OF DOCTORS IN INDIA: THEIR GESTATION, BIRTH, GROWTH, MATURATION, AND MORE

‘The whole life of the individual is nothing but the process of giving birth to himself; indeed, we should be fully born when we die—although it is the tragic fate of most individuals to die before they are born.’

–Erich Fromm¹

This somewhat delayed letter and reflection was triggered by my attaining the milestone of turning 60 earlier this year. I, too, like the would-be doctors of the present, entered medical school at the young age of 17, still struggling with the crises of adolescence, and was thrust into the role of a medical student with all its trials and tribulations. Looking back at the period of 43 years since I entered medical school, I look at being a doctor not as an outcome of our training and education but more of a process and a journey that is a bit like life itself, with the same parallels of the life cycle of humans—gestation, birth, growth, maturation, and eventual dissolution.

Doctors, like other professionals, are transformed from lay people into members of a profession with its requirements for scientific knowledge, technical skills, and norms of professional behaviour and conduct. For the humans of yore, becoming a doctor was enough but now with the growth of the specialties and their prestige, changing expectations of the patients especially those of the higher income groups, and promises of better prospects, medical students in India aspire to further periods of transformation into a specialist, and ultimately for many as a sub-specialist (in India the moniker is super-specialist). All these transformations occur in medical colleges and institutions that, in the USA, are referred to as medical schools, in recognition of the fact that, while we enter them as nearly adults, we have only the most rudimentary ideas about the workings of the human body and mind in health and disease. We have to be literally schooled in the basic knowledge, skills, and attitudes of being a doctor. Specialist and sub-specialist trainings also assume that the trainee is a novice and a neophyte to be moulded to suit the form and function required in the field.

The gestation and later birth, as they occur in India, span 9 semesters, akin to the 9 months of human gestation. One could compare the 3 trimesters of gestation to the I MBBS, II MBBS, and III MBBS. The first trimester of medical school is a crucial developmental period, as at the end of it, an amorphous individual becomes a foetus. Earlier, this trimester was 1.5 years long, with painful details of anatomy and pathways of metabolism to be learnt, but of late this trimester has been shortened to 1 year, which has its pros and cons. The rates of failures (threatened abortion) in the first trimester were earlier high, but the incidence of threatened abortion has declined considerably of late. The main danger in the first trimester is also of teratogenic influences, and many permanently malformed doctors have a history of exposure to subtle but malign influences in the environment of their medical school. The second trimester is the phase of rapid growth and development. Also, the period when students assume the recognisable form of a doctor in their dress, visit the hospital, and make their initial forays into clinical skills, which are perceived by the alma mater as ‘quickening’. This transition to clinical years also marks a transition in some from not only pre-clinical to clinical, but in the words of celebrated physician-author Abraham Verghese, ‘from pre-cynical to cynical’,² to where their ‘sense of idealism and empathy can take a hit, but can be resurrected by role models’. Finally comes the final trimester of maturation, in which the dominant concern is the painful process of birth ahead. If the process of growth and development is ok, the child is born at term, or they may be born with intrauterine growth retardation, or may require assisted delivery after a prolonged process of birth. In the days of the past, the alma mater had modest expectations of the newborn—it was ok if there was a living, breathing individual with the normal complements of eyes, ears, hands and feet, brains and heart, who could be trained. However, according to current expectations of India’s undergraduate curriculum, the Indian medical graduate should not only attempt to fulfil national and institutional goals but also be a complete finished product with the following attributes, ‘A clinician who understands and provides preventive, promotive, curative, palliative and holistic care with compassion; Leader and member of the health care team and system with capabilities to collect, analyse, synthesize and communicate health data appro-priately; Communicator with patients, families, colleagues and community; Lifelong learner committed to continuous improvement of skills and knowledge. A professional who is committed to excellence, is ethical, responsive, and account-able to patients, community, and profession.’³ That as an expectation, sounds less appropriate for a freshly minted graduate than for a goal for a lifetime in the profession.

At birth, the doctors emerge as interns, now expected to be part of a clinical team, even if they see themselves and others as both helpless and useless. However, exposure to patients in a close, sustained way as part of a medical care team is a transformative experience I had as an intern, and I observe in the interns I see. There is a different look on their faces, a different tilt in their gait, and overall, a sense of purpose—that is, if they live in the present and are not occupied with the thoughts and nightmares of the impending National Eligibility cum Entrance Test (Postgraduate); the NEET-PG. The latter could be labelled ‘NEET-zombies’. Sometimes this transformation is most evident and interesting in those who appeared disinterested in their undergraduate days and were middling in academics. Although they are seen as undifferentiated doctors doing scut work, a lot is going on in their minds that we don’t know or don’t tap into. There is a distinguished list of undergraduates and interns who have made important contributions to medical research: from the discovery of insulin (Charles Best), performing cardiac catheterizations for the first time (Werner Forsmann), the discovery of heparin (Maclean), and the discovery of the connection between streptococcal sore throat and rheumatic fever (Alvin Coburn).

For those who enter postgraduate training, an even more intense experience awaits, with individual responsibilities for patients being assumed for the first time, and as an infantry soldier in a medical unit, of being on the firing line for 3 years in wards, theatres, departments, seminars, etc. The lifecycle approach in health teaches us that early-life influences, especially in the first few years, are a determinant of long-term health and disease. In our medical colleges, it is a moot point whether we have an adequate sense of nurturing students’ mental growth and development during their residency days. The problem is that many of us, the faculty, have not really been exposed to a positive environment ourselves in those formative years. I had a very enriching educational experience at AIIMS, New Delhi during my residency years under many stalwarts of Indian medicine. However, I really experienced mentorship only in my 40s, with Dr Dick Menzies, when I got the opportunity to train in epidemiology at McGill University in Canada. I am truly grateful for that experience and to Madhukar Pai, a great mentor himself, who provided generous support for my training. If paediatricians are sensitive to the long-term impact of child abuse, we should be sensitive to the verbal or psychological mistreatment of our trainees, who are in the process of birth and growth under our care, too. Unfortunately, many of us have either normalized this phenomenon or embedded those patterns in our own behaviour, and, as I have realized personally, can seamlessly transition from being a victim to, at times, a perpetrator.

Following birth, the other stages of growth, reproduction, and maturation are specialist or sub-specialist training (in that order). As we grow in our skills and knowledge, we begin to acquire a reputation among our patients, then our juniors, and finally our peers. In terms of reproduction and creating a second generation of doctors, some doctors encourage, inspire, or coerce their own progeny into the profession. Others (like me) whose biological children do not take up their profession can hope to have instead some adopted professional sons and daughters.

In terms of opportunities for maturation as doctors and human beings, it has been said that doctors have a front-row seat to the drama of life. A life in medicine offers us endless opportunities for life-shaping experiences with thousands of people, who often exhibit heroism and resilience in the face of disease and death. Reflecting on our experiences can provide rich perspectives and insights into life. In a profession that constantly changes its practice, we also need to act as if we were still sitting in the front row of our lecture halls. The old man of medicine, Hippocrates, also wrote in this vein, ‘Ars Longa, Vita Brevis’, or simply, life is too short to acquire the art/science of medicine. I have personally found this aspect of our profession—the need for continual reflection of our human experiences and the need for self-directed learning, the most satisfying and fascinating.

I would like to take a broader philosophical view of our lives as human beings who have become doctors. Do we, as doctors, possessors of esoteric knowledge and remarkable skills, really experience or achieve what is to be experienced and achieved, in the only life, as a person and professional, that we have on this planet? Earlier, our theories of growth and development were limited to the period of childhood and adolescence. Now it is recognized that these processes continue throughout life, as Fromm’s quote suggests. Among the models of adult development, the one proposed by the psychologist Robert Kegan, which builds on the work of others, including Maslow and Erikson, can be applied to the process of maturation or professional identity formation of doctors.^4,5 This proposes a continuum of development from stage 1 (impulsive mind) to stage 2 (imperial mind) where these stages are focused on individual needs and aspirations, which is followed by stage 3 (socialised mind) that conforms to the norms and expectations of the group and lives by those values, perhaps for example, as a good member of the local professional body. Stage 4 (self-authoring mind) may involve deliberation over issues and a comfort with their own values, which may contrast with those of their peers. Finally in stage 5 (self-transforming mind) the person has achieved self-transcendence and connects with something larger than oneself.

I now come to the final stage of dealing with retirement, ageing, and dissolution. In academia, one can now work till 70 years of age, and in practice, till any age that our patients may accept. At some time in our lives, we who identify so closely with our professional identities will, willingly or unwillingly, face the human predicament of old age, disease, decline, and death, and accept the impermanence of things, responding with equanimity and letting go. On a positive note, Charles Handy, the management thinker, has talked of a second curve of growth and development as we reach the peak in one, and these are now also called ‘encore’ careers.⁶ Dr Sunil Pandya and Dr M.S. Valiathan, the famous cardiac surgeon and developer of the Sree Chitra valve, are recent examples of meaningful encore careers. In his last years in Seth G.S. Medical College and K.E.M. Hospital, Dr Pandya got involved in issues of medical ethics and contributed to the founding and growth of the Indian Journal of Medical Ethics, a remarkable open-access journal, now respected the world over. Later, he devoted himself to writing and researching the history of medicine in India and elsewhere. Dr Pandya authored the memorable Letter from Mumbai column in this Journal and continued to contribute articles until his passing away last year.⁷ Dr Valiathan became an explorer and chronicler of Ayurveda, leaving us a legacy of 5 scholarly books on Ayurveda and research.^8,9 Both of them are exemplars of a rich and varied life lived to the full and with purpose.

There are, however, also exemplars whose passion for their core career never ends—Dr Farokh E. Udwadia continues to direct the intensive care unit at Breach Candy Hospital in Mumbai in his nineties, while also penning books, including a recent full-length play on Albert Schweitzer.¹⁰ Dr Michael DeBakey continued to operate until he was 90 and travelled across the world to lecture even later. Dr Denis Mitchison, the famous mycobacteriologist, finally retired at 95. Dr Shigeaki Hinohara, the famous Japanese physician whose work contributed to Japanese longevity, continued to have fun and an active social life, in addition to seeing patients, a few months before his death at 105.¹¹ Still, the prize for the greatest longevity and productivity among doctors should perhaps go to Dr Phillip D’Arcy Hart, a pioneering researcher involved in the first randomized trial of streptomycin in tuberculosis in 1948, who published a seminal paper in 1971,¹² and was still writing in journals past 100 years of age. ¹³ Born in 1900, he died in 2006.

My own thoughts on the final exit echo those of Woody Allen: ‘I am not afraid to die. I just don’t want to be there when it happens.’¹⁴ I started this letter on a personal note, and I will end on one too. After nearly 10 years at Yenepoya Medical College, I moved to a position at the Department of Medicine at Kasturba Medical College (KMC), also in Mangalore. I enjoyed my tenure at Yenepoya tremendously, seeing patients, teaching students and residents, conducting tuberculosis research, and interacting with colleagues. However, at 60, I felt I should stop being sedentary and step outside my comfort zone. At KMC, I am part of the clinical team serving the 175-year-old Wenlock District Hospital under a decades-old agreement. It has been an interesting and educational experience over the past few months, and I will be writing about it in the letters to come.