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 the six-year MBBS programme at Odessa National Medical University.
“Bombs were raining literally and even the neighbourhood was not visible in the resultant dust and smoke. I almost stared at death in the eyes. 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 23-year-old remains tense, though. 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.
“There is no option for revaluation. Besides, the exam costs about ₹7,000 for every appearance. The only benefit is that there are no negative marks,” he rues. “But clearing the exam is just the beginning of a long road ahead filled with hurdles before I can secure the permanent registration to practise as a doctor in India,” he says glumly.
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 computer-based test consisting of 300 objective-type multiple-choice 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.
As per the guidelines for registration of foreign medical graduates by the NMC, State medical councils can grant provisional registration for a 12-month internship after they clear the FMGE and other conditions stipulated by the council, including submission of documents related to their qualifying examinations
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 All-Kerala 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 8-10 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 12-hour duty in the casualty ward.
Foreign medical graduates cite a circular issued by the NMC to all the State medical councils and Directorates of Medical Education on March 4, 2022. It directs that stipend and other facilities as fixed by the appropriate authority applicable to the institution/university or the State be provided to foreign medical graduates on par with Indian medical graduates. The council had also clarified that the medical colleges shall not collect any amount/fee from foreign medical graduates for the internship.
A senior official at the Department of Health says no decision has been taken on whether to provide stipend to foreign medical graduates undergoing internship in government hospitals.
Taking a much-needed break from his hectic duty at General Hospital, Alappuzha, Sandeep T.M., who completed his MBBS programme from State Medical University in Tajikistan, says: “After completing our internship, there is a further delay in getting permanent registration. On an average, foreign medical graduates lose around one year of their career to bureaucratic delays. The majority of foreign medical graduates have taken bank loans to complete their study abroad and the hurdles being faced after clearing the FMGE add to our woes,” he says.
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 clinical-case scenarios,” says Dr. Ghafoor.
B. Ekbal, a public health expert and former Vice-Chancellor of the University of Kerala, refers to the gaps in the hands-on training for foreign medical graduates as a key factor for the falling pass percentage levels in the FMGE. “Clinical experience is crucial. For Indian medical graduates, the high number of patients in government hospitals is a major advantage, as it provides them with necessary clinical exposure. I doubt foreign medical graduates are getting a similar exposure in their institutes,” he says.
Dr. Mukundan says the first year of medical degree in foreign countries is devoted to basic general science subjects and languages. “They teach the language so that we can communicate well with the people of the place. The first, second, and third years are non-clinical subjects, while the last three years of study are focused on clinical subjects. Nearly 52-56 subjects have to be learnt in a total of 12 semesters,” he says.
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 and academic 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.
