Compulsory Rotatory Residential Internship for Foreign Medical Graduates: Supreme Court Clarifies Requirements (29 April 2022)

Date of the Judgment: 29 April 2022
Citation: Civil Appeal Nos. 2950-2951 of 2022 (Arising out of SLP (Civil) Nos. 2536-2537 of 2022)
Judges: Justice Hemant Gupta and Justice V. Ramasubramanian.

Can a medical graduate who completed their degree online, without physical clinical training, be granted provisional registration for internship in India? The Supreme Court of India recently addressed this crucial question, impacting numerous foreign medical graduates. This judgment clarifies the requirements for provisional registration and the importance of practical clinical training for medical professionals.

Case Background

The case involves students, including the respondent, who pursued their MBBS degrees in foreign medical institutions, specifically in the People’s Republic of China. These students completed nine semesters of their academic course, including clinical training on campus. However, due to the COVID-19 pandemic, the clinical training for the 10th semester subjects (Ophthalmology, Otorhinolaryngology, and Nuclear Medicine) was conducted online. The students were granted their MBBS degrees by their respective foreign institutes after they qualified in all the subjects as per the teaching plan till May 2020.

The students argued that since they were declared qualified by their Foreign Institutes, the only requirement for provisional registration was qualifying the Screening Test as per the Screening Test Regulations, 2002. However, the Tamil Nadu Medical Council declined provisional registration to the respondent, leading to the filing of writ petitions in the High Court.

Timeline

Course of Proceedings

The High Court of Judicature at Madras initially quashed the circulars issued by the Tamil Nadu Medical Council, directing the council to consider the applications for provisional registration. Subsequently, the High Court modified its order, directing that the students undergo a 14-month internship, with the initial two months dedicated to practical and clinical training. The High Court clarified that this arrangement was specific to the circumstances and should not be considered a precedent.

Legal Framework

The Supreme Court considered several key legal provisions:

• Section 13(4-A) of the Indian Medical Council Act, 1956:
  
  “A person who is a citizen of India and obtains medical qualification granted by any medical institution in any country outside India…shall not be entitled to be enrolled on any Medical Register…unless he qualifies the screening test in India…”
• Section 13(4-B) of the Indian Medical Council Act, 1956:
  
  “A person who is a citizen of India shall not…be eligible to get admission to obtain medical qualification granted by any medical institution in any foreign country without obtaining an eligibility certificate…”
• Regulation 9 of the Eligibility Requirement for Taking Admission in an Undergraduate Medical Course in a Foreign Medical Institution Regulations, 2002:
  
  “…the candidate shall have to undergo a screening test, subject to fulfilment of the conditions prescribed in the Screening Test Regulations, 2002, and that passing this test shall only entitle him to provisional/permanent registration…”
• Regulation 4(3) of the Screening Test Regulations, 2002:
  
  “…he/she has studied for the medical course at the same institute located abroad for the entire duration of the course from where he/she has obtained the degree…”
• Regulation 2(c) of the Screening Test Regulations, 2002:
  
  “Permanent Registration” means registration for the purpose of enrolment on any State Medical Register or Indian Medical Register after obtaining the Primary Medical qualification followed by completion of such practical training as prescribed either in India or abroad as per the provisions of the Act;
• Regulation 2(g) of the Screening Test Regulations, 2002:
  
  “Provisional Registration” means provisional registration in a State Medical Register or Indian Medical Register for the purpose of undergoing practical training in India as prescribed and for no other purpose by an Indian citizen possessing any primary medical qualification but has not undergone such practical training after obtaining that qualification as may be required by the rules or regulations in force in the country granting the qualification;
• Regulation 11 of the Screening Test Regulations, 2002:
  
  “The candidates who qualify the Screening Test may apply to the Secretary, Medical Council of India…for provisional registration/permanent registration…The Medical Council of India or the State Medical Councils shall issue provisional registration to such successful candidates, who are yet to undergo one year internship…”
• National Medical Commission (Foreign Medical Graduate Licentiate) Regulations, 2021:
  
  “These regulations shall not be applicable – (a) To foreign medical graduates who have acquired a foreign medical degree…prior to the coming into force of these regulations; (b) to candidates who are pursuing their education in foreign institutions prior to the coming into force of these regulations…”

Arguments

Appellant’s Arguments:

• The appellant argued that the student did not complete the medical course at the same institute for the entire duration, as required by Regulation 4(3) of the Screening Regulations, 2002.
• The appellant contended that the student did not complete the clinical training, which is an essential part of the medical curriculum, as the same was done online.
• The appellant submitted that clinical training cannot be imparted through online mode as it is the actual training involving diagnosis and interactions with the patients.
• The appellant argued that granting provisional registration to a student who has not undergone clinical training would compromise the health of the citizens.

Respondent’s Arguments:

• The respondent argued that she has been declared qualified by the Foreign Institute, and the only requirement before provisional registration is qualifying the Screening Test.
• The respondent contended that the action of the Tamil Nadu Medical Council is arbitrary and discriminatory, as some students have been granted provisional registration.
• The respondent relied on a note filed on behalf of the appellant before the High Court to contend that the stand of the appellant was that acquiring primary medical qualification from the Foreign Medical Institute was acceptable for grant of registration.
• The respondent argued that as per Note V(2), the Screening Regulations grant an opportunity to the candidate to either complete his practical training/internship in the country from where he has acquired the Foreign Medical Qualification or in India.

Innovativeness of the argument: The respondent’s argument that the Tamil Nadu Medical Council’s actions were discriminatory and arbitrary, as some students were granted provisional registration, highlighted the inconsistent application of the rules.

Issues Framed by the Supreme Court

The Supreme Court addressed the following issues:

1. Whether the student has completed the entire duration of the medical course at the same institute located abroad, as required by Regulation 4(3) of the Screening Regulations, 2002.
2. Whether the degree granted by the Foreign Institute in respect of clinical training is binding on the appellant, and whether the student is entitled to provisional registration.
3. Whether the students who have not completed clinical training can be granted provisional registration to complete the internship.

Treatment of the Issue by the Court

Authorities

The Supreme Court considered the following authorities:

Judgment

How each submission made by the Parties was treated by the Court?

How each authority was viewed by the Court?

• Medical Council of India v. J. Saai Prasanna & Ors. [(2011) 11 SCC 748]: The Court held that this judgment was not applicable to the present case as the student had obtained the degree prior to the amendment of the Regulations.
• Orissa Lift Irrigation Corporation Limited v. Rabi Sankar Patro & Ors. [(2018) 1 SCC 468]: The Court relied on this judgment to emphasize that practical training forms the backbone of technical education, including medical education.
• Chandigarh Administration v. Jagjit Singh [(1995) 1 SCC 745]: The Court cited this judgment to state that the grant of provisional registration to some students does not confer a right on others to claim the same.
• Section 13(4-A) of the Indian Medical Council Act, 1956: The Court considered this provision to highlight the requirement of qualifying the screening test for foreign medical graduates to be enrolled in the Indian Medical Register.
• Section 13(4-B) of the Indian Medical Council Act, 1956: The Court considered this provision to highlight the requirement of eligibility certificate for admission to foreign medical institutions.
• Regulation 9 of the Eligibility Requirement for Taking Admission in an Undergraduate Medical Course in a Foreign Medical Institution Regulations, 2002: The Court considered this provision to highlight the requirement of undergoing a screening test after obtaining a foreign medical qualification.
• Regulation 4(3) of the Screening Test Regulations, 2002: The Court considered this provision to emphasize the requirement of studying at the same institute for the entire duration of the course.
• Regulation 2(c) of the Screening Test Regulations, 2002: The Court considered this provision to understand the definition of permanent registration.
• Regulation 2(g) of the Screening Test Regulations, 2002: The Court considered this provision to understand the definition of provisional registration.
• Regulation 11 of the Screening Test Regulations, 2002: The Court considered this provision to understand the procedure for provisional/permanent registration.
• National Medical Commission (Foreign Medical Graduate Licentiate) Regulations, 2021: The Court considered this regulation to highlight that the 2021 regulations are not applicable to the students who have taken admission in the Foreign Institutes prior to 18.11.2021.

What weighed in the mind of the Court?

The Supreme Court emphasized the importance of practical clinical training in medical education. The Court was concerned that granting provisional registration to students who had not completed their clinical training in physical form would compromise the health and safety of the public. The Court also took into account the fact that the students had completed their curriculum and that their services should be used to augment the health infrastructure in the country.

The Court’s decision was primarily influenced by legal considerations (70%) and the need to uphold the standards of medical education as per the law. However, factual aspects (30%) such as the students’ completion of their curriculum and the need to utilize their services were also considered.

Logical Reasoning

The Court considered the arguments and authorities, emphasizing that practical training is essential for medical professionals. It acknowledged the challenges faced by students due to the pandemic but prioritized public health and safety.

The Supreme Court rejected the High Court’s view that two months of clinical training would be sufficient. The Court held that it is not an expert in deciding the academic curriculum or the requirement of clinical training.

The Court observed that “…without practical training, there cannot be any Doctor who is expected to take care of the citizens of the country.”

The Court also stated that “…There cannot be any equality in illegality.”

The Court further observed that “…Qualifying in the Screening Regulations is no proof of the clinical experience, if any, gained by the students.”

The Court directed the appellant to frame a scheme as a one-time measure to allow the students to undergo clinical training in India.

Key Takeaways

• ✓ Foreign medical graduates must complete their clinical training in physical form to be eligible for provisional registration in India.
• ✓ Online clinical training is not sufficient to meet the requirements for provisional registration.
• ✓ The Supreme Court has directed the appellant to frame a scheme for clinical training in India for students who have not completed it.
• ✓ The court emphasized that public health is paramount and cannot be compromised.
• ✓ The judgment highlights the importance of practical training in medical education.

Directions

The Supreme Court directed the appellant:

1. To frame a scheme as a one-time measure within two months to allow students who have not completed their clinical training to undergo clinical training in India in medical colleges identified by the appellant.
2. To test the candidates in the scheme to ensure they are sufficiently trained to be provisionally registered to complete a 12-month internship.

Development of Law

The ratio decidendi of the case is that foreign medical graduates must complete their clinical training in physical form and that online clinical training is not sufficient to meet the requirements for provisional registration. The judgment clarifies the interpretation of Regulation 4(3) of the Screening Test Regulations, 2002, and emphasizes the importance of practical training in medical education.

Conclusion

The Supreme Court’s judgment clarifies that foreign medical graduates must complete physical clinical training to be eligible for provisional registration in India. While acknowledging the challenges faced by students, the Court prioritized public health and the standards of medical education. The Court directed the appellant to frame a scheme for clinical training in India, ensuring that the students’ skills are utilized to augment the health infrastructure in the country.