Too Few For Too Many: India’s Cancer Care Faces Oncologist Crunch
In this week's The Core Report: Weekend Edition, Dr K.S. Sharma, from Tata Memorial Hospital, talks about how India faces a severe shortage of qualified medical and surgical oncologists, despite improving training capacity; corporate hiring worsens retention.
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Dr. Sharma, thank you so much for joining me on the core report. So we are going to talk about the incidence of cancer, the way it has spread in India and the challenges faced in responding to it being the dreaded disease it is. But before I come to that, you have been an anesthesiologist all your life.
When did you first realise that there are bigger challenges that we need to address in trying to fight cancer? Was it in the operating room? Was it at Tata Memorial Hospital in general?
Yeah. So good morning, Govindraj. It's really my pleasure to meet you.
And since I had joined Tata Hospital way back in 1983, my appointment was only as an anesthesiologist. But in Tata Memorial, as it is being only for cancer care, all the major cancer surgery used to happen in operation theatre. And then while giving anaesthesia, I realised that this type of anaesthesia, these types of patient on table, they are different than the normal patients who are being operated at a medical college, where I learned my MD, there was a stark difference.
And that difference was because all these patients when they come on operating table, either they have been radiated before surgery, or they may have been administered chemotherapy. So these are side effects of chemotherapy, radiation, and there are metabolic changes in the body, which happen. Maybe patient immunocompromised, or maybe patient feeling weak, their haemoglobin may be low.
So all these things for a major surgery really draw your attention that how best care you can take, how optimally you can manage these patients on table, and what will be the outcome in the post-op setup, and how will you manage these cases in post-op when they are in the intensive care unit. So there I learned what is oncology, and how anaesthesia and post-op care or clinical care is related to oncology in a patient who is suffering from cancer, and have been treated with medical oncology, so say for chemotherapy or for any kind of radiotherapy, or he may be not being done anything. But per primum, the cancer surgery may be a major surgery where you can expect a lot of many hours of anaesthesia, you have to manage good pain relief, at the same time, you have to manage the vital parameters, and maybe major blood loss, or fluid balance, electrolyte balance, everything you have to delicately manage, so that the outcome from the major surgery will be really successful.
So that was my main thing, and I learned oncology, I'm not an oncologist, or say qualified. But being an anaesthetist, and in touch with everything, we used to see what was the treatment given to this patient, what was the chemotherapy, how was the radiotherapy given, and what is presently happening to the patient's body, physiology, and pathology.
So I'm going to come to the number of cases that we're seeing in India, but before that, why is it that, this is a sort of top level question, why is it that there's such a big gap between the number of patients who are seeking care, versus the infrastructure that exists in India to respond to it, or to provide care?
So if we go into the, say, epidemiology of cancer, and how many cancer cases per year in this country, maybe around 1.4 to 1.5 million cases at any given moment. And with these cancer cases, the usual mortality happens between say, 8 to 8.5 lakh per year. And these cases are every year increasing, they are increasing, there are two reasons.
One, the population is increasing. Second thing, the longevity of the human being also is now beyond 70, 75. So there are few cancers which are related to, say, old age, or because of some lifestyle diseases, some are hereditary, some are genetic.
So all these things considered together, we find that number of cases are increasing. Number two will be that when there were no major cancer hospitals in this country, all over the country, all the patients used to come to Tata Hospital. So we used to find that these are the number of cases.
But patients who could not approach Tata Hospital, they were dying in their home state or in their hometown, and they will never get registered. So that time, the number of cases were not properly noted also. So that is a challenge.
Second challenge is number of hospitals are required. Cancer care is such that to treat a cancer patient, a comprehensive cancer hospital is required. Comprehensive means there should be three core specialities, like surgical oncology, medical oncology, radiation oncology, and very important branch, which is often, say, neglected is pathology.
A pathologist has to be so well trained that oncopathologists will give the guidance that what type of cancer, whether it is invasive, non-invasive, then there are immunohistochemistry markers, then there are molecular diagnostic markers, which will give the correct diagnosis, the stage of the disease, then the prognosis also will be marked on whatever the number of tests. So these are the things. Then of late, maybe, say, 20 years back, we realised that there is a department which is very much needed, is the Department of Palliative Care.
So with all the departments, that oncopathology, three major core specialities, and palliative care, they are the pillar to manage any comprehensive cancer hospital. So Tata Hospital has its own history. Way back in 1939, with the House of Tata, it was founded by them, and then by 1962, it was handed over to the Department of Atomic Energy, and now it is a standalone cancer hospital under administrative and financial control under the Department of Atomic Energy.
So we were the only person available in this country to manage, but for the last, say, maybe 20 years, there are a large number of cancer hospitals in this country, which are under government organisation, whether it is state government, whether it is central government, or maybe under public sector undertakings. But there are a large number of private, corporate hospitals also, not full-fledged for cancer, but they are multi-speciality hospitals having a small cancer wing, where they have got three or four specialities available, and then they manage the cancer care there. So presently, with number of cases and number of hospitals, what we want that to cater to this load of cancer, the availability of a cancer hospital should be in public domain, and they should be available by government so that you can treat them cross-subsidised, highly subsidised, very poor patient, non-paying, and under government scheme also, like PMJ scheme, Matma Phule, Arogyashree, different, different, say, different schemes are there. So at any given moment, when I saw all these hospitals, more than 85% patients are under scheme.
So these are very good schemes where we get a good package, and these patients are being taken care with the, under the scheme, and then there are around 20% patients who are out-of-pocket paying. So we have to cater to out-of-pocket also, and to this free or subsidised patient also. But my thinking is that the hospital should be in such a way that it should not look like as a government hospital only for poor patients.
No, it should attract the out-of-pocket paying and good paying patient also, may not be covered by scheme. Why? Because there are expertise and expert doctors available in this hospital so that everybody will come to this hospital.
And when all the facilities are for paying patient also, at the same time, you are going to give the same benefit to the poor patients.
Right. So when we say that we have about 1.5 million cases every year, so you're also saying that roughly 50% is the mortality? Yes, around 8 to 8.5 lakh cases every year. Okay. So is this uniform across types of cancer or is it there, are there some kinds of cancer within that which are more?
So good question. I will touch upon, say, four major and common cancers. One is, say, hedonic cancer, which is because of the smokeless tobacco or smoking tobacco, the pan chewing, betel nut, all these habits.
Second will be breast case. Then third will be hepatobiliary, like colon cancer, pancreatic cancer, gallbladder cancer. And fourth, if you want to touch upon, it will be major gynaecological cancer like cancer cervix and cancer uterus, endometrial and all.
And this is in India?
Yes, India. So these are the four major types of cancer cases, which we usually see. And our main aim will be to treat such cases.
Then a large chunk will be hematolymphoid cancers, like blood cancer, which we call it as leukaemia or lymphoma. That is adult hematolymphoid and paediatric hematolymphoid. Why we differentiate?
Because there is a stark difference between the treatment and the outcome. In paediatric cancer, say, below five years, there is acute leukaemia. And if it is really intensely treated, the outcomes are very good and their survival rates are very, very high as compared to adults.
And when you treat adult cancer, there are comorbid conditions also along with the patient with the age, like they have hypertension, they have a cardiac problem, they have metabolic syndromes. So all these things together, the mortality and the morbidity goes high and high.
And if we are saying that there's a roughly 50% mortality, does it mean that 50% are getting cured?
No. When you treat cancer, say breast or colon or any other soft tissue or any, we usually first do the diagnosis, then the staging. And then it is decided that this patient is for a front surgery.
Afterwards, surgery, depending on whatever you have removed and their pathology report and markers, you may give chemotherapy or you may give radiotherapy. Few cases you will find more than 50% which are not for a front surgery because they are now metastatic disease. So they have not come with primary disease.
While you diagnose primary, already you find that there are other sites also which are affected by this primary tumour and it is known as metastatic. So that time you will try to control this cancer or lower down the tumour burden by giving chemotherapy and then surgery followed by radiotherapy. So all these things together, when you find that three categories of treatment which will be available to the patient or as per the guidance of the pathology report or report of PET-CT or report of CT and MRI, the treatment will be guided for surgery, chemo and radiation.
Or it may be one after another. So depending on that, the major hepatobiliary pancreatic case or major thoracodominal cases like cancer oesophagus, cancer lung, where the mortality is high because of their age and other comorbid conditions.
Okay. So you're saying some cases will therefore get cured or it will take much longer, whereas others we may see higher mortality and faster because it's already in an advanced stage.
When we start this treatment with these main three pillars of oncology, it is usually decided that we give this treatment and we may declare tomorrow that it is now controlled. So every three months follow, six months follow, one year follow, we will try to see by investigation maybe CT or PET-CT or clinical examination and we find that at this stage, the primary and the metastatic is controlled. It is not spreading.
So it is known as a controlled state of the cancer. It is not cured. At any given moment, after say one year or two, you may find that it has got some more again recurrence.
So usually we count the disease-free interval. So today the treatment is over. All three are momentarily over.
Radiation is over, chemo over, surgery over and we are following up. So at any given moment for one year, two year, three year, till five year, so when we calculate, it is the survival rate beyond five year and the mortality within five year. So this five year criteria is applied to just gauge that what was the response of the treatment and how long the patient got controlled status of the cancer without any recurrence.
So, you know, if I were to compare it now to let's say cardiac ailments, which are a much bigger killer, number one killer in India. Now, I think you've explained why cancer is more specialised, because there are these three or four sub-disciplines which are all critical as part of the response or cancer care, as opposed to let's say cardiac, which I'm assuming is maybe a single doctor with a single discipline doctor can treat you and the chances of cure are higher as well. So that's the background.
Now my question is, in a country like India with let's say 1.5 million cases, what is our current capacity in terms of treating cases at various stages? And where are we falling short?
Yes. So now after decentralisation from Tata Hospital, from Mumbai, we have got one big centre, which is ACTREC in New Bombay. Then last seven to eight years, we started establishing cancer hospitals across the country under Department of Atomic Energy.
If I can quickly ask you, so the ACTREC, which is the Advanced Centre for Treatment, Research and Education in Cancer. So how is it that different from the Tata Memorial hospital?
No, no. Initially, the cancer hospital for treatment was at Parel. And we wanted all our major research lab in the campus of ACTREC.
That was our main aim. But being a big land parcel available, we started that Tata Hospital in Parel. Even if it has got five, six buildings, we cannot have capacity to treat all these people who are coming from all over India.
So we migrated all our clinical services, radiation, chemo, surgery in different, different buildings. And we tried to achieve a good clinical workup there also. So right now, there will be, say, around 800 beds available there and 800 here.
And now we are expanding just in front of Tata Hospital in Parel in the Hafkin campus, where we have got, Government of Maharashtra has given us, say, 10 years before a land of 4.5 acres, where we are going to build up a hospital, which will have around 800 to 1000 beds. And it will be a full-fledged comprehensive cancer hospital. And our old building will get demolished.
Right. And so how many specialist cancer hospitals are there in India today?
Yes. So under Tata Hospital, when we started decentralising, we established two hospitals in Varanasi, two in Punjab, one in Chandigarh and one in Sangru, one in Vishakhapatlam down south, and one hospital in Guwahati, that is B Barua Cancer Institute. And now, under, say, in a short time, we'll be commissioned, one is in Muzaffarpur, Bihar, and Orissa and Bhubaneswar is under construction.
So considering all these things, there will be eight more cancer hospitals in the country. Out of them, six are well-functioning. Bihar and Orissa will be now functioning in a short time.
So with all these hospitals, there is one thing which I realised, that say, last to last year, say we had 65,000 new cases coming to Tata Hospital, and six to seven lakh cases coming every day, so every year on the follow-up. When we established all these cancer hospitals, we thought that the part of UP, part of Punjab, part of north, part of south, part of northeast will be controlled, and all patients will go in these different directions, and less number of patients will come to Tata Hospital. It has failed.
The number of cases in Tata Hospital still remains the same, in the range of 60,000 to 65,000 new cases per year. And all my hospitals are of different capacity, like 100-bed hospital, or 250, or 350, or 400-bed, like in Varanasi and Punjab, all hospitals are full. That means, up till now, when patients could not come to Tata Hospital, I think they were dying in their home states, and it was not noted.
So now, when Punjab is also full, Varanasi is full, Vishakhapatnam is full, Guwahati is full, that means now patients from that province are closer to their home, they are getting services, and these numbers are also full. And Tata Hospital also, patients coming are also full, that means cancer cases are definitely on the upstream.
So that means our 1.5 million figure is not accurate.
Maybe.
It may not be accurate. No. Okay, so this is under Tata. If you were to look at all cancer hospitals, or specialist cancer wings within other hospitals, what is the capacity today in India, roughly?
So right now, apart from, say, 8 cancer hospitals all over India, by Department of Veterinary, under TMC control, there are regional hospitals. Like in Ahmedabad, there is a Gujarat Cancer Hospital. Then in Karnataka, there is a Kidwai Memorial.
In Kerala, there is a Regional Cancer Centre. Then in Tamil Nadu, there is an Adyar Cancer Hospital. And considering all these things, and there are a few hospitals, like in Telangana, there is one cancer hospital attached to a medical college in Hyderabad.
Then there are a few cancer hospitals, which are now being established in the campus of a medical college, usually by a private organisation, private college, or by a government medical college. So recently, we have developed, for the last 10 years, one very good comprehensive cancer hospital attached to a government medical college in Aurangabad, that is in Maharashtra. And I was an ex-student of that college, so I took my interest and I developed that hospital.
So you're saying in all?
In all.
In India, there are not more than 20?
No, not more than 20 big public sector hospitals.
Okay. And if you were to include private?
Private, then you have to count corporate hospitals, under Apollo chain, or Fortis chain, or Max chain, and all that, they have got cancer hospitals. And in Delhi, there is a big cancer hospital, which is Rajiv Gandhi Cancer Institute. And then there is the Delhi Cancer Institute.
So some are controlled by the Delhi government, some are controlled by private organisations. Then there is a big wing of cancer care in Kangaram Hospital. And all the AIIMS, like there are 22 AIIMS in this country, and those who are the first generation, older AIIMS, they have all got a comprehensive cancer hospital.
Like AIIMS Jhajjar, then AIIMS Delhi, then AIIMS Rishikesh, AIIMS Jodhpur, AIIMS Bhubaneswar, all they have got cancer hospital. And initially, there was one misnomer concept, that if you have a radiation unit, that means you are a cancer hospital. No, it is not like that.
Only radiation you are doing, okay, you may be able to do some chemotherapy, but to have major diagnostic chain, major laboratory, major radiology department, HCT and surgical department, to make it as a comprehensive hospital, the thinking for last 20 years is like this. But otherwise, there are standalone radiation centres all over the country. They say there may be around more than 100 by private or by public-private partnership.
They are there. Where if you find that into Tata Hospital, there is a waiting list for radiation. I find that patient is from, say, Solapur.
I will tell them that there is one radiation good centre in Solapur, and my student is working there. So, you take this protocol, go to him, and he will take proper care. That means the patient is near to his home and getting same kind of radiation where the doctor has been trained in Tata Hospital, and the machine is also good, and he will follow the protocol which otherwise I would have given in Tata Hospital.
But because there are limited number of machines and limited number of capacity, we cannot give each and every patient radiation in Tata only.
Right. So, the problem clearly, or at least one problem seems to be the affordability that most people who have cancer and need good treatment cannot afford the private hospitals, which could apply to other disease conditions too, but it is more pronounced in cancer. So, which is why there is a need for more government capacity.
Government public sector hospitals where you will have all sorts of treatment and class available, like, say, for poor patient, no funding required. Then for cross-subsidised patient, they will pay something. Then those patients who are eligible to go under the scheme and those who are out of pocket.
So, in your sense, I mean, as an approximate of the patients who come, let's say, to Tata Memorial in Mumbai, in Parel, where the main headquarters is, how many patients do you think are or have been traditionally of the economic class where they cannot afford to pay at all or they can barely afford?
So, in Tata Hospital, our mandate under DAE, Department of Atomic Energy, at any given moment, we are treating 60% patients who are either non-paying or cross-subsidised. And 40% patients are only paying in Mumbai. Yeah, at our hospital.
So, therefore, I mean, so 60% is a safe figure to assume that these are people who are from the poorer section of society and this would apply across India. So, from an infrastructure point of view, the other 40%, if that's an approximate figure, can afford good quality care, including in corporate hospitals, 60% cannot. But the 60% is large enough and there is not enough capacity to beat that.
To take care of them. 60%. Okay.
So, now let's come to resources and training. So, as you look at this challenge ahead of you, where do you feel we are lacking the most? This is a super speciality problem or a medical challenge.
And there are so many super speciality challenges, but cancer is pronounced and it's something that we all fear because we don't know how it will evolve. So, what are the key challenges when it comes to addressing it in terms of resources, in terms of training, in terms of infrastructure?
So, big bottleneck will be the trained and qualified human resource in this field of oncology, all the speciality field like surgical, medical oncology, radiation, palliative care and oncopathology. There is a huge amount of shortage. Initially, say around 20 years back, we used to train people because the number of seats were not available.
And we used to train them for two years, three years. And as on today, suppose you ask me, the senior most surgeons available in this country who are practising surgical oncology, all are trained. Nobody's qualified.
But now the middle cadre and the junior most cadre you find at every district or at every state, they are all qualified people now. Because the number of seats were less. And the number of faculty also were available less.
That's why they proportionate to faculty, the allocation of seat by, say, Earthwhile Medical Council of India, now National Medical Commission and the National Board of Examination, they conduct DNB courses also. So, calculating all the seats, I have been of my knowledge that at any given moment, there is a shortage of all these three specialists available. And when we try to catch them in Tata Hospital, when we give them three-year course of MCH and DM and MD, we ask them to work one more year with us and that is our bonded service.
So, we utilise their services. They also get trained and then they are available to the country. So, most of them are again absorbed by us only for our Varanasi, Punjab and Guwahati and Visakhapatnam Hospital.
But considering all these hospitals, as on today also, I need, say, double the strength of the trained people available in this country.
And between those three sections that you said, you talked about, I mean, surgical being a critical one, where do you feel is the biggest gap? Is it for surgeons? Is it for radiologists?
Number of radiation oncologists, a good number is available in this country. But because there are large number of standalone radiation centre, they are being practising there, right? Then the availability at the institute level is, I think, it's good.
The number of radiation seats are good. But the number of medical oncologists, those who treat with complicated cases and chemotherapy, immunotherapy, all these targeted therapy, the numbers are very, very less. And when they are available in that hospital, say, for five years they practise and then they want to go and they will be absorbed by the corporate sector with a huge salary.
So that is the difference and that is the attraction for them. So every year we see, for last, say, maybe 40 years, every year I have seen that every five to six years, a batch of five, six people, surgical, radiation, chemo, and they leave that hospital, they join either Max Hospital or they will join Apollo or they will join some other corporate sector.
But in terms of the most sensitive requirement, you're saying surgical oncologists?
Surgical and medical oncologists.
So how do you define a medical oncologist?
Medical oncology means those who do a specialisation of DM in medical oncology after doing MD medicine or MD radiation. They undergo extensive training of all the chemotherapy protocols and then they learn that at what stage of the disease, what type of chemotherapy can be given. And at the same time, they have to see the side effects of the drug, whether the drug is available, not available, and how to give and how to protocolize the drug.
The protocol is very important. Staging of the disease and then giving the chemo, radiation, or surgeon is very important for a disease. So there is a need of a tumour board.
So in a tumour board, when they see all those cases, when their cases are very simple, you will decide the treatment. But all complicated cases, all will be kept aside and a joint clinic will be there which will have a tumour board and then in that tumour board, they will discuss the status of the case, they will define the stage and at that time, it will be decided whether you are doing upfront surgery or whether you are doing new adjunct chemotherapy followed by surgery and radiation. So tumour board has to be there.
And if you are standalone practising outside, then you will require the help of all the other specialists who will decide the correct discussion and the treatment plan.
So for surgical oncology and medical oncology, I'm assuming that for those who can afford to pay it, including in corporate hospitals, there is enough capacity. But where they cannot afford is where there is a gap.
And so what's the pipeline like? I mean, how many do we need every year? And before we come to how we find them?
Recently, I presented to the central government that at this moment, I need nearly 600 radiation centres in this country to cope up with all the radiation requirements. So minimum 600 radiation centres. And I also presented that there are a few old government medical colleges where there is the existence of a radiotherapy centre standalone, where the old cobalt machine is functioning.
So half of the year it is not functioning. And sometimes it functions and you have to give only cobalt. But now there are sophisticated machines available, which are known as linear accelerators, which really give a good kind of radiation to the patient.
At the same time, they will try to avoid the neighbouring tissue being affected. And the training of the students who do MD radiation will also be optimum on these good machines. So there the proposal I have given to central government to upgrade these medical colleges with new bunker and new ultramodern Linux.
So that's the radiation centre, which is being run by medical oncologists?
No, radiation centre is being run by radiation oncologists. And while they do MD radiation, they learn a part of chemotherapy also. So a radiation oncologist can treat this solid tumour, breast and all head and neck.
They can do radiation also and they can give chemotherapy also. But for a complicated cases and for hematolymphoid cases, there is a need of qualified DM medical oncology in the country.
So coming back to how many surgical oncologists we need in India or medical oncologists.
Suppose now, I think we have got more than 750, 780 districts all over India. So every district, if I calculate, I must have at least two surgical oncologists available at a district place or maybe one at a good town place, which is not a district place. So you consider these three, then at any given moment, I want 2000 surgical oncologists available.
And our present capacity of every year, the qualified people coming out will be not more than 300 or 350 by all the medical colleges and by all the big cancer hospitals and by the private sector where they are qualified as DMV in surgical oncology.
But that's every year.
Yes, every year. But they are being absorbed by all big hospitals. So suppose in Mumbai, Mumbai is a metro city, Kolkata, Bangalore, Madras, this thing, all these places are this thing. So if you consider a district and they are, say, 20 times more than district, then they require more than 100 surgical oncologists, more than, say, 50 medical oncologists and around 50 to 60 radiation oncologists.
So they're absorbed in a metro city. They're not going to the district place. So our aim will be to develop a cancer hospital, either which is attached to a medical college, because nowadays, presently under NMCN, Government of India, I think there are good number of government colleges which are attached to the district hospitals.
So a district hospital being converted into a government medical college and having a cancer wing will be very good, because at a medical college, you have got good laboratories, you have got good radiology facility, and you have got operation theatres also available. So if you make a ward for radiation person, a radiation machine with a CT simulator and that attached radiotherapy block with a daycare chemo attached to a medical college will be a win-win situation where you will not waste money, you will not duplicate the department and resources, say, equipments, and you can run a good hospital of these things so that you can give 40 to 50 chemotherapy daycare per day and you can radiate around 80 to 100 radiation patients on the machine attached to a medical college.
So you said 350 surgical oncologists pass out every year.
Yes, every year.
What is the figure for medical oncologists?
Medical oncologists may be around 120 per year and the requirement is 500 per year.
And in one district, you would need?
In one district, at least there should be two medical oncologists, those who are qualified, practising, so that they can take the load of the district. Because at district, you will find patients coming from more special areas also. From taluka, they will be referred.
So the government has a national programme for prevention and control of cancer, diabetes, cardiovascular diseases. So under that, there are 770 district non-communicable disease clinics. There are 230 cardiac care units, 372 district daycare centres, and over 6,000 or close to 6,500 community health care non-communicable disease centres. So all of this is leading to what?
So all these other centres, which are for non-communicable diseases, one of them will be cancer, major part under NCD.
And they're supposed to have some cleaning capability.
Yes. So recently, in their budget, they have announced that initially, they will have daycare centres of four to six beds attached in a district running hospital and it will be managed by medical oncologists. So it's a good proposition, but it will be difficult to manage because who will refer the cases there and who will manage?
At district hospitals, nobody is trained in medical oncology. And if a DM qualified medical oncologist goes to a district hospital, there is no cadre for him or for her to get attached in a proper designated fashion. There is nothing.
Then second thing, he or she will not be attached to a district hospital where less number of cases are there. So all these qualified people will get attached to a comprehensive cancer hospital where other branches are also available.
So at a ecosystem.
So now, say 200 daycare centres. So I gave my proposal to Honourable Finance Minister in a pre-budget meeting that, okay, you are developing 200 daycare centres, but at the daycare centre, there has to be a radiation machine where a radiation oncologist can treat this patient on radiation and they will be able to give chemo to all the solid tumours. So that will be a win-win situation.
But when government thinks there will be a construct, there will be required, say, 5 to 10 crore of bunker construction, allied rooms, then there will be a cost of around 30 crore for the machine. So I have given a proposal of 75 crore for each district or each medical college where they can have a well-developed radiotherapy block either attached to a district hospital or to a medical college. That will be the win-win situation.
But even if, let's say, the number of doctors passing out in surgical and medical oncology were to increase, what you're saying is that they're unlikely to go and take up a job in a district because there is no ecosystem. So where do we address the problem?
Suppose I am in surgical oncology attached to a district hospital where there is no pathology department which will be like an oncopathology where they can give the correct diagnosis. So I will be handicapped. I will not go.
Medical oncologists also will think like this. But our main aim is to decentralise the care to make these centres comprehensive, available to the patient. And we will refer the patient from higher centres to there.
Suppose there is a patient in Tata Hospital which belongs to, say, Amarnagar district. I will tell him that in Amarnagar district there is a good radiation and chemotherapy facility available. I'm giving you protocol.
Please go there. You are in your home place and you get radiated chemo. There I have got my confidence that if I refer the patient to that centre where a qualified person is available, then I think the treatment will be good.
But if somebody is not available and they want to give treatment, I think that will be a loss to the patient.
So how do we then address this gap? I mean, since... So one is to train people, which is your specialisation.
So I will come to... Before qualification, there is a training required. So if you give training and there are this number of seats available, I'm not worried about qualification.
In Tata Hospital, way back from, say, 2010 onwards, we started fellowships. So suppose you can't do MCH surgical oncology of three years, you can't do DM medical oncology of three years, if you are MD Medicine and MA General Surgery, I will train you for two years, maybe three years. You will become trained and that trained person can definitely give chemotherapy and surgery.
So that's a capacity building and augmenting the capacity of trained human resource available for taking care of all these major cancer cases. So that I have been doing and other centres are also doing. So at a given moment, if I say to you that there are 400 surgical oncologists every year available in the country, but there will be more than 200 who will be not qualified, but trained also available and they will do the equal type of job, but they can't become faculty to train a student.
So they will go to district place, they will start operating on large number of people.
So when you say trained but not qualified, that means they would be trained in general surgery, but not in oncology.
No, after general surgery, that is MS qualification, they will be trained only in surgical oncology. Three years, that is a super speciality training.
Which they may not have right now.
So right now we are doing this fellowship programme, training programme. Suppose in Tata hospital, I have got 24 MCH seats available and I have got 40 people to train. I will take 24 from the NEET.
They will get same kind of training and qualification after examination. And the other 20 will be trained along with them, but they can't appear for exam. I will have my own exam of fellowship and they will be also equally trained minus degree.
So as you look ahead now, as we are trying to address this gap of trained resources, particularly in these 203k key areas, including surgical, medical oncology and then other forms of oncological response, including radiation and so on. Where do you feel we should be focussing most of our energy on and how? As a country.
As a country, we should make comprehensive cancer hospitals available in the government sector. That is number one.
So we have 19 state cancer institutes, 20 tertiary care.
Yes. That was under NCBDCS scheme and all these state cancer institute attached to medical college are now functioning, but they don't have qualified manpower. So there the trained people are working.
And usually it happens there is a sort of apathy on the government side, say from a district hospital or from a medical college. I invite sponsored applications that from medical college every year, I want 20 people to come to Tata for training and they should be employed by them, paid by them. On deputation, they come to Tata and get trained and go back to the same centre.
Government doesn't have that capacity to depute them to Tata hospital because at the same time, they are losing one person from their college or district hospital for training because they have deputed. So that government is not encouraging. And I am of the opinion that from government medical colleges and district hospital, there should be a proper sponsorship programme and they should send to all the available centre across country for training.
That will really give them a kind of a training available at a comprehensive centre. When that type of training is imparted on these people, they will definitely practise the evidence based type of cancer care at district or at a medical college also.
And so this is, let's say the training part. If you were to come to, let's say, retention, I mean, you know, making sure that doctors are working. So what are the other challenges? I mean, not challenges, but what are the pathways?
To retain the best quality of manpower is also a very big challenge because, you know, at the government sector, the same type of salary, which is under six pay or seven pay commission and in the available market in the corporate, it is more than 10 or 20 times that they pay the salary. People will not, but why still at the same seven pay commission, why people are attracted to Tata because they take assistant professor job, then they become professor also. There is a graded promotion.
They have a student, they have a name and they can perform everything. But every year, what I said that every year after five to 10 years, I find that a batch of five, six people, they leave, they join corporate sector. I'm happy because they were trained in Tata Hospital.
They gave their services for 10 years. And now after 10 years of service in Tata Hospital and training, if they're practising at corporate, they will impart the same kind of evidence based cancer care to these patients. They will not have any shortcuts which are related.
OK, they will have money. I'm not angry. But at the same time, I will be very happy that I have trained these people.
Right now, I can give you an example. You name the district and name the district where one of my trained, either surgical, medical or radiation oncologist will be there who was trained in Tata Hospital. And I will be happy that they are practising there.
And I'm very sure that they stick to the protocol guidelines and they are doing ethical practise.
So you're saying that almost 780 districts that you talked about, all districts are covered today or?
No, not covered. So if you consider Rajasthan, then Madhya Pradesh, Bihar, Uttar Pradesh, Uttarakhand, I don't think more than one-fourth districts are covered.
In India?
In India. So people are obviously… In say Andhra and in Tamil Nadu, most of the specialists are available. And in district places, if it is say Coimbatore, Coimbatore is not a metro place, but you will find Coimbatore, at least 10 or 15 good, well-trained surgical and medical oncologists are available and they are attached to big hospitals who are doing, in a public domain, they are doing practise.
And they are still stick to the protocol and ethics. So in such centres, they are available. But if you consider UP, Rajasthan and Uttarakhand and Uttar Pradesh, no, they are not.
Okay. So, you know, let me ask you as we wrap up, if you were to be talking to young doctors today, and I'm sure you do as part of your training, what is the one thing that you tell them? I mean, you know, as to why they should…
You have touched upon a very good thing. So 10 years before, I realised that we have to motivate the MBBS and the PG doctors that they should come and follow. Somebody goes to orthopaedics, somebody goes cardiac, somebody becomes nephrology, somebody wants urology.
But to make them and motivate them towards oncology, I started summer school in oncology, where I used to attract third MBBS student and those who are doing MS or MD second year to come to Tata Hospital. For 10 days, we used to train them right from what is cell and what is cancer to the treatment available. And up to one o'clock, we used to classroom teaching.
And after that, they used to go to department. And I find that after this summer school, number of students opting for oncology career has increased. And large number of students are now going for MCS, surgical oncology, DM, medical, radiation, all they are coming.
So it was my, that time, a big dream. And I ran it for five years. And it was totally free for the student.
Their accommodation, their food, everything was arranged by Tata Hospital. And we had a collaboration with Guy's Hospital, London, where out of these 150 students every year, we used to select five students. And we used to devote them to Guy's Hospital to see what type of care also they're available.
And that was all with our money only. So that was my big aim. First to incentivise that they should take oncology, which is a very intense branch, very dedicated branch, intense branch.
You have to really pour your life into it. Then only you become oncologist. And for next 20 years or 25 years, till you become around 60, 65, you have to practise very ethically.
So that's the hallmark of this training and education, which used to be my passion for last 40 years.
That's a good note to end on. Dr. Sharma, thank you so much for joining.
Thank you very much. Thank you.
