Letter from Mumbai

Medical Students: Their Hopes and Priorities

A recent question and answers to it in QUORA (https:// www.quora.com) caught my attention.

The question was: ‘What’s wrong with medical students nowadays?'

Dr Aheli Bal from Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry provided an answer.

The practice of seeking tuitions outside the teaching institute, initiated in the latter years in school, intensifies in medical college. (In Mumbai, attempts at getting students to attend events in the humanities must take this into consideration. If the events are held during their hours of tuition, an almost empty hall will greet the speaker or performer.)

Dr Bal tells us that the priority for the undergraduate medical student is NOT learning medicine—at the bedside, in clinics, in wards or even in lecture theatres. It is ‘cracking the postgraduate entrance’.

Teaching by professors and others in the medical college aims at imparting knowledge and skills that will enable the student to treat patients. Notes offered and tips given in coaching classes help obtain more marks. Ergo, coaching classes triumph over whatever is on offer in the medical college.

Evidently, much has changed since the prehistoric times when I was a medical student.

In response to Dr Bal’s observations, Dr Sandeep Das pointed out that one reason that teaching in the medical college was devalued was the disinterest shown by its teaching staff. ‘Most of the teachers and professors in my college … are least enthusiastic to teach students. Most of their time is spent on showing slides, hardly explaining one or two of them, which (made the presentation) incomprehensible.' On the other hand, in the coaching classes attended by him, ‘almost all the teachers were enthusiastic, teaching us actively while helping us remember facts which we wouldn’t have considered important. In fact, part of my understanding the anatomy of the brain and the head and neck was because of the coaching classes (and also because of the dissection period, which I used to love), and less because of the mundane teaching in our college.'

That these are not isolated experiences is borne by an email sent by a resident in cardiology in a teaching hospital in Mumbai to a senior physician.

I feel sad that inspite of all efforts by young medical students and resident doctors to learn, our generation has suffered an almost total lack of mentorship. Most of my colleagues don’t even know what mentor means.

There is almost nobody to inspire our generation in medical colleges.

Most teachers leave the institutions after spending a few hours in order to attend to their private practice. I see my teachers interested only when there is a fascinating case for interventional therapy. They prescribe costly drugs after attending conferences sponsored by pharma and device companies.

Most teachers have sent their children to medical schools in the USA as they have already predicted that things are going to be worse day by day.

Whoever is left for teaching is doing his job out of some compulsion or waiting for retirement.

This is a most difficult time to get trained in medicine and practise in the current hostile environment in India.

I don’t see any teaching faculty from MBBS to DM whom I would like as my role model.

I also cannot expect any kind of research or ground-breaking invention from our generation as my teachers neither carry out such studies nor guide us into doing research.

Ask any resident or teacher what was the last original research paper they have read completely? You will get your answer.

Leave alone research, I am scared to go to any of my teachers if I have any medical ailment myself.

When will your generation wake up to save medical education and future of heath care in India. Why should our generation be victimized?

He also referred to coaching classes

I find it sad that medical graduates have to attend coaching classes.

Private coaching classes are arranging seminars in medical colleges and nobody cares. What a shame!

The senior teacher to whom he had addressed his email had to confess:

You are, unfortunately, right.

What does one do under these circumstances?

You can, as you have done in your email, complain and grumble, attack earlier generations, curse those in medical councils and the government who have let us down so badly.

I am afraid this will get you nowhere.

The other option is to triumph over circumstances, be an outstanding student and resident despite difficulties and obstacles and then show by example that it is possible to remain ethical, honest and sincere and yet lead a modestly successful life.

In the process, you will teach others—not by lecturing to them, but by showing how you have triumphed over odds. If you do not struggle, change for the better will remain a mere dream.

But even as he wrote this, the teacher realized that this young mind may not find the responsesatisfactory.

Dr Badakere C. Rao

Dr Rao of Bengaluru is a seer not adequately recognized outside his own state.

He has chosen to be a family physician and has served his patients and their families for over 40 years. A respected colleague in Bengaluru tells me that Dr Rao ‘is one of the best physicians I have ever come across’.

Dr Rao is blessed with deep moral insight. Since this is coupled with humility of high order, many of us have been deprived of the opportunity to learn from him.

His familiarity with the writings of Hippocrates, Osler, Shelley, Matthew Arnold, Ralph Waldo Emerson, the Dalai Lama, Swami Nithyananda, Gerald Durrell, Plum Wodehouse and the bird- lover T.N.A. Perumal inspire respect.

He informed me that Dr M.K. Mani is one of his mentors. In turn, I have learnt from Dr Jaya Bajaj, scientific chairperson for the 4th National Conference on Family Medicine and Primary Care: ‘Dr B.C. Rao has been our mentor.' And so, the virtuous cycle continues to cast its beneficial spell.

I am trying to learn more about the man and his work but would like to present to you whatever I have uncovered in the hope that you will also benefit from what I am learning.

Apart from treating his patients with expertise, compassion and empathy, Dr Rao does his best to educate younger family doctors in Bengaluru. He plays golf twice a week and has a current handicap of 16. (Since I am an ignoramus on golf—as on many other subjects—I had to make enquiries before learning that a golfer with a handicap between 10 and 18 is a skilled player with a moderate handicap.) I am also cheered by the fact that he is fond of studying birds and the lives of plants.

We are fortunate that he is fond of writing. Some of his essays can be found on his blog site: http://badakerecrao.blogspot.com/ 2007/ The blog appears to stop at 2016 but he continues to inform, educate and, at times, amuse right up this date.

He has other achievements to his credit. He set up a study group of general physicians in Bengaluru. Professional bodies such as the Indian Medical Association profess to promote learning but end up catering to politically powerful individuals and the interests of the sponsors of meetings—usually from the pharmaceutical companies.

Dr Rao describes his initial experiences as he set about trying to form a group dedicated only to learning:

My practice those days was semi-urban, though today it is fully urban and, in the vicinity, there were four general practitioners [GP], two of them senior to me. I felt I should moot the idea to them. The first worthy I went to thought I was a patient and I could see the disappointment on his face when he came to know that I am a fellow GP and possibly a competitor. He was polite but dismissive of the idea and told me to my face that he gets enough updates from pharma company representatives. I later came to know that he never attends any professional meetings but still was quite successful and no wonder he felt mine was a wasteful venture. The other senior was also lukewarm to the idea and felt he may not be able to attend given his busy schedule.

The other two agreed and we set up a meeting at my home. For want of an appropriate name we called it Doctors ' club.

Within a few years the club grew to 15 members who lived in different parts of the city. We decided to put a cap at 15 as we found it difficult to host more than this number in our homes. From the beginning we were clear—the meeting will be in our homes and the expenses will be borne by the member doctor and the hostess and no outside agency will be involved. As the meeting is held on Sunday afternoons, once a month, followed by high tea, alcohol does not come into the picture.

Did this experiment work?

This monthly activity has led this group of doctors to become good family physicians and I suspect their rate of referrals and needing specialist help is far less than others. It has fostered friendship based on respect and affection to each other and their families.

More recently, he has published a paper enshrining the principles that have guided his general practice and lessons learnt over the decades (Rao and Prasad 2018^[1]). I hope that like me, you will find the case studies fascinating.

Readers of this Journal will be pleased to learn of how he studies each issue as it reaches him.

I am a regular reader of NMJI and I read the journal from the back to front. There are a few reasons why I do this. The front-page articles and papers are often full of statistics and other details which my old [grey] brain refuses to understand. In these, I end up reading the introduction and conclusion. Whereas in the back pages I find material that is more interesting and easier to understand and thus hold my undivided attention. These pages also cover a wider range of topics.

Professor Mani’s Letter from Chennai is one such and those of us who worry about healthcare delivery and the related issues can easily understand and share his concerns.

Wise, But Unheeded Suggestions From a Retired Dean of the L.T.M.G. Sion Medical College and Hospital

Dr Sadanand Nadkarni is a modest and thoughtful surgeon. He was not a flamboyant Dean, preferring to go about his work quietly but effectively.

Speaking of the needs in the field of medical education, he pointed out that ‘the Indian healthcare system is a mall, not a shop. It is an industry for the repair and maintenance of human beings.'

He has made excellent suggestions to the powers-that-be in the Municipal Corporation of Greater Mumbai (that runs three public sector teaching hospitals and several other hospitals and clinics in Mumbai).

I am referring here to just three of them.

1. The average Mumbaikar (the local term to denote a citizen of this megalopolis) grumbles all the time about the terrible overcrowding in the hospitals run by government and the municipality. The mere seeking of a diagnosis and advice regarding treatment of an ailment can cost the average patient and his family an entire day—with attendant loss of that day’s earnings.

Dr Nadkarni advocates decongesting outpatient clinics by having on the premises of each teaching hospital a primary health centre manned by family physicians. This centre would deal with simple ailments from diagnosis to treatment. The load on the main clinics will be automatically reduced. No patient will be seen in the principal clinics unless (s)he has been referred by the clinicians at the primary health centre.

2. From the inception of these hospitals it has been the practice to make a single unit responsible for outpatient service and emergency admissions each day. This casts a tremendous burden on the resident staff. No sooner have they seen the final outpatients, often around 2 p.m., than they need to rush to attend to the seriously ill patients admitted while they were in the outpatient clinic. They are often toiling into the wee hours of the night examining and writing up the case notes of the ‘cold’ admissions and, simultaneously, dealing with the emergencies.

Dr Nadkarni has unsuccessfully advocated having a separate unit dealing with outpatients and the ‘cold’ admissions and another unit dealing with emergencies. This would be to the advantage of both patients and physicians.

3. He has long advocated a common entrance test for the private and public sector medical colleges in each state. Such a practice would ensure that each college received meritorious candidates. This is not a step welcomed by the politicians who own and run private medical colleges as it would take away the need for parents to pay the obscenely high admission and annual fees for their children. Obviously, the quality of doctors emerging from their institutions is of little value.