
Health care has become one of India's largest growth sectors. There is no doubt on a global scale that people are living longer and are healthier than they were decades ago. In view of India's economy getting bigger, health care also needs a bigger contribution both in terms of the investment in money, infrastructure, technology, and above all workforce. Junior doctors and resident doctors form a major part of this workforce. More bodies/associations and studies need to be done/formed to improve the workforce needs of the junior/resident doctors. There also needs to be a regulatory body governing the residents – from working hours, leave and ombudsperson kind of facilities for them to perform their duty well. Performing duty in the right manner also helps improves the quality of health care delivered. Regulations and governance must be strictly adhered to. There must be focus on the establishment of autonomous organizations to enable accountable and evidence-based good-quality health-care practices and development of appropriately trained human resources. Above all, there needs to be a recognition and awareness of the contribution of medical residents toward the cause of health care in the country. They are the chunk of the health-care professionals and need a lot of attention – HR initiative wise, regulation wise, governance wise, and availability of opportunities.
Limitations of the study
The online survey respondents had a small sample of doctors across India and those who were active on Twitter and do not represent the entire junior workforce of the country. The secondary research obtained from various articles/journals does share details of research done but does not exclusively focus on junior doctors. The researcher aims to address these needs in her research.
| Scope for Future Studies
The study has a lot of scope for future. One thing is certain – we need more HR focus on the health-care industry. In a lot of ways, the Indian health-care industry today is similar to the business processes outsourcing industry as it was 10 years back. Health care has become one of India's largest sectors – both in terms of revenue and employment. There are a lot of studies done on nurses, but the focus must also be on the junior doctors who are the backbone of the hospitals.
This article aims to highlight the HR attention needed with regard to attrition of junior/resident doctors in India. There are a lot of studies on nurse attrition/engagement, etc., but not as much for the resident doctors. These doctors form a major part of the health-care workforce and attrition can be very harmful. Attrition control is an immediate and an imperative need. They are the future health-care specialists/leaders and hence must be focused on in terms of growth to all individual organization/industry and the nation.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
Grobler PA, Warnich S, Carrel MR, Elbert NF, Hatfield RD. Human Resource Management in South Africa. London: Thompson; 2006.
Azhar GS, Azhar AZ, Azhar AS. Overwork among residents in India: A medical resident's perspective. J Family Med Prim Care 2012;1:141-3.
] [Full text]
Shah SU. The medical students' dilemma: Which postgraduate specialty to pursue? J Postgrad Med 2009;55:294-5.
] [Full text]
Nandakumar S. What's Up Doc. New Delhi: Parity Paperback; 2004.
Davey S, Maheshwari C, Raghav SK, Singh JV, Singh N, Davey A. Impact of occupational health hazards prevention messages on perceptions among rural clients in India: The outcomes of a panel study. Int J Health Syst Disaster Manage 2017;5:11-7. [Full text]