Training abroad, especially in the developed Western  hemisphere, is generally seen as a desirable adjunct to qualifications obtained in India. Dr Bernstein, who offers a fellowship in neurosurgery, identifies certain areas of concern (1).  For one, the training may be inappropriate in the country from which the candidate hails. Second, the candidate may be tempted to stay on in the developed West, and this would be a loss for the home country. Finally, the candidate may be abused by his supervisor. How relevant are these concerns in relation to India? To understand this we must first look at some of the characteristics of the Indian medical care system.

Medical care in India
A striking feature of the medical care system in India is the apparent lack of planning. There is no clear perspective on the medical care needs of the Indian population. The Shrivastav committee on medical manpower submitted its recommendations which were accepted in 1977, but these were never implemented and they are now out of date. In the recent past, the government has planned by default. In other words, by failure of regulation, it has permitted private interests in medical education to offer those courses which are considered to be 'in demand'. The courses that are in demand, as dictated by the market, are those which are most lucrative in the private sector. Thus we find that at present, radiology, orthopaedic surgery, cardiology and cardiac surgery are most sought after.
Another striking feature of the Indian medical care system is the lack of scope for career planning for most doctors. This is a result of the absence of a systematic medical care system. The uneasy coexistence of a grossly under-funded, poorly equipped and overloaded public medical system, alongside a poorly regulated private medical system, has given rise to many unhealthy practices.
Most doctors, having completed their basic medical education, try to acquire a specialist qualification. Having acquired this qualification, they must choose one of two options. If they choose the public sector, there is a great likelihood that they may not be able to utilise their skills due to lack of infrastructure or deliberate hurdles by the medical bureaucracy. If they choose the private sector, they will have to compete for the limited number of patients who can pay for private care. In today's world, it is a fact that as the skills required increase, so too do the technology and cost.
Therefore the reality in India today is that the government has not identified areas of shortage in medical manpower and offered incentives to doctors to acquire the required qualifications. When a doctor seeks a foreign fellowship, it is a personal decision and the fellowship is often obtained by strenuous personal effort. It is highly unlikely therefore; that a doctor will apply for a fellowship without an idea of what he/she is going to do with the skills obtained. We must remember that sometimes, the advantages are intangible. In India, the very fact that you have trained abroad adds prestige to your resume and this is reward enough for many.

The value of fellowships
So what does all this add up to? Regarding the problem of  appropriate training, it means that, by and large, the candidates have reassured themselves on this. If they are in the public sector they will try to ensure that they get the requisite infrastructural support. If they are in the private sector, most probably they are attempting to get a skill that will give them an advantage in the marketplace of private medicine in India, a unique selling point. As one doctor told me with disarming candour, "We always have to learn something new to stay ahead."
What about the so-called brain-drain?  This may cause concern if there are large vacancies in the public medical system due to migration of doctors. In India, this is not the case. There are too many doctors applying for jobs in the public system. The vacancies that do exist are in places nobody wants to live in, a situation found throughout the world, even in the most developed countries. When a society - as represented by its government - is not interested in the skills that an individual possesses, I see no problem in the person using it where they are appreciated. In a larger sense, I think everyone should have a right to choose where he or she lives. Also, using your skills for the welfare of humankind is all that is required. Forcing a person to work in a particular country is a narrow kind of nationalism. Abuse by a supervisor is hardly important at this level. The fellows can simply quit if they find the situation intolerable.
Overall, fellowships are a wonderful way to acquire not only skills but friends and mentors. The exposure they afford to a different way of doing things, a different culture, a different people, is usually a tremendously positive influence. People like Dr Bernstein who take care to ensure that fellows from the less developed world are also selected are doing a lot for the welfare of humankind. May their tribe increase.