So, I have been meaning to blog for a while now, but as all my online blog-ey friends know, I have been suffering from a massive attack of Bloggers’ Block. However, I recently got the inspiration to write again because of a recent article I read in the massively popular Anandabazar Patrika, titled মেধা থাকলেই ভাল ডাক্তার হয় না (only merit does not a good doctor make). The article is written by a well respected physician, and I must say, it is brilliantly written, and sheds a lot of light on what is wrong with the Indian medical education and the system as a whole. Unfortunately, it takes to a lot of generalizations, which, simply stated, are inaccurate and cast the entire profession in a poor light. I shall try to draft a few responses to the “allegations” and tinted as they are with my own bias, I reason if the author of the article has a right to a biased assessment that gets published in an extremely widely read daily, I have the same rights when it comes to writing a blog post on my own blog!
So, yes, back to the article, as I was saying. If you can read Bangla, please take a look at the linked article and read it for yourself. I reiterate it is a fantastic read, extremely well-written, and if you’re judging based on eloquence, I shall lose, so you might as well stop reading here! Plus, this is going to be a long, rambling post, so you might as well shift to the TL;DR version in the last paragraph if you’re not up for a long and slow read.
The author laments the rise of a “goal oriented” entrance examination system which guards the hallowed pantheons of medical education. He mistakenly equates the fact that the medical entrance examination system (and the education system as a whole) is faulty and places the onus of responsibility on the students. No, he does not lash out at his peers, who, in the board rooms of their air-conditioned ivory towers are so far removed from the reality that they do not even realize the ridiculousness of the examination system that they have deployed.
The author lampoons the typical middle-class Bangali family for going beyond their means to find the way to this Nirvana of a medical career. But let me just ask this: why place the blame on these people, these parents and students, who are just trying to find the means to be the best that they can be? Of course, it is a game, and they are playing to win! If anything the mother who gave up her career to dedicatedly push her son/daughter into a medical career needs to be lauded. Now whether or not that son/daughter has the aptitude to take up medicine as a career has never been evaluated, mainly because the son/daughter never really got a chance to “grow up”! We go to medical school right out of high school; what do we know what we want, when we have grown up in a society that has always conditioned us to be doctors or engineers? If we are really concerned about this, we should not ridicule these students and their parents, for they are struck with a social malady! We need to find a cure to the malady and implement it through a more well-rounded primary, secondary and higher secondary education system: one that helps you grow as a person before you begin to grow as a professional! So, the article, in my opinion, starts off with a major bias aimed at painting in unflattering colors the doctors of today.
I will deviate from the article for a minute and go back to the chapter on Health from our Second Five Year plan document. The second plan document was in action by 1956, and ostensibly written before the first decade of Indian independence was completed. In the section on Medical Education (point number 11), the document laments:
11. Medical colleges in India are now staffed by teachers who are permitted private practice. This concession is an important reason for low standards of teaching and for the small amount of attention which medical research has received. To remedy this situation, the Medical Council of India has recommended that every department of a medical college should have a full-time non-practising unit consisting of a professor and other teachers. The strengthening of medical colleges by the inclusion of whole-time units is essential for raising standards of undergraduate and post-graduate medical education and for developing research. The additional cost involved in this proposal in respect of each college is expected to be Rs. 2 lakhs per year. The provision necessary for about 35 medical colleges will be about Rs. 3.5 crores in the course of the second plan period.
So, that sort of pushed the author’s contention about the recent batch of doctors being “money minded” into the gutter. If anything, it indicts the whole profession! Doctors being trained in the 1950s and 1960s were so busy making money in private practice that they did not have time for teaching or research! Now we are aware that several states have an injunction of asking physicians who are involved in medical teaching to sign up for a non-practicing allowance. It so happens West Bengal is one of the states without such limits. So, naturally, the teachers are within their right to refuse a non-practicing allowance and indulge in private practice. However, the problem is, even with the NPA in place, the pay in certain states is so meager, it makes more sense to give it up and practice instead.
I know the age-old dictum of doctors being a noble profession and they should not ask for money shall be raised at this juncture (as the author has raised multiple times in his article, both implicitly and explicitly). However, what we, the young guns getting into the business end of careers want, is not a multi-millionaire lifestyle… all we want is that we get paid enough to be at par with other professionals and enough to have a decent quality of life. (Also, we want that we do not get bashed up while working in hospitals, but that is a post for another day!) Is it so lamentable? While the powers-that-be have no qualms about bringing medical profession under the realms of the Consumer Protection Act, basically certifying we are providers of a service, not unlike any for-profit company, the societal image of the doctor laboring away without right to respect (societal and fiscal) has stayed. I laud the move to bring accountability to the profession by bringing it under the COPRA; I get an urge to be a copro-flinger when people stand up and sing paeans about the honorable professional who works without seeking glory, respect, financial freedom or physical safety.
Let me come to the allegation that students who enter medical schools are such intellectually laggards that they have to enter into morning or evening classes at coaching centers run by their medical teachers to just get by. The scenario is not that simple. Actually, what happens is that though the scenario changes, the dramatic personae change, the story line of the drama remains the same. In medical schools, studying for the classes or even doing internship soon becomes secondary because the medical education system has become so wayward, that it has lost sight of the real goal. You know what the magic words are, which, when spoken in class will awaken even the sleepiest of souls hungover after a night of intense partying? It is: “Listen up folks, this topic is important for the PG Entrance Exams. They have asked it three times in a row!”
I have previously contended that the MBBS today has become a worthless degree, which was met with a lot of indignation and outrage. But the truth remains, that we have, as a system, a culture and as a society, placed so much stress on specialization, that the generalist has been pushed to the verge of extinction. It is rare to find that kind, local family doctor, who would know you by your daaknaam (nick name used by family and friends, it’s a Bong thing!) and know your wheezes and colics so well that they could tell when you were faking to get out of going to school on a day when your homework was due. We failed to glorify them, and instead wrote up the specialist, who waltzes in with a diagnosis and saves the day with a stroke of his pen. Truth be told, irony died a hundred deaths when they started mulling a specialization course labelled Family Medicine and General Practice.
So, when the students enter medical schools, they are like: “They said you won’t have to do MCQs anymore; they said college is fun; they said this is the end!” But, instead of getting an environment where they get to learn about the beauty of the mind and the body, they are thrust into a position where they are told that for every 30 graduates, only one shall enter into post graduation courses. Sometimes, if you have a subject preference, then the ratio may be even worse. I am not even opening the issue of caste-based reservation, which is yet another Pandora’s box!
So, put into this situation, what do you expect this student will do? He will grow up, go through his years in medical school looking up and idolizing people who were no good at wards but managed to crack a top rank in the entrance exam. Someone who is not interested in ObGyn will end up ignoring the internship posting where they get to learn some of the most important skills a generalist needs just because that is not exactly “high yield”. They will try to wiggle out of college lectures to attend lectures in coaching classes because they teach how to crack MCQs there. They will attend the classes of residents and teachers who bow to the pressures and teach MCQ-based medicine in class instead of providing a holistic learning experience.
Naturally, the MBBS exams are of secondary importance to these students, little more than an inconvenient bump along the path that leads to a PG degree. Why is it then so surprising that they are wary of “home centers” being shifted out of the examination system? These are the beasts that the system has bred. And now, instead of taking a deep look within, we place the burden of guilt on the product and not the process that leads to their formation. That is the easy way out. The way that garners the most hits, the most TRP raking headlines and of course, as a profession, the medics lack the numbers to make themselves heard over the din and bustle of everyday life, which has, admittedly, bigger problems to solve than a medical education system that lacks the empathy it seeks to develop in its students.
If you have read the two articles, the author’s newspaper article, and my blog post, you shall see we both share the same grudges, but come to grossly different conclusions. I see no fault in the medical students that the author has convincingly labeled to be tantamount to “poultry”. I think he got the species wrong. The animal I would have gone for is the sheep. We are trained to be meek, unquestioningly loyal to convention, afraid of breaking barriers, wary of breaking out of the beaten path and writing our own adventures; those that do dare to be different are chastised by society as failures, mocked by peers as idealist fools, ridiculed by the markets as unworthy of investing in and worst of, looked down upon as failures by their parents and near and dear ones, from those they seek validation and sustenance for their moral and personal well being. Add to that a sort of societal grudge that has built up towards a profession, and we just add more fuel to the fire. With a new study by the Indian Medical Association (IMA) finding that over 75% doctors have faced workplace violence, the odds are just stacked now: why be merciful to a person who comes up to you, brings a neglected nonagenarian with a huge bleed in the head, with significant midline shift, then states with a swagger and a drunken snarl: “It’s his life and yours: you save one and the other gets automatically saved!”
The sheep analogy holds water even when I take my argument to the next level: black sheep! Every profession has them, but unfortunately, the ones frolicking in the medical profession are the ones that are used to spray paint the entire canvas! How does that work out? Being a doctor is like being a wicket-keeper or a goal-keeper. You labor on throughout the day, unnoticed, but at the end of a long and hard game, you miss one catch or let one easy shot go in, that is all they will remember you for. The entire day’s labor is as good as lost. In fact, the problem with the medical profession is, if you have had a good game, just because someone else playing in a different league in a different country took a bribe from a match fixer to drop a catch, all your faults will be put down to you being a match fixer. Not to push the analogy too far, but you get my point, right?
The author recognizes a problem plaguing the system, he identifies what is going wrong, and he gets it all wrong about the where to apply the balm. Stop blaming the doctors. We are what you make us out to be. One moment I am God Himself because I conducted CPR on your mother and revived her; the next I am the Devil incarnate because I prescribed an expensive antibiotic to keep her alive and ensure that the bugs that could kill her stay out of her system. But the truth is, I am neither. I am not God nor am I the Devil. I am just another person, not unlike you, who castigate and chastise and slap me, and I am trying to do his job, and do it to the best possible extent I can manage. And it is true for most of us. There are lots of allegations that are true, but do try to go and see what an average Intern in a Government Medical College works like.
At a very rough reckoning, with a lot of rounding off, an intern in the Internal Medicine department pulls 12-hour shifts 5 days a week, one 24 hour shift on the wards day, and one 18 hour shift on the emergency/admissions day, bringing up a work week of 102 hours. Last I heard they were making something to the tune of Rs. 15,000 a month, which makes an hourly pay of Rs. 37! And this is in hospitals where there are enough consultants and residents to run six units, one for each day of the week. For those which have a smaller workforce (which is most places!), there may be an even higher workload. So, is it wrong that these doctors crib about the pay and when they look at their friends from engineering who are raking in hundreds of thousands a year, they feel slightly jilted and disillusioned? And if, as a remedy you ask them to change professions or “just suck it up and bear it”, then hell are you wrong!
The author portrays the medical career to be a much more financially rewarding choice than it actually is. He actually states that if we can just manage to hold on for four years, then we have hit the grand jackpot. Oh boy I am sure we cannot wait for that 40 Rupee/hour workweek to begin!
So, to conclude, the TL;DR version: the author has put his fingers on a very important problem, a problem of grave importance about the survival and well being of the profession, one can say without indulging in hyperbole, but he has gone about blaming the wrong people for it. Just because the doctors are interface to the system that remains hidden behind the facade, they are the ones coming under fire. The failing of the education system is massive, not just for doctors, for almost everyone everywhere. It is unfair to blame the product as defective if you have set up the system to produce them that way.