A question of equivalence

September 12, 2018 0 By CH Unnikrishnan

With the union government going ahead with its plan to introduce the National Medical Commission (NMC) bill to implement drastic changes to medical education in India — including the replacement of the Medical Council of India (MCI) — the demand for making Diplomate of National Board (DNB) equivalent to Doctor of Medicine (MD) has been growing.

DNB is awarded by the National Board of Examinations (NBE), an autonomous body under the Ministry of Health and Family Welfare, while MD/MS degrees are offered by universities affiliated to MCI.

The Association of National Board Accredited Institutions (ANBAI), which formed the All India DNB Alumni Association in June this year to raise the voice of DNB graduates, is at the forefront of raising the demand. The body recently submitted a Charter of Demands to the PMO and Union Health Minister J. P. Nadda on behalf of DNB graduates in the country. The decision to submit the Charter of Demands was taken at the inaugural meeting of the All India DNB Alumni Association, which was held in Hyderabad in June.

When ANBAI officials met J.P. Nadda with the demand of DNB-MD equivalency in May this year, the minister reportedly assured them that DNB graduates would be given equivalency to MD degree as per the 2012 Government of India (GOI) gazette notification. “Government of India has categorically said that DNB and MD are equivalent. But some people are still not ready to give equivalency, which is against law. The government has agreed to implement it stringently once they introduce the new bill,” said Dr. Sunil Sharma, Joint Secretary, ANBAI.

Follow the law: DNBs

The 2012 GOI gazette notified DNB equivalence to MD for all those who have undergone DNB training in institutions which run MCI-recognized postgraduate degree courses in a given subject and those who have undergone training in multi-specialty teaching hospitals with at least 500 beds. The notification proposed one additional year of senior residency or equivalent training or research job in an MCI-recognized hospital or institution for others for equivalency. But the gazette notification issued by MCI in 2017 proposed DNB equivalence only for those candidates who have undergone training in institutions which run MCI-recognized postgraduate degree courses. The National Board of Examinations regulates almost 7,000 post graduate medical seats, mainly in private hospitals.

When contacted, Dr. Alexander Thomas, President, ANBAI, said, “The GOI 2012 gazette notification stated that both DNB and MD are equivalent. We are asking the government to follow the law.”

However, the Parliamentary Standing Committee on Health and Family Welfare recommended that ‘the DNB qualification awarded by NBE shall be equal in all respects to the postgraduate degrees awarded by MCI, except in relation to teaching in medical colleges.’ But ANBAI has been demanding equivalence as per 2012 notification.

Dr. Sunil Sharma further said that by establishing DNB-MD equivalency and allowing DNB graduates to teach, more specialist doctors can be created and this in turn will contribute to the build-up of healthcare sector in the country.

In a related development, another representative body of DNB doctors have filed an appeal to the Delhi High Court seeking equivalence. ”The Delhi High Court has already admitted our case and the next hearing is slated for October,” says Dr Jateen Ukrani, President, Association of DNB Doctors.

Dr Jateen Ukrani, President, Association of DNB Doctors

The association is also lobbying with the government simultaneously, he added.

Eligibility rules are binding: MCI

Medical Council of India (MCI), on the other hand, makes it clear that the revised norms are not against DNBs teaching provided they have secured the qualification from a medical college where “teaching and learning taking place for the same.”

Explaining the rationale for the additional stipulation, MCI points to the governing teachers’ eligibility qualification regulation that prescribes requirements for full-time teachers in medical colleges.

“The stipulated conditions are prescribed to evoke parity from the point of view of the material fact
that what is incorporated in regular
MD/MS courses of three years duration including the pedagogical skills which are gained by the regular learners by teaching the undergraduate students in a medical college is missing with reference to the DNB learners in places other than medical colleges.,” according to a response issued by Dr Jayshree Mehta, President, MCI.

Since the eligibility so prescribed in the regulation is binding in nature and mandatory in character, they “are not open for any waiver, condonation of concession of any type.”

Setting and monitoring the standards of medical education through the medical colleges in the country are well under its ambit and jurisdiction of the MCI as per the statutory mandate vested with the regulatory body.


Single PG authority: Solution?

The raging debate hit a wall with the Indian Supreme Court quashing a writ petition seeking DNB-MD/MS parity filed by Sankalp Association of DNB Doctors.

Experts propose the merger of DNB with MD/MS/ MCh/DM as the only way out to sort this issue out permanently as India is the only country in the world having parallel systems of PG degrees.

In the west also, medical education is not restricted to medical colleges and non-medical college hospitals also contribute to the PG seats in huge numbers, and they do not discriminate between the degrees with separate nomenclatures.

However, the clause proposing a single post graduate degree from the National Medical Commission (NMC) Bill was dropped when the bill was tabled in the Lok Sabha. The merger of the Post-Graduation Board and the National Board of Examination (NBE) was one of the proposals in the draft version of the NMC Bill, which was intended to overhaul medical education in India by replacing MCI. The PG Board, under the MCI, awards MD/ MS degree to MBBS doctors, while the NBE, under the Union Health and Family Welfare ministry, awards DNB (Diplomate of National Board).

Meanwhile, the Indian Medical Association (IMA) has endorsed the demands of DNB students and the DNB Association for complete equivalence and common nomenclature for Indian PG students. In a letter to the Union health minister, IMA said ”There has been a long-pending demand of the DNB students to have one authority and hence merge the DNB course with the MCI in a ”One Nation One Degree” policy…This will also remove the dichotomy in medical education with two parallel, vertical institutions performing the same function.”

Want of uniform training

There appears to be no major dissent amongst the medical fraternity on DNB holders’ demand for on-par status.”We don’t consider our DNB colleagues inferior or superior to us. There are many DNBs in our association. We don’t discriminate against them,” says an ENT surgeon from Chennai. ”Still, I can say the difference between a specialist trained in a medical college and a DNB is huge,” he adds, preferring anonymity.

Currently, DNB training is not uniform across the country. Most of the students get away with theory marks. They won’t get sufficient practical exposure. After DNB, one year of experience is required in a Medical Council of India-recognised higher learning centre. Sometimes, DNBs are trained in some district or corporate hospital. Theoretically, they may be qualified.

However, the majority of hospitals are not equipped to offer a comprehensive training programme for PG students. The MCI has set certain conditions, such as the number of out-patients and in-patients for hospitals attached to medical colleges offering postgraduate qualifications. But that stipulation is not there in DNB centres.

Some of the DNB training centres may be smaller, but training and skill-sets vary in medical colleges as well, and not just in DNB training centres, others argue.

In another recent development,
the Post Graduate Committee of the MCI rejected the proposal sent by Devendra Fadnavis, Chief Minister, Maharashtra, to the Health Ministry for flexible conditions for starting DNB courses in government medical colleges. Fadnavis had proposed simultaneous running of DNB courses along with MD and MS courses in government medical colleges against extra faculty, if available. The committee, after detailed discussion, rejected the proposal citing that PG seats require other facilities like a certain number of beds and infrastructure, apart from faculty. MCI stated that if an institution has extra faculty and all other facilities, they can add more number of MD/MS seats rather than requesting for DNB.


Eligibility for teaching–
The bone of contention

The ongoing controversy on DNB equivalence started when the Medical Council of India (MCI) revised its Minimum Qualifications for Teachers in Medical Institutions Regulations in June 2017. The requirement now is that doctors who have completed their DNB from institutions not recognised by MCI, such as private hospitals, need to complete three years of junior residency and two years of senior residency, if they wish to qualify for the post of an assistant professor in a teaching institute. It implies that DNB doctors need an additional five years of service experience if they want to have a career in a medical college.

DNB doctors found the new norm a major impediment to find a teaching job soon after qualifying for the diploma. The new standards also cast doubts on the eligibility of those DNB members who are already working as faculty.

DNB doctors maintain that teaching is an integral aspect of their curriculum and the MCI has acted unilaterally without consulting them or the health ministry. The Ministry of Health has made it clear that DNB is equivalent to MD/MS through notifications. However, the MCI is continuing with its policy, they allege.