Medical students training with a simulated COVID-19 scenario in the ICU of a hospital in Java, Indonesia. Photo: Mufid Majnun/Unsplash.
When we appeared for our final microbiology examination on January 30, 2020, the only thing we were concerned about was if we had brushed up enough on obscure respiratory viruses to tackle any unexpected questions in the paper. Because little did we know that the novel virus would completely turn around the lives of all medical students around the world.
The state governments of Maharashtra, Gujarat, Karnataka, Haryana and Delhi have asked medical students to join COVID-19 duties due to a shortage of doctors. In July, the Gujarat government mandated final-year MBBS students to report for COVID-19 duty in municipal corporation-run medical colleges. The Delhi government has asked even second- and third-year students to sign-up for COVID-19 duty.
Students in Gujarat were threatened with debarment from university examinations and were sent show-cause notices under section 188 of the Indian Penal Code and the Disaster Management Act 2005 if they didn’t report to colleges. Yet even after having worked for two months, they are yet to receive their promised stipend of Rs 500 per day.
The Maharashtra government has given Rs 50 lakh in insurance, Rs 30,000 remuneration and free accommodation to undergraduates recruited for COVID-19 duty. The Gujarat government has not announced any insurance.
Final-year MBBS students in private colleges in Karnataka and those pursuing internships say they have been asked to report to fever clinics or COVID-19 care centres on short notice. Many alleged that they have had to make their own arrangements for accommodation, pay for their treatment if they tested positive for COVID-19, and for tests as well if they had to visit privately operated testing facilities.
The situation is somewhat similar internationally as well. The demand for more doctors has prompted the medical colleges in Italy, the UK and the US to graduate medical students earlier. As a result, almost 10,000 medical students from all of Italy’s medical schools were fast-tracked into the healthcare system, even before they had given their postgraduate examinations, which concludes their practical training. They are to be sent to work in general practitioners’ clinics and at old peoples’ homes, freeing up more experienced doctors.
In a crisis situation, when faced with a shortage of healthcare workers and lacking the capacity to produce more doctors on short notice, reasoning students of medical education seems like the next best option. However, this doesn’t free us from considering whether MBBS students are competent enough. Because let’s face it: just as our hospitals weren’t equipped with enough doctors and beds, our medical colleges and universities haven’t been training students with an epidemic in mind either.
According to the Gujarat government’s resolution, undergraduate students will be trained for three to five days before being deployed on duty.
The first ethical principle of medicine is primum non nocere – Latin for ‘do no harm’. It means that even if a doctor can’t save a patient, they must never do anything to worsen the patient’s condition. From personal experience, we can testify that most students in the third year of an MBBS education are unlikely to know how to draw blood samples, insert intravenous lines, catheterise the patient, etc.
If the Medical Council of India’s Graduate Medical Regulation 1997 has been followed, a third-year student has attended clinics for 1.5 years. However, the places where students learn the aforementioned procedures are the medicine and surgery wards. The total duration of being located in these two facilities prior to entering the third year is only three months.
In addition, the undergraduate curriculum lacks lessons on disaster medicine.
Earlier, parents of the students enrolled at the Nathiba Hargovandas Lakhmichand and Municipal Corporation Medical Education Trust medical colleges, in Ahmedabad, approached the Gujarat high court to quash the conscription order. The court turned down the prayer, however. The bench maintained that an attitude among medical students choosing to shy away from their responsibilities was “quite condemnable”.
Gujarat state also said it was having a difficult time procuring the necessary medical help in its hour of need. However, there is no evidence to suggest the Gujarat government was really desperate. The NITI Aayog had simply appealed for volunteer doctors citing the crisis, and the state government itself had issued advertisements for doctors. And even so, they were not looking for permanent hires. Instead, they offered 11-month contracts that would end with the epidemic. These contracts didn’t have enough takers, leading to the shortage of healthcare workers.
In a communication dated June 16, the medical education division of the Union health ministry said final-year medical students could only be trained for COVID-19 but not be assigned to COVID-19 duty.
A trained doctor needs to supervise students when performing any invasive procedure or when prescribing drugs. However, doctors won’t be able to supervise the students – as the state governments have newly claimed – principally because there is a shortage of doctors at COVID-19 care centres. And when even intern-doctors have been struggling to find good accommodation, there’s no telling what position student-assistants will be in.
And as students have not had experience in performing many medical procedures, their per-patient time of exposure will be higher compared to trained doctors.
All of this places MBBS students reassigned to COVID-19 at higher risk of contracting COVID-19, and spreading the infection among themselves. The fact of 34 medical students testing positive for COVID-19 across Gujarat points to exactly this nightmare scenario.
The age-specific mortality rate of COVID-19 is described in the table below. The mortality rate is higher among the older sections of the population – which means younger people are relatively safer. This feature of the COVID-19 pandemic makes younger healthcare workers more desirable in the field.
Second, trained doctors are expensive, whereas students only require a stipend. However, note that before the Gujarat high court’s intervention, the state wasn’t even offering a stipend for students at work – on top of making COVID-19 duty compulsory. And even after the court said the state government would provide some remuneration, the latest order stays silent on it.
If students are to help, they need to be treated properly, and state governments and any other body that requires students’ assistance must avoid this ‘Gujarat model’ and pay them fairly.
And it’s not that students can’t help at all! They can certainly help screen patients for COVID-19 symptoms at a hospital’s entrance, follow-up mild and asymptomatic COVID-19 cases through phone and video calls, and help in non-clinical work like data-entry and patient education.
Ultimately, we believe that COVID-19 duty should be voluntary in nature. In a survey conducted among 283 medical students in Gujarat, some 75% of students felt the same way. As the country’s healthcare workforce of the future, we are certainly part of the healthcare system’s response to public-health emergencies.
Conversely, we have limited roles and knowledge to deal with something as monumental as a pandemic. Exposing us to risk we have neither been educated nor trained for only raises the possibility of doing more harm than good by forcing us to serve on the COVID-19 frontline, and providing more fodder for the virus.