Letter from Mumbai

Why are Teachers Unwilling to Let their Students Learn from Others?

I was invited to deliver a guest lecture in a medical research centre in one of our major cities. The occasion was the inauguration of a workshop on operative neurosurgery. Experts from India and Japan were to demonstrate operations not frequently performed in most of our smaller neurosurgery departments. Young resident doctors and other trainees in neurosurgery were enabled to see the operations being performed in the theatres as well in an auditorium through high-resolution video cameras. When the operation microscope was in use, the images were transmitted directly from the microscope. An expert commentator guided the audience within and outside the theatre. Additional inputs were provided by the surgeon through a microphone under his mask.

Questions were invited from members of the audience during and after the operation.

In addition, there were discussions on a variety of patients. Clinical findings, results of tests, diagnosis, modes of treatment, pros and cons of surgery and steps of the operations were considered in fair detail.

Had I been fifty years younger, I would have given a lot to be able to attend this workshop, spread over 2 days.

Imagine my surprise when, during the inauguration ceremony, the young members of the audience did not exceed 20 on the first day of the workshop, which was a Sunday. The rest of the audience was composed of senior, retired teachers and some members of the diplomatic corps in the city. On the following day, the number of trainees dropped to less than 10. This was the number of the faculty from Japan alone!

The workshop was free of any charges, the organizing institute absorbing the costs. I made it a point to chat with the young doctors and tried to learn from them the reasons for poor attendance.

What I learnt shocked me and will surprise you as well. Teachers from other institutes in the city, instead of encouraging their students and resident doctors to attend this workshop, went out of the way to prohibit them from having anything to do with it. Those postgraduates who decided to disregard this prohibition could do so with impunity on Sunday but had to attend to their duties on Monday with resultant attrition of numbers of learners within the operation theatre and auditorium.

Further questioning led to even greater demoralization. The operations being performed during the workshop were not being performed at all in many of the teaching institutes in the city and no similar workshops had been held in those hospitals.

Why did the teachers in the other institutes not attend the workshop and bring with them their trainees? Much could have been learnt and perhaps they would have been encouraged to undertake similar operations in their own departments.

Alas! I could get no answers to this question.

The Decline of the Essayist in Indian Teaching Institutes

As a medical student and resident surgeon in the Grant Medical College and its attached Sir Jamsetjee Jejeebhoy Hospital, I was taught by my teachers to elicit a detailed history from the patient. We were told to use the acronym ODP (origin, duration and progress of symptoms), which was to be followed by details on the personal habits of the patient, previous illnesses in the patient and illnesses in other members of the family. All this information was to be recorded in considerable detail. Similar details on findings on examination—general and systemic—had to be noted. Finally, each of us had to offer our own differential diagnosis and opinion on one or more likely possibilities of what ailed the patient.

Our teachers painstakingly studied our records and corrected errors, improved our expression and generally ensured that the note on the patient was accurate and readable.

Studying notes written by resident doctors today alarms me and causes concern. Since I am conversant with the nervous system, I study the relevant notes carefully. I often find the resident content with writing: ‘Nervous system (often shortened to CNS): conscious, cooperative.’ There is nothing more even when the presenting symptoms point to disease in the spinal cord or peripheral nerves!

What has brought about this change? Is it the use of using tick marks into printed slots on the case sheet or is it the undue dependence on tests, with consequent atrophy of the clinical senses?

Worse, most case reports at clinical meetings and publications in our journals are dry as dust. There is no sparkle, dash of humour, flash of wit or literary allusion in them. It is probably too much to expect references to relevant medical history—Indian and foreign.

I realize, of course, that time is of the essence, especially when our resident doctors are faced with large numbers of patients and a multitude of tasks but as I hark back to the days when the world was younger, I feel we were similarly placed as regards shortage of time. In some ways we were worse off as we had to perform many of the simple laboratory tests such as examination of the urine and stools, blood counts, blood grouping and studying blood smears for malarial parasites ourselves in what was then termed ‘ward laboratories’. On our ‘emergency days’ we would often work into the middle of the night getting these reports ready for the clinical round the next morning.

Would it be outlandish of me to suggest that our students and residents immerse themselves in the clinical works of such masters as Dr Charles Morehead, Sir William Osler, Sir Henry Head, Sir William Gowers, Dr Oliver Wendell Holmes, Dr Arthur Conan Doyle, Dr Francis Peabody, Dr Atul Gawande and Dr Siddhartha Mukherjee with as much enthusiasm as they study such books as Harrison’s principles of internal medicine? When Dr Siddhartha Mukherjee was asked by an interviewer about how a literary novice, with a full-time job and a young family, teach himself to write so beautifully, he replied: ‘I think the cardinal rule of learning to write is learning to read first. I learned to write by learning to read.’ Dr Mukherjee read everyone from Susan Sontag to Primo Levi and Mary Shelley. I wonder how many of our younger colleagues are familiar with the books written by any of the persons named in this paragraph. Perhaps it would be too much to demand familiarity with the works of Rabindranath Tagore or Bankim Chandra Chatterjee, Amrita Pritam or Premchand let alone Dr Samuel Johnson, Henry David Thoreau, Ralph Waldo Emerson, Richard Steele and Joseph Addison.

While on the subject of written clinical case notes, may I remind our young readers of the crucial role these notes play should the patient’s family decide to sue the doctor or institute in the court of law? Judges pay no attention whatsoever to hearsay. Without exception, courts of law will only consider information that has been put on paper in the official case notes on the patient. If the quality of notes be abysmal and the notes incomplete, the judge may rule in favour of the plaintiff. Besides, only data on official case records can be relied upon in any research study. Lack of availability of valid and accurate data will make it impossible for the budding researcher to publish his findings in any respectable journal.

Paperless Interviews at Nimhans: A Welcome Initiative

The National Institute of Mental Health and Neurological Sciences (NIMHANS) has, for some time now, been conducting its interviews held by the selection committee without the huge bundles of printed and bound volumes accompanying each application.

Candidates for fresh appointments to its staff and those seeking promotions are now required to submit all documents and texts of publications in digital format. These are then loaded on to the computers provided to each member of the selection committee and can be studied before and during the individual interview.

Several advantages have followed this change. Most obvious is the saving on paper and the expenses incurred by each candidate in collating and binding their forms, certificates and reprints of papers into spiral bound volumes. The ability granted to each member of the selection committee to easily move back and forth between details on the forms, certificates, theses and other publications permits them a better understanding of details. Since these computers are also connected to the internet, it is easy to check on the quality of journals in which the candidates’ papers were published (see the next section) and query Uncle Google on the veracity and authenticity of any fact or proposition made by the candidate even as she/he is referring to these in person.

It is possible that other institutions in India are also using this innovation. If so, I am sure our readers would like to learn of their experiences as well.

Predatory Journals

In 2012, Jeffrey Beall of the University of Colorado in Denver sounded a warning, which we are yet to heed. Writing in Nature (2012;489:179), he pointed out that just as the miracle of email was polluted by the advent of spam, that of scholarly open-access journals was vitiated by the development of predatory journals.

Unethical publishers in America, European and Asian countries (including India) sensed an opportunity to make easy money and have flourished beyond their expectations. Preying on young scientists, eager to gain reputation without expending the effort needed to do so, these publishers set up websites resembling those of reputed publishers. They invited and even solicited papers for publication in journals with titles approximating those of old and respected journals. They guaranteed rapid publication for a substantial fee. They used underhand techniques to ensure that the author falling into their trap could not get out of it. One such method was to ensure that the copyright to the paper was signed over to the publisher on submission. Unlike genuine and respected journals, papers published by predatory journals were never reviewed by peers.

Publishers of predatory journals are exultant when researchers and clinicians working in institutes such as the All India Institute of Medical Sciences or NIMHANS send in their papers to them as they can now boast of affiliations with these justly reputed institutes.

Since many such journals are brought out from foreign countries, young Indian researchers are tempted to publish in them, which can then be included under the head ‘Publication in international journals’. The researchers ignore the fact that their work, published in such journals, will scarcely ever be read or referred to.

Selection committees for appointment to the staff of our reputed institutions and those required to select individuals to be given awards and grants need to be on guard against such ‘questionable’ publications. At NIMHANS, thanks to the efforts of Dr Vedantam Rajshekhar, member of the selection committee and professor of neurosurgery at Christian Medical College, Vellore, candidates listing among their publications those in predatory journals are routinely pulled up during the interviews. NIMHANS is taking steps to ensure that such publications will carry negative value during the process of selection.

Two additional suggestions are worthy of consideration by heads of institutions and members of selection and award-giving committees:

1. Instead of requiring long lists of publications and thus encouraging predatory publication, they should insist on the candidate selecting and providing references to and texts of only five publications where they are first or corresponding authors. These five papers, selected by the applicant, would form the basis for assessment of their scientific contributions.
2. All those concerned with shortlisting or selecting candidates must screen the journals in which these papers were published against lists such as are provided at https://predatoryjournals.com/journals/.

Discussing Feature and Documentary Films in Medical Colleges

Pioneering effort in Mumbai by Mr Amrit Gangar and Dr Kartikeya Bhagat

Several years ago these two aficionados who have been studying films for decades decided to stimulate students at the Seth Gordhandas Sunderdas Medical College in Mumbai to watch films and discuss their merits and demerits after each screening.

While their efforts were met with initial enthusiasm by undergraduate and postgraduate students, over time, those attending dwindled to the extent that on one occasion the entire audience in the auditorium consisted of one student, the projectionist and Dr Bhagat!

Since the stars in the heavens appear to be in more favourable positions, they have revived their efforts and are meeting with increasing success.

Mr Gangar started the new series with a thought-provoking interview with Mr Satyajit Ray recorded on film. It included Mr Ray’s views on topics as disparate as what it took to make a remarkable film and how he viewed his own death.

Mr Gangar’s descriptions of his own interactions with the great Bengali maestro added to the understanding the audience gained of the artist and his work.

These were followed by a screening of the entire feature film Ganasatru. You will recall that this film is loosely based on the Norwegian dramatist Henrik Ibsen’s An enemy of the people. I can do no better that quote from Mr Gangar’s introduction to the screening: ‘Ibsen’s play has been transformed by Mr Ray, unlike its treatment by Arthur Miller. The setting is now totally contemporary: 1989, a small town in Bengal with a reputation as a health resort, some way from Kolkata. Ibsen’s Dr Stockman, that obstinate whistle-blower who destroys a comfortable life for the sake of a principle, has become Dr Asok Gupta, the head of a hospital run by a trust established by a local industrialist, Bhargava. Gupta’s brother Nisith is a bigwig, but younger than Asok. He is the head of the hospital committee, and therefore technically his brother’s boss and the head of the committee running the town’s very successful Hindu temple—built at his suggestion with money given by Bhargava, who is both shrewd and pious.

‘In Mr Ray’s hands, instead of spa waters, it is the temple’s water supply that is contaminated—the result of shoddy pipe-laying when the temple was built 10 years previously. Dr Gupta is the first to suspect it: there is an outbreak of jaundice among his patients, most of who happen to live near the temple or regularly visit it. Laboratory tests in Kolkata confirm his suspicions. But there is faith that holy water—charanamrita—in temples just cannot be impure … tension develops …’

The genius of Mr Ray, the simplicity of the narrative and the obvious medical connotations—brought alive by the pure and ethical behaviour of Dr Asok Gupta despite catastrophic consequences for himself and his loved ones made a deep impression on the audience.

We look forward to more such feasts for perception, reason and the soul from Mr Gangar and Dr Bhagat.