Courage under fire
Foreign medical graduates are fighting for an easier licentiate exam that will qualify them as doctors. G. Krishnakumar tracks their travails, even as some Indian medical professionals allege that the students are just not good enough
Mahesh K. ( name changed to protect identity) continues to be haunted by the night of February 24, 2022. The thunderous noise and the sound of shattering glass continues to ring in his ears to this day. The next morning, he learnt that Ukraine was under attack by Russian forces. At 21, Kumar had experienced an aerial bombardment, something most people don’t in a lifetime. He was evacuated in a week, going back in January last year to finish his sixyear MBBS programme at Odessa National Medical University.
“Bombs were raining down, literally, and even the neighbourhood was not visible in the resultant dust and smoke. I almost stared death in the eye. When I eventually made it back, my parents were relieved to see me in one piece,” he recalls.
Sitting now in the safety of his home at Thrikkakara in Ernakulam district, Kerala, the 23yearold remains tense. This time, the worry is over his future career as a doctor.
Mahesh could not clear the Foreign Medical Graduates Exam (FMGE) conducted twice a year by the National Board of Examinations in Medical Sciences. “I fell agonisingly short just by two marks in my first attempt,” says Mahesh, who took the exam in January, adding that he will now have to wait another five months for his next chance.
However, clearing the exam is just the beginning of a long road before he can secure permament registration to practice as a doctor in India.
Mahesh was one among an estimated 3,400 students from Kerala who were pursuing medicine and engineering programmes in Ukrainian universities at the time of the Russian invasion two years ago, according to estimates by the State government.
A licentiate exam, FMGE, is conducted for Indians and Overseas Citizens of India earning primary medical qualifications from foreign countries and desirous of practising medicine in the country. Clearing it is a prerequisite to register with the National Medical Commission (NMC) or any State medical council. A computerbased test consisting of 300 objectivetype multiplechoice questions, candidates need to score a minimum of 150 out of 300 marks to pass the exam. Though not against the screening test, aspirants such as Mahesh are upset about the lack of answer keys and sample question papers for the exam.
Navigating obstacles
Besides Ukraine, medical aspirants from Kerala have been fanning out to places such as Russia, Kyrgyzstan, Kazakhstan, Georgia, Moldova, Tajikistan, Armenia, Philippines, Bangladesh, and Malaysia to study. Costs there, over private medical colleges in India, are the primary consideration in choosing these destinations.
The many hurdles strewn along their wards’ academic and career paths have left parents stressed about their children’s future. “Our children are paying a big price for opting for a medical programme abroad. Not all could score marks in the NEET (National Eligibility cum Entrance Test) that would make them eligible for admission considering the limited number of seats for undergraduate medical programmes in government colleges,” says Silvi Sunil of the AllKerala Ukraine Medical Students and Parents Association, a collective formed to address the problems faced by over 3,000 aspirants following the confusion that emerged after the Ukraine war.
She claims parents will have to incur around ₹1 crore to complete the MBBS programme in a private medical college in Kerala or in other States, whereas the total expenses, including tuition fee, for an undergraduate medical programme in a country such as Ukraine come to about ₹60 lakh.
An analysis of the pass percentage in the FMGE shows that only a small section of the students has been able to clear it. As per the results compiled by the Association of Foreign Graduated Physicians (AFGP) – Kerala, in 2021, 23.9% of the students who appeared passed; in 2022, it went up to 30.8%, and slipped to 10.2% in June 2023, and improved to 20.5% in December.
Sanjay Mukundan, Joint Secretary of the AFGP – Kerala, says FMGE was introduced in 2002. “It is an arbitrary examination purposefully devised and designed to hassle us as there is no prescribed syllabus for the exam. Questions are set at par with postgraduate standards for assessing undergraduate medical graduates. No question paper or answer key is published after conducting the exam,” he says adding that exam results get delayed regularly without any specific reasons.
Dr. Mukundan explains that once students pass the exam, they are issued the pass certificate from the NMC in New Delhi. Foreign medical graduates have to then apply for provisional registration. “This usually takes 810 months in Kerala,” he says.
A hard day’s night
Paul Antony, a native of Manjali, near Nedumbassery, in Ernakulam who completed the MBBS programme in the Philippines and doing his internship at General Hospital, Ernakulam, shares a long list of grievances faced by the foreign medical graduates who work as house surgeons in government hospitals in the State.
“There are around 120 foreign medical graduates pursuing their internship at General Hospital, Ernakulam. Unlike the Indian medical graduates, we are not paid a stipend despite clear instructions from the NMC. Around 1,000 foreign medical graduates are at present pursuing internships in various district general hospitals and medical colleges in the State. None of us has received a stipend yet, while the Indian medical graduates doing their internship receive about ₹25,000 monthly. Why are we being treated as second class citizens even after qualifying the equivalency examination?” he asks, amidst his arduous 12hour duty in the casualty ward.
Arguments, this way and that
In March 2022, at the peak of the evacuation of the stranded students from Ukraine, the Union government had stated that 90% of the Indian medical students who graduate from foreign universities are being found unable to clear the qualifying exam to practise medicine in India.
“The standard of medical education abroad, except U.S. and U.K., is no match to the quality standards in our country. The lack of adequate clinical and patient exposure is a major drawback. Students from our country, who enrol for medical programmes abroad, also face the problem of language hurdles to converse with the patients there,” says senior neurologist P.A. Fazal Ghafoor, president of the Muslim Educational Society.
He also cites curriculum shortcomings in other countries and the differences in diseases being reported there and in India as another impediment for foreign medical graduates.
“The standard of an exam like FMGE cannot be diluted on the ground that it is tough to clear. The Indian medical education has a robust standard and the equivalency exam will have to test the knowledge of the aspirants in various areas, including clinicalcase scenarios,” says Dr. Ghafoor.
Foreign medical graduates admit to the difference in standards of education, curriculum, and methods followed in the countries they opt for, but oppose the sweeping generalisation of all foreign medical graduates lacking merit.
They also question the double standards of those who voice support for a stringent FMGE but oppose the National Exit Test (NexT) proposed by the NMC as the common final exam for all medical graduates. “Is it not a contradiction that they are opposing it by raising the argument that one test for the entire country will not be feasible due to the lack of uniform standards of medical education across institutions in the country?” asks Gopika Suresh, pursuing internship at General Hospital, Ernakulam.
Caught in this policy mess, Mahesh feels he is in the middle of a war of a different kind; one that will decide his future. That is a battle that he can hardly afford to lose.