Eulogy to a safe space called intern’s review meeting

Eulogy to a safe space called intern’s review meeting

Vijayaprasad Gopichandran

In 2018, we had the first batch of interns in our department. While planning for the internship postings in our department for the first time, we were exploring various models including my own internship in community medicine at the Madras Medical College way back in 2001. Community Medicine internship was a roller coaster ride. It was filled with travel to exotic rural locations to serve in the primary health centers, work outside of the hospital in communities, attending camps and outreach activities, with a school health screening visit thrown in to enhance the fun and play experience. In all this, one thing that was missing was a mentorship to link the myriad activities to the goals and objectives of internship in community medicine. I remember being clueless at the end of the posting, sometimes not even realizing what all I had actually absorbed from the centers and the community where I was posted. 

 

As a postgraduate resident in community health in CMC, Vellore, I was entrusted with the responsibility to manage a group of interns posted in the community health department in my first year. The internship there was completely different. Interns learned largely by participating in all hospital based and outreach community-based activities. In addition, they also had weekly seminars and review meetings where they presented small research projects that they designed and conducted, read interesting journal articles and also made a clinicosocial case study presentation and an ethical case discussion. I saw the benefits of having these review meetings in which there was room for reflection on what the interns learned during their posting. I am sharing this background just so that I can explain my logic for the way we planned the internship postings in our department. 

 

Working in a medical college which does not have a geographically delimited field practice area, as all our beneficiaries are people insured under the Employees State Insurance Scheme living scattered all over the city, there was a lot of struggle in designing the first internship postings. We had to give the interns exposure to rural and urban health and some exposure to community-based work. So we forged collaborations with the Department of Public Health and Preventive Medicine of the Government of Tamil Nadu to allot primary health centres in Tiruvallur district and with the Greater Chennai Corporation to post our interns in the Urban Primary and Community Health Centres within Chennai. In addition, we also wanted the interns to be constantly in touch with the Department through a weekly review meeting. The review meeting was planned to be held on Fridays. The plan was to provide a reflective space for the interns to talk about and discuss their work in various centres in the past week and learn from the experiences. This essay is about the review meetings, the things I fondly remember about them, the way they rose from a mere formality to a safe space for interns to discuss and reflect on important matters, to how it has now been dissolved. 

 

I still remember the first review meeting. The interns had just started their internship postings with community medicine. Clueless about anything clinical, they were thrown into the open world of the primary health center. They had to travel 40 KM to go to the center. They finished a morning’s work and travelled all the way back by local train and bus, in the sweltering hot sun and came back to the community medicine demonstration hall. They were all tanned, sweaty, irritable and angry. One of them, who later on went on to become a very good friend of mine, remarked, “I hate this review meeting. Why did you make us travel this far just for this meeting?” Nothing is easy when we start doing it. The initial few meetings we all had starting trouble. We did not like the meeting, it seemed like an unnecessary formality. But we persisted. By the time, the third batch of interns, who usually come in small batches of 15-20 at a time, joined us we had settled into a good routine of the review meetings. I started looking forward to the meetings. 

 

One of the commonest themes that interns would talk about is the indiscriminate and irrational use of antibiotics and many drugs in the PHCs and other centers. “Every cold is given an antibiotic” they would lament. That is when we started discussing clinical treatment guidelines. As part of MBBS curriculum, we are never taught how to read standard treatment guidelines, how to critically engage with them and how to use them. We are used to read off textbooks and remembering things from there. Now, we slowly started converting the review meetings into academic discussions of important treatment guidelines. In one of those meetings, we discussed approach to low back pain and indications for MRI in low back pain. One of the interns quipped, “No, this cannot be true, orthopedics people taught us differently”. Then we discussed how to look for answers to clinical questions like these. Where to search for them? What search terms to use? And at the end of the session the intern realized that there is so much more to medicine than just obeying what one is asked to do during ward rounds. The review meeting morphed into a space where critical engagement with clinical questions was taught to the young interns. The experience was so rewarding. Some of the interns came back and narrated stories of how they had respectfully suggested to the medical officers in the centers, changing the dose of Amlodipine, a drug used for treatment of hypertension, from twice a day (wrong dose) to once a day (right dose). 

 

Sometimes interns brought interesting stories and anecdotes. I remember one of the interns discussing a case where he had seen a man with seizure disorder in a state of continuous nonstop seizures. His wife had brought him to the PHC. The medical officer in charge of the PHC had requested a transfer to a tertiary care center for specialist care. But the wife of the patient was reluctant to take her husband to the far-off tertiary care center. She was pleading with the intern to not send them away. The intern had faced a serious moral conflict and he brought this to the review meeting for discussion. I vividly remember his distress and the way we discussed various matters including right of the patient, rights of the wife, support systems that must be in place while referring patients and so on. The review meeting also served as a space where moral and ethical conflicts and dilemmas faced by young interns were actively discussed. 

 

We split the interns into small subgroups of 3-4 in each and asked each group to design and conduct a minor research project in the 2 months that they were posted in the department. This research exercise became a competitive and interesting activity with batches of interns competing to do the ‘best project’. In the process of conducting the research studies, the interns learned and engaged deeply with the research topics. I clearly remember projects on prevalence of malnutrition among school students that was done by a group, complementary feeding practices among new mothers in the community, antimicrobial prescription audits performed in the health care facilities and many other exciting projects. One project that led to an intense learning experience for the interns was a study of lived experiences of discriminations faced by members of the LGBTQIA+ community. The research project experience slowly and organically led to a felt need to learn how to read journal articles and critically appraise them. With that, was born the intern’s journal club. 

 

The intern’s journal club was an exciting academic forum. Interns engaged in deep reading and understanding of the research papers, presented the details of the study and discussed the various aspects of the study in detail. Some of the intern’s journal clubs have been enriching and personally fulfilling for me. One batch of interns discussed a paper on postpartum depression and factors influencing it. The entire psychiatry department had also joined us for the meeting. The discussions were superlative. Almost every journal club meeting ventured into discussions on politics of health and social implications of that research. What started initially as taking out old, simple and short research papers and trying to learn the design and method elements of the research, slowly evolved into reading current papers in Lancet, BMJ, New England Journal of Medicine etc. In fact, we would pick up all the current papers during the COVID 19 times and read and discuss them elaborately. The quality of the journal clubs and the engagement of the interns rose to such standards that a few new faculty who joined our department commented that the intern’s journal clubs were far superior to the post graduate residents journal clubs in their previous institutions. 

 

The interns review meeting, which started as a learning space, metamorphosed into something much bigger than that. It became a safe space to discuss oppression, it became a space where sometimes abuse faced by the interns was discussed without any fear of judgment. It became a space to vent out frustrations. It became a space where you could always bounce your insecurities, frustrations, confusions, and anger and go back feeling light. Some of these review meetings were so therapeutic for all of us who were present there. Some of us, faculty, relived our pasts and there have been instances where some of us have broken down in the meetings remembering the errors and mistakes that we had committed in the past which keep haunting us to date. The interns got to see that the emotional burden of our mistakes never vanish, they just remain and we learn how to deal with them. Jokes and laughter were also abundant in these sessions. One handsome young intern was stalked by the father of a young unmarried girl and demands were made by the father to the intern to marry his daughter. This was a matter of great fun and laughter for the entire batch. I personally connected with interns at an individual level during these meetings. I got the opportunity to know many of the students, whom I never had the chance to interact with when they were in college. I became close to several of them, who still stay in touch with me over the years. 

 

Today, with a very heavy heart, I typed a circular on behalf of the department to end the weekly review meetings. The National Medical Commission recently changed the guidelines for internship postings. The complicated framework of postings made it almost impossible to have a coherent set of interns go through various departments together. This would mean that at any time interns would be spilt between various departments and people would move in and out of community medicine department at various points in time spread throughout the year. This lack of continuity is making it difficult to engage meaningfully with the interns. Because of this haphazard posting rotations, we are unable to do research projects, unable to make a schedule for journal presentations and discussions. This has made the review meetings a difficult formality for the interns to fulfil. We called off the research project and journal club. We just asked them to come every week to discuss and reflect on their learnings over the past week. It is becoming difficult for them do even do that, and it is becoming a logistic nightmare to track their attendance in the review meetings because interns keep dynamically moving in and out of the department. Therefore, we called off the review meetings. On one hand, it is a necessity to have called it off, because it was becoming too difficult for the interns to manage and for us to handle. On the other hand, I am left with a very heavy feeling of loss in my heart, for having lost the opportunity to closely engage and relate with young interns. I just hope there will be some other opportunity to connect with them and share their journey towards becoming good doctors in the society!