Hopefully the world is getting better…

 “Sir, I want to participate in a case presentation competition in that prestigious medical college” – this was a first year medical student who approached me a week ago. “Sir, I am planning to write my USMLE, I need to strengthen my CV, can I start coming to your rural clinic with you?” – this was a young second year student. “Sir, I want to go there and train the rural surgeons how to do certain surgeries. I feel like I have so much to offer them” – this is an intern who has just finished her surgical internship postings. 

The days of self-doubt and uncertainty of medical students and freshly minted doctors is slowly phasing out. Many medical students with whom I work today have unbelievable clarity about where they are headed and what they need to do to get there. I remember a very interesting conversation that I had with a young third year medical student. We were talking about behavior change and life-style modification for patients with diabetes. This student had read somewhere about the transtheoretical model of behavior change. Needless to say, that this is highly appreciable. Most students in his class wouldn’t be aware of such a theory of behavior change. While I was trying to explain the challenges of implementing behavior change interventions in the real world, this student quoted the theory and insisted that it was a failure on my part to not have attempted what is described in the theory. It is not out of a sense of hurt ego that I am saying this, but I am intrigued by the fact that just being aware of a theory, without any hang of ground realities, makes a youngster feel that they know everything about it. There is another first-year student who speaks such deep philosophy, but whose words, and actions do not reflect the internalization of such deep philosophy. He is a typical collegegoer but engages in and explores higher order philosophy. If these are explorations and discussions, I do not have a problem. But this young man sometimes gives me advice on what I should do and how I should live my life. I find that a bit funny at times and quite disturbing at other times. 

 

I have been thinking about this for some time and here are some of my thoughts on these issues. I explore the key issues of (a) target-oriented work versus purpose oriented work (b) conflating awareness with knowledge (c) hurry to become an important person.

 

Target oriented work versus purpose-oriented work

 

The often quoted analogy of maps and compasses comes to my mind when I think about this. While maps help us reach the exact point where we want to reach, compasses only show us the general direction. Maps are like target oriented work. They point out where exactly we should go. But compasses are like purpose oriented work. They only show general directions. Target oriented work is becoming common in medical schools and in general. Nowadays many medical students study to pass the exams. I work to pass an exam, so that I become a good doctor, used to be the motivation of the past. Now things are more complex. I work to pass an exam, so that I can write my postgraduate entrance exam, so that I can get a good postgraduation position to train, so that I get a good super specialty training position, and the commas just keep continuing. I have noticed that in the pursuit of these commas, the purpose of the whole endeavor is completely lost. 

 

When I go for the orientation course for first year MBBS students who have just joined the course, I thoroughly enjoy the sessions. The students are full of energy and enthusiasm. They are young men and women with a purpose, the purpose of serving people with the skills and knowledge that they obtain as a medical student. But 6 months down the line, after a couple of internal assessments and block end examinations, I can see tiredness in all their eyes and the joy of medicine completely sucked out of their minds. I see attendance in community medicine classes slowly dwindle over the months in the first year. Initially, the hall used to be full, as we used to discuss social issues and play interesting games. Slowly, as months roll by, the attendance falls because the interest in knowing the society around them, the interest in engaging in social discussions are replaced by overwhelming fear of impending examinations and assessments. Target oriented approach, to pass exams, generally drains energy, enthusiasm, and life out of learning. The medical student is not to be blamed at all. It is the education system and the way we teach medical students which is the culprit. 

 

I remember attending evening clinics with Dr. K.P. Misra, cardiologist, from my second MBBS. He taught me how to talk to a patient, how to examine them, how to communicate with them, how to empathize, how to break bad news and almost everything that is to know in the practice of medicine. I remember I learned more about medicine in Room 101 (that was the name of the clinic where Dr. Misra worked) than at medical school. But the goal of attending the evening clinics was to absorb everything that was to be learned from Sir. It was never for a recommendation letter, or for some brownie points during a United States residency application. Today, I have young second year students approaching me to shadow me in my rural clinic. They don’t even try to hide their motives. They just tell me “I need to strengthen my CV for my US residency application. Shadowing a doctor who works in an underserved areas will help me”. In the past I have had a few students who have showed up once or twice in my clinic, did not engage much with the patients or the rural setting, but asked me for letters of referral for the ‘volunteering’ that they did there. The target here is a “strong CV” which means putting in a lot of volunteering activities in it. I was amused by the fact that there are even organizations which offer such volunteering activities for a fee. The medical student must enroll on these organization, pay a fee, and participate in some ‘volunteering’ activity and then they get a certificate to ‘strengthen their CV’. I feel that this completely beats the spirit of volunteership. 

 

When work is target oriented, it takes away the joy from the process of doing work. When students study to pass an exam, it takes way the joy of studying. When students go to an evening clinic so that they get a certificate at the end of it, it takes away the commitment and purpose behind the volunteership. 

 

Conflating awareness with knowledge

 

One peculiar phenomenon I have noticed is when some interns come for weekly review meetings from the primary health center postings and share their experiences, they assume they are experts in treatment of diabetes and hypertension and refuse to engage with some important evidence-based guidelines which sometimes go against their practice. For example, once I remember having a discussion with an intern who was used to prescribing the anti-hypertensive drug amlodipine twice daily. I pointed out that it must be given only as a once daily dose as it has a long half-life. The intern said, “this is how we do in general medicine” probably implying that they know what they are doing and somehow their knowledge is stronger than what I was quoting. This probably comes from a strong resistance to change established practice, which is common among senior doctors in practice. I don’t remember feeling like an ‘expert’ who knows what I am doing when I was an intern. I remember being ready to learn, modify my practice, sometimes go to the library, and verify what the teacher was saying and if what they were saying turned out to be right, change myself. But as an intern, I think having rigid views and resistance to change is a harmful attitude. This attitude comes from conflating awareness with knowledge. Some students think, “I am aware that something like this exists. I can talk well about it. I can articulate my ideas well. Therefore, I know this”. I think that is the beginning of the end of learning. 

 

A first-year medical student asked me if they can go to a prestigious conference and present a case study of a patient. I believe that there is a time and place for doing things. In first year, one should try and study the first-year subjects to the best ability. Usually there is very little clinical exposure during first year. We teach only basic sciences such Anatomy, Physiology and Biochemistry in the first year. So, I asked the student to wait for one more year before going for the contest. But the student was impatient and went right ahead and submitted their abstract for the contest. The abstract was even selected for presentation. I wonder if the selection committee even considered that the student was still in first year. Here is another example where the system enabled the attitude of ‘I am aware of it therefore know it’. There is a certain mastery and expertise that comes from repeated practice of a craft, be it music or medicine. This mastery and the internalization of the core processes, rights and wrongs of the craft is what makes one capable of calling onself as ‘knowing’ the craft. This is why my post-graduate teacher once told me, “you should never become a teacher or an examiner without adequate years of practice of medicine on the ground”. 

 

Hurry to become an important person

 

One common feeling that many young medical students experience is the inordinate hurry to become an ‘important person’. I remember attaining ‘personhood’ in medicine several years after I passed MBBS. As an intern, as a fresh MBBS doctor, as a post graduate resident, I remember not having any agency at all. I am not saying that is the right thing. Every person needs to be respected. But in the initial years as a doctor we barely get opportunities to make important decisions. Our opinions are barely considered significant. There may be a rare occasion when we may have flashes of brilliance that influence the treatment decisions of patients. But routinely the young medical doctor only does the scutwork and learns. I think such a practice has its own merit. It is the time for the young doctor to stay away from heavy responsibilities and imbibe and learn the craft of medicine. But nowadays some young doctors are extremely impatient and want to become ‘important people’ quickly. I see interns complaining that all that they get to do in the hospital is ‘clerical jobs’. One intern was very upset and complained to me. “Sir, they are asking me to write clinical notes for all the admitted patients in the case sheets. I am bored of writing the clinical notes. They never give me chances to operate”. Well, writing clinical notes for patients is a very important matter. It is what a basic MBBS doctor is expected to do. To examine the patient thoroughly, made a clinical judgment and document it is a core responsibility of the intern. It is a very important task in the hospital, as it is the way the hospital monitors the clinical progress of the patient during their stay. But these interns who complain are impatient and want to start by doing sophisticated procedures right away. 

Having said all this, I must also mention that there are many young interns and doctors who are promising and who give me the hope for a safe, bright, and secure tomorrow. These students are patient, sincere, hardworking, smart, curious, persistent and disciplined. I see them slowly grow and transform into intelligent doctors. Some are apathetic during medical college day. But suddenly when they enter internship, metamorphose into amazing young doctors with the perfect attitude to work, learn and evolve. As I write this, I am telling myself that this is what is called as “generation gap”. Every generation thinks the next generation is degenerating compared to their own generation. But this cannot be more distanced from the truth. In his book “Factfulness” Hans Rosling has an entire chapter titled “The Mega Misconception that the World is Getting Worse”. In this chapter he says that the world is improving and not getting worse. Therefore, most of what I have written in this blog are probably just this major “The World is Getting Worse” misconception. Hopefully the world is getting better!