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Return of the Native

After IT professionals, NRI doctors are coming back to be a part of the sunrise sector—healthcare. Nancy Singh and Sonal Shukla analyse the trend

The great brain drain is just getting reversed. And it's a sort of a homecoming for some. For instance, Dr Ramcharan Thiagrajan, a liver transplant surgeon, who practiced for 15 years in the US, took two years to make up his mind to return and join Manipal Health Systems, Bangalore as Consultant, Surgical Gastroenterology, Multi-organ Transplant. "It's been just three months, so I guess I'm in the honeymoon phase and everything seems so optimistic. I just love it!" he says.

He is not alone. A significant number of doctors are taking the route back home.

Home-coming

Consider this: Fifteen per cent of doctors at the Kerala Institute of Medical Sciences, Thiruvanthapuram are former Non-Resident Indians (NRIs). Twenty-eight specialists at Wockhardt Hospitals Group have recently returned from abroad. Fifteen former NRI specialists are working with Image Hospitals, Hyderabad. Around 80 per cent of the doctors at the Madras Medical Mission are former NRIs. There are more than 20 NRI doctors working with Yashoda Hospitals, Hyderabad. Six NRI doctors have joined yet-to-open Artemis Health Sciences (AHS), New Delhi.

This phenomenon is not new, insist industry experts. Apollo Hospitals Group has been receiving applications from NRI doctors ever since the first hospital was inaugurated in Chennai, nearly 25 years ago. Dr K Hari Prasad, CEO, Apollo Hospital, Hyderabad, says, "Over 70 per cent of doctors working in our Hospital have had an international stint. However, the frequency of applications has escalated recently." The Hospital receives about 15-20 applications per week.

Aditya Birla Memorial Hospital (ABMH), Pune, is another case in point. "The percentage of NRI doctors applying to our Hospital would be 15 to 25 per cent depending on their field of specialisation," says L N Rawat, CEO of ABMH.

Although in comparison home-coming doctors may grade relatively low than IT professionals, Dr TK Parthasarathy, Pro-Chancellor, SRMC, Chennai, says there is a linear increase. "For instance, I received 15 inquiries last academic year compared to the previous year," he reveals. At New Delhi's Max Healthcare, the number of applications from NRI doctors constitute two to three per cent of all the applications received (at least 15 per week).

For Dr Sanjeev Singh, Senior Medical Administrator in AIMS, Kochi, what is encouraging is the changing trend of trained and experienced hands in the West, looking to settle in India.

CMC, Vellore does not get too many applications, primarily because Medical Council of India (MCI) does not recognise most foreign degrees. "Those who apply to CMC should obtain degrees in India. This problem obviously will not apply to institutes that are not accredited for undergraduate teaching," opines Dr George Chandy, Director, CMC, Vellore.

According to Dr Parvez Ahmed, Executive Director, Max Healthcare, there are three categories of NRI doctors returning to India. The majority are those doctors who have done their postgraduation abroad. The second category is one with 5-10 years experience abroad. Though not as high as the first category, it's still considerably high. "Typically, it's the 40-plus category that wants to return," says Daljit Singh, President, Fortis Healthcare. The third group, the least among the others, includes those with more than 15 years of experience.

Nostalgia got Better?

It's tough starting afresh, when you are at your peak. So what makes these practitioners make a comeback? It's a mix of both professional and personal reasons. "It's the India booming factor, especially the healthcare sector, which has made NRIs bullish about returning home. Factors like family, culture and roots also bring them home," believes Singh. Echoes Rawat, "NRI doctors are coming back because the housing, education and lifestyle are better here than what they can afford abroad."

It's also 'boredom' that brings most of them back. "After a point, I felt I had stopped growing, while India has plenty of challenges to offer," says Dr G Satish Reddy, Orthopaedic Surgeon, Yashoda Hospital, Hyderabad who has spent four years in Europe and returned a year ago.

Most of them have been conditioned to believe they should return after a few years abroad. Dr Mira Ramkrishnan, In-charge—Paediatric ICU, Paediatric Emergency Room, Manipal Hospital, who has done two stints in the US, once from 1991-98 and then from 2003-06, is a case in point. "I missed India, as I grew up here. Having made a decision with my husband, we wanted our child to grow up with her cousins, as we had decided to have one child. Family matters."

"The choice to return to India is a personal one," says Dr Sarika Raj, Consultant, Department of Paediatrics, AHS. "In my case, our parents need us as they are ageing. We also wanted to adopt a child," adds Dr Sarika, a paediatrician from the US. She completed her MBBS at the MDU Medical College at Rohtak and went to the UK to join Prince Charles Hospital at Merthyr Tydfil.

Same is the case with Dr Hassan Trehani, whose only connection to India is his father's Indian origin. Born and brought up in the UK, little did he know that his father's homeland would one day make him start a new journey accompanied by his American doctor wife. "I realised I had reached a plateau. I saw opportunities in India that I wouldn't ever have got in the US," he says.

He chucked his career as cardiac and endovascular surgeon in the University of Miami and Jackson Memorial Hospital and relocated to Gurgaon, joining AHS as a Consultant Surgeon.

But the thought of returning to India is not an easy task. Apart from personal issues, there are hurdles in getting work visas, especially in the US. Doctors in the age group of 32-35 have to serve in under-served areas for some time before they can get permanent residence. While the older group, those who have spent a couple of decades abroad and have earned enough money, do not expect much in monetary terms. "This group of NRI doctors (aged 50-60) return with rich experience. They feel secure about the change and adjust well," believes Dr Parthasarathy. The average group of 40-45 are the ones who face problems such as finding a good school for their kids' education and maintaining a lifestyle. What's happening is the pull and push factor, experts believe.

Push & Pull Factor

The pull factor is that high-value private players are entering healthcare and rapidly creeping in the corporate culture. "Corporate hospitals are taking keen interest in these doctors and from the doctors' perspective they see a lot of opportunities to work in a professional environment. By professional, I mean infrastructure, environment, management practices, and, of course, salaries," says Daljit Singh.

When it comes to the push factor, doctors in the US and, in particularly, the UK, believe they cannot grow further because of their rigid work policies. The unfavourable change in the immigration laws in UK, abolishing the permit free training for overseas doctors and mainly Indians are key reasons for the turn of the tide. Agrees Dr Girish Dewnany, who works as a Consultant Orthopaedic Surgeon at PD Hinduja Hospital and Asian Heart Hospital, Mumbai and worked in the UK for 10 years, "The reason bulk of doctors return, especially from the UK, is the lack of progress in their career or being stuck in middle grade. Very few like me have acquired consultant status and returned out of choice rather than compulsion."

Dr P Sharat Kumar, Consultant Orthopaedic Surgeon and Sports Medicine Consultant, Apollo Hospitals, Hyderabad who has stayed in the UK for nearly 11 years and returned four months ago agrees. "I believe this change won't have much effect on well established Indian doctors in the UK," he says. "But doctors who have gone there five to six years ago and are working on training posts bear the brunt as they cannot find a job."

Believes Dr JS Rajkumar, Chief Surgeon, Lifeline Multi-Speciality Hospital, Chennai, "For doctors in the UK, after a point of time you don't grow. An Indian is offered a post, which an Englishman has rejected. The job offering is purely racist in my idea." So disgruntled was Dr Rajkumar with the draconian policy that he placed an advertorial in the British Medical Journal urging them to come back and serve their 'homeland'. "There were around 20-30 applications after that and there are seven to eight NRI doctors working now," he says. "Though they may be a little costlier than the Indian counterparts, but they definitely add value to the organisation in terms of awareness of practical knowledge and expertise, clinical acumen and interpersonal skills."

Brand View

The change in the immigration laws in UK is a key reason for the turn of the tide

Since it's difficult to establish credentials, the strategy that most doctors prefer is to go the brand way, unless and until the job in a greenfield project is irresistible. In Dr Ahmed's view, many prefer established brands, as working in greenfield project involves establishment.

Dr Rajkumar agrees when he says, "Branded hospitals are like an umbrella that offers basic
security. It helps them learn the ropes and establish themselves from where they can then take off."

Dr Amit Trehan, a Gastroenterologist working with Fortis Hospital, says the reason for joining Fortis is more for its esteem. "A reputed hospital with good infrastructure is a preference for NRI doctors. This is because of the environment they are used to and so can prove their skills," he explains.

According to Dr Sharat Kumar, the selection of hospital, whether small or big, depends on the physician's confidence that he gains from good experience.

A supportive team is a crucial factor in a surgeon's life. "A multi-disciplinary hospital like Apollo has provided me with a good support team and word-class infrastructure. It is likely that this would not be available with a smaller set-up."

Dr Sujeet Jha, an Endocrinologist with Max Healthcare, New Delhi who, after being in the UK for 11 years, came back three months ago feels that established brands help establish oneself. Based on several visits to different corporate hospitals, he selected Max Group, on the basis of infrastructure, opportunity to grow and its preference towards promoting ethical practices.

According to Dr Dewnany, choosing a brand that replicated the working conditions in the West was easier said than done. There are major issues. “For instance, the most prominent one could be the fact that in the UK, healthcare is state funded, while in India it is fully privatised."

The NRI Workforce

What: Apollo Hospitals Workforce: One of the first ones to witness this reverse trend (since 1975) around 70 per cent of doctors here have had an international stint and today it receives 15-20 applications per week.

What: Max Healthcare, New Delhi Wokforce: The hospital receives 15 to 20 applications from NRIs per week.

What: Yashoda Hospitals, Hyderabad Wokforce: There are more than 20 NRI doctors working currently.

Dollar vs Rupee

Despite the eagerness to work in India, it must also be remembered that salary scales are different from what the West has to offer as compared to India. Although several corporate hospitals offer minimum assured salary in the initial period, it is not the case with everyone. This creates problem for doctors who have to struggle to maintain a decent lifestyle.

"Once you have been in the West for more than five years, you will find it difficult to return to India as your package drops dramatically," echoes Dr Jha. In such situations, they rely on their savings. "The most important part was the financial cushion needed to tide over initial settlement hassles—we saved money for this period. Secondly, our jobs in the US will take us back if we don't succeed in India in two years, and so will our residency status in the US," believes Dr Raj.

When it comes to remuneration, NRI doctors command around 30 per cent more than their Indian counterparts.

One of the unknowns they worry most about is the professional satisfaction. Dr Dewnany says, "I applied to this hospital on the basis of their reputation and infrastructure, and to allow me to do quality work. But the tragedy is that not all the hospitals hold the same view, vis-à-vis merit as a criterion and base their selection on commercial basis. They prefer to hire doctors on the basis of quantity of work they can deliver, rather than the quality," he says. He had this experience with a couple of hospitals who rejected his application on the basis of no business experience in India.

In Dr Sharat Kumar's opinion, the biggest casualty in India is the working style. Coming from an environment in the UK that is salary-based, he finds performance-based settings in India stressful. "Majority of our doctors are on a fee-for-service basis, while the new doctors have a minimum guarantee arrangement for a short time, enabling them to settle down and develop a patient base," explains Dr Hari Prasad. Then there are others who have concerns about India's pace to keep up with latest developments, high level continued medical education, lack of laws and regulations for practices. Dr Jha feels that, "Many of the hospitals in India still do not practice internal medical audit system which critically reviews the internal systems with the established standards."

Dr Sujeet Jha came back to join Max Healthcare after 11 years in the UK

Dr Sarika Raj came back to join Artemis Health Sciences after 12 years in the US

Dr Sharat Kumar joined Apollo Hospital, Hyderabad after 11 years in the UK

Smarter Competitor?

But NRI doctors also bring in an edge with them. Maybe that's the reason why hospitals and high-tech medical centres catering to medical tourism prefer to recruit them because of the quality and prestige of their international credentials. R Basil, MD and CEO, Manipal Health Systems, says, "These doctors have an edge in terms of International Board Certifications that attracts international patients who come to India."

While some believe that doctors coming from good institutions in India have similar capabilities as those coming from institutions abroad, it's the experience that matters. They also understand the implications of cost, working or adopting various modules like OPD, IPD, teaching, operation/procedure and research. They are found to be savvy with the internal audit system that helps in sustaining quality assurance programme. By and large, NRI doctors are highly aware of patient rights and medical documentation.

Recruiting NRI physicians is an opportunity for a hospital to develop areas that fall under specialised fields. As Dr Ahmed puts it, "India, that has such high rates of infectious diseases, has chosen to not develop this as a sub-speciality, and we don't find specialists who have been trained especially in infectious diseases." AIMS is keen on taking trained hands from West in the areas of joint replacement, spine, cardiac transplantation, single lung transplantation, non-invasive neuro-radiology, nanotechnology, stem cell research, etc.

Multi-organ transplant surgeon Dr Ramcharan is a case in point. Doctors from fields like organ transplant, neonatology and sports physicians are also in demand. "Since it's easier to conduct research here than in the US, most doctors prefer to return to India when they want to carry out clinical research since the laws are easier here," adds Trehani.

According to Dr Singh, the trend is both country as well as speciality-driven. In India, and especially in Kerala, it has been largely speciality-driven where NRI doctors look for an institution to teach undergraduates and postgraduates, and carry out clinical trials and research. "I recently hired a physician with an experience in bone marrow transplantation that can also help us further develop this unit," says Dr Parthasarathy.

There seems to be a void in support specialties, and "since we don't have people in geriatric care, critical care and infectious diseases, they are more in demand here. We don't need many surgeons since there are already many Indians with good surgical skills," believes Dr Ahmed.

Reverse Brain Drain?

Is this a sort of reverse brain drain? "Not really", believes US-based Dr S Balasubramaniam, President, American Association of Physicians of Indian Origin (AAPI), "As a matter of fact, most doctors who come to the US, want to stay here. One of the reasons is the opportunity to have postgraduate training in India is limited." He further adds that, "I feel the UK law has significant impact and I feel more want to come to the US rather than the UK."

In unison adds Dr Navin Shah, Founder President, AAPI, "I do not know of any significant number of US practicing physicians returning to India to practice medicine. Every year some retired physicians do return for part- or full-time charitable work." To substantiate his statement, he says, "Currently, there are 42,000 practicing Indian doctors here. In the US, there are 8,50,000 Indian physicians. There are nearly 1,00,000 Indian doctors training in the US and about 70,000 medical students. So there is a vast pool of Indian physician manpower in the US."

Experts believe that NRI doctors returning to India is nothing new and has been happening since ages. "I think only a small portion of them come back but the numbers are a little higher than earlier. If it was 99 per cent doctors willing to stay back in foreign countries earlier, today it's around 90 per cent. So, there has been a small but a significant change," says Dr Rajkumar.

nancy.singh@expressindia.com
sonal.shukla@expressindia.com