Medical EducationPart I

Everyone should know that the three basic principles on which this world is moving are teaching, learning and procreation. Procreation is required because every living being is mortal and life is limited. If no body procreates one day the species will be extinct. The other two (teaching and learning) are required for continuous flow of knowledge. Always somebody is teaching and somebody is learning, it may be farming, weaving, pottery, construction work, cooking, the work of a black smith, or others including medicine. Ordinarily the parents teach their children. This has continued for thousands of generations. If the parents do not teach his child the knowledge they have acquired in their lifetime will come to an end after their death. So everyone should teach his children. With the progress of time some highly intelligent people became gurus (teachers) and they taught the students. They mostly taught the principles of living in a society in addition to few other subjects. Nowadays teaching has become more compartmentalized, but the basic objective of teaching has not changed. Every teacher should teach his students whatever he has learned in his lifetime for continuation of knowledge. To teach well one has to learn well; means before somebody becomes a good teacher he has to be a good student. A teacher cannot teach well if his knowledge is limited. Every teacher should introspect himself whether he has been able enough to explain his knowledge to his students, if not he should always try to adopt means by which he can do better. Everybody cannot be a good 3teacher. To be one, his first requirement is depth of knowledge, his ability to explain, which itself needs the grasp on the language and he should know what is the gradient of knowledge between the teacher and the taught. Teaching undergraduate students is different from postgraduate students. As one teaches more and more he becomes more and more efficient in explaining things provided he tries himself to improve. The summary of this is every teacher should try to acquire as much knowledge as possible. Today's student is tomorrow's teacher, so every student should try to learn to the best of his ability. In the field of medicine the health care of the society and teaching of the future doctors will be in the hands of present medical students. So it is my appeal to all the medical students to learn as much as possible and understand their subjects as thoroughly as possible.

Medical science is a practical science. The primary beneficiary of our knowledge is the patient. The knowledge gained should be used for the benefit of the patient. The knowledge, which is not going to be useful for the benefit of the patient, can be considered as useless knowledge. I always say my students, “do not acquire useless knowledge.” So every medical student whenever learning something/reading something should know how this knowledge is going to help the patient. The teachers can guide this. Sir William Osler has said that what the mind does not know the eyes cannot see. It means he has given stress on the theoretical knowledge and correlation between theoretical knowledge and practical knowledge. Unless you have sound theoretical knowledge you cannot think much when you are faced with practical problems. To correlate the theoretical knowledge with the practical knowledge one has to work sincerely for the patients. He who works more develops better power of correlation, so that a particular thing will come to his mind automatically 6(right thing comes to mind in right time) and he can deal with the situation better. To emphasize the importance of practical learning Sir William Osler has told—“to study the phenomenon of disease without books is to sail in uncharted sea, while to study books without patients is not going to sea at all.” Here he has given lot of importance to practical knowledge. So much of importance has been given on practical learning because every human being is different from the other. A particular illness may present in different ways in different persons, can behave differently with or without treatment. Unlike physical science 2+2 may not be 4 always; at times it may be 5, may be 3 and at times it may be zero. So to get acquainted with all these variability one should have extensive practical training. The diseases described in the books are data of several patients observed by several doctors over several years. All these patients have not behaved identically nor in future such patients are going to behave as described in the books. So every patient must be evaluated and treated on its own merit. That is why it is often told that every patient is a book. Medical students should try to acquire as much theoretical knowledge as possible and should know how to apply this knowledge on every individual patient. Unless one utilizes the theoretical knowledge well he will not be able to recollect the correct thing at the required moment. I shall give a simple example to emphasize the need of practical knowledge. If one knows very well how much fluid, what fluid and at what rate to be given to a patient of dehydration, but does not 7get a venous access, all his knowledge becomes useless. Truly I know a situation when the doctor straightforward told that he cannot get a vein and referred the patient to a referral hospital and the patient died on the way.

Students should try to know about a subject as clearly and as completely as possible, particularly the things needed for daily patient management. Patchy knowledge is not helpful; rather it can be harmful at times. I shall give an example how patchy knowledge was proved to be fatal. In our student days intrathecal penicillin was routinely being given in pyogenic meningitis. A junior doctor did the lumbar puncture; there was purulent CSFF microscopic examination showed plenty of pus cells. He decided to give intrathecal penicillin, but he did not know the dose of it. He gave 10 lakh units of benzyl penicillin intrathecally. Soon after the injection the patient developed repeated convulsion and died. Here, his diagnosis was correct, he did a non-traumatic lumbar puncture (procedure was correct), he decided to give intrathecal penicillin (treatment choice was correct); all these correct things he did but for a single mistake (not knowing the correct dose of intrathecal penicillin) the patient died. This is an example how incomplete knowledge can be harmful.

It is my observation over the years that many students try to know several syndromes and try to remember several signs named offer different scientists. Peculiarly some teachers also ask the students about them. Most of the syndromes are uncommon; some of them are seen at intervals of several years. So students need not try to remember them. Similarly there are several signs in different diseases. Many of them go by the name of different scientists. Some are very helpful for bedside diagnosis but many are not so much. So while remembering them students should know the diagnostic importance of these signs and accordingly remember them. For example, in aortic regurgitation there are so many peripheral signs, hardly they are of any diagnostic importance except a few. So there is no need of remembering all these signs. The teachers are in a better place to guide the students. They should tell the students which are common and worth remembering signs and syndromes.

There are several medical books available in the market. Several books are available on each subject also. It is not possible to read, understand, remember and reproduce 9all these books nor it is required also. Whatever may be the book there is little difference in the basic knowledge though there can be some differences the way they explain certain points; as explanation of some points vary from teachers to teachers. So students can follow any one or two books for basic knowledge. I consider these books as the skeleton books. Students can read as many books as possible and add flesh to the skeleton. Repeated reading of same book gives better understanding than one reading of so many books. However, they can refer to specific topics in different books. If a particular point is not understood clearly from one book he can try in another book. Teachers can help to guide the students which topic is to be read from which book. It is not possible to recommend any particular book because all points are not available from one book. For patient management at times it is required to refer several books. Most of the institutions follow certain skeleton books.

These days several super-specialized departments have come up. They often claim their superiority and gradually these branches are going to engulf the medical care in such a way that a MBBS student is confused what is his role in medical care, people have also thought similarly that these MBBS doctors do not know anything. So the MBBS students complete their course in a confused manner. After completing MBBS they are trying to get a PG seat and not interested to know the basic knowledge every doctor is supposed to have. The knowledge we get in MBBS course is the basic knowledge and this can be considered as the trunk of the tree of medical care. The specialized subjects are its branches and the super-specialized subjects are the sub-branches. If the trunk is not strong enough it cannot support the tree and one day the whole tree will collapse onto the ground. The way health care system is going these days, particularly in this country, collapse will not take long time. A textbook of critical care describes that the situation arises when all the organologists (super-specialist) declare that their organs are normal, but the patient dies. I have also given examples elsewhere. This means we started looking patients as group of organs not as a human being. A well-trained basic doctor 11can save more number of lives than the specialist or super-specialist doctors. What I want to emphasize is every doctor, in whichever field he might be working should have sound MBBS knowledge. As I discussed earlier, because the MBBS students feel that this course is nothing, they are not very much interested in learning what they are supposed to know. So the basic knowledge of most of the doctors these days is poor. Doctors these days speak/do big things but often they do not know small life saving, decisive things. They find ways to treat a case at one lakh rupees, but do not know that the same thing can also be done in ten thousand rupees.

This family may be thankful to the operating surgeon, but should be obliged to the doctor in the PHC.

Truly the clinical medicine (clinical subjects) is relative science. Because– (1) With similar clinical features diagnosis may be different in different time and place, (2)treatment with same medicine for same illness may produce different outcome, (3) response to a particular drug may vary dramatically from person to person. If the clinical medicine had been absolute science, these differences would not have been observed. However, the anatomy, physiology and biochemistry are absolute sciences as they are same everywhere. The anatomy of skeletal muscle is same in USA, India or Japan. The Krebs cycle is also same everywhere. The physiology of cardiac cycle is also same everywhere. So every other branches of medicine must be studied in the background of the knowledge of these non-clinical subjects. In fact he who has got sound knowledge in these subjects can challenge the investigation reports (discussed elsewhere). Pathology helps in the understanding the symptoms and signs of different diseases as well as interpretation of reports. Knowledge in pharmacology and microbiology helps us in giving proper prescription. The most important requirement of non-clinical subjects is in the field of research, it helps in the 14advancement of knowledge. In conclusion I can say that medical students should not/should never forget the non-clinical subjects even after they complete these subjects. Details may not be needed for daily practice, but certain basic knowledge is very much required.

Knowledge in almost all fields of science is changing, so also in medical field. So all medical students and doctors should try to know the latest knowledge. These days books are edited in every few years. One can get fresh knowledge from the latest edition books. Latest knowledge can also be obtained from journals and web sites. But old knowledge is not always useless. In fact these knowledge (particularly related to diagnosis) are very useful in less developed part of the world like ours. These are clinical methods. Most of the books these days give lot of importance to various investigations and less emphasis on clinical evaluation. But students should remember that clinical methods are the cheapest method to reach at a diagnosis and it can be practiced anywhere, anytime and can be repeated as many times as possible. This does not mean that the investigations are not useful. I remember a situation—one of my student was doing residency in Delhi in a big hospital. In a respiratory case he made the diagnosis of pleural effusion by applying the clinical methods. The other doctors there were astonished to know how he could diagnose without X-ray chest. Similarly one of my friend was working in a private hospital, he could diagnose 15perforated peptic ulcer by clinical examination and was also proved to be true later on. This made his colleagues surprised that how he could know without any test. There are several situations where clinical examination has proved to be superior to costly tests. This is my personal experience that many things can be known by taking a good history and detail clinical examination. As we are depending more often on the investigations; then day; we skip these aspects. This has led to atrophy of the clinical acumen amongst many medical teachers and so it is bound to be transmitted to the students. So try to know new but not at the expense of the old, particularly in relation to diagnosis (clinical medicine).

There is a statement that if you know what to do you can save more number lives than knowing why to do. The meaning of this is, in day-to-day management of cases it is enough to know what to do. With experience many untrained persons also acquire the knowledge of what to do, but they cannot become equal to trained persons who know why to do also. By knowing why to do, one does the work confidently. Knowing why to do will also help in situations when things do not go in the desired way. For examples—we want to do something but the things required are not available, then we can find out the alternative means to do the same if we know why. Similarly for advancement of knowledge we have to know why. Without knowing why in any topic it is not possible to undertake any research work. If we know why a disease occurs we can take steps to prevent, if we know why a particular drug is effective in a given situation we can try other drugs with similar properties. So as the men of science we must know what to be done in a given situation and also should know why that is to be done.

Every junior doctor should know to present the case at bedside before the seniors. This will develop the habit of presenting data briefly. This should include the complaints, the part of the history that appears to be relevant to the case, his physical findings and his provisional diagnosis. He should also emphasize the points that may not go in 17favor of his diagnosis. He should plan the investigation of the case and how they have contributed or not contributed to the final diagnosis. He should plan the patient management also and should assess the response of the patient to the given treatment. If he continues this method of working within a few years he can independently deal with any type of case. The seniors instead of finding fault with the juniors should encourage him in his progress and rectify him in right time.

Record keeping is an essential part of medical education and patient care. I have seen many doctors facing problems because of inadequate and improper recording of patient's data. The reasons why the records to be kept properly are:

In every hospitalized patient junior doctors are supposed to write the daily progress of the patients' management. This is called daily note. I have seen on several occasions these are not written properly. The following points must be mentioned in a daily note. These are:

It is a common experience that when a question is asked to students whether in clinical class or theory class, they tend to give the answer together. But this group answer has no value. So the question should be asked to an individual student and if he is not able to answer, the same question can be asked to others. By answering individually one develops the habit of answering, whatever inhibitions will be there will gradually decrease and the particular student gets a chance to exercise his own brain. Besides they are not going to treat a patient together in future, so they should be discouraged to answer together. Whenever a student gives an answer he should try to give the full answer, as completely and as clearly as possible. This will improve his power of expression and explanation.

This is also a common scene that undergraduate students tend to examine a patient in groups. This should not be allowed because this will not help his ability to collect good history and ability to examine a patient independently. The patient will not feel comfortable before so many people and may not give a detail history. At times group examination may harm the patient. For example, if so many students try to auscultate the chest and ask the patient to take deep inspiration (as it is done commonly in auscultation of chest), after sometime the patient may feel dizzy or may develop frank syncope due to wash out of carbon dioxide leading to cerebral vasoconstriction and 21decrease in cerebral perfusion. Similarly if a patient has got a painful condition and if so many students examine him the patient will suffer and may decide to leave the teaching hospital. So students should look for the comfort of the patient while examining him.

I have seen students trying to know the answer of a question from their friends, seniors or teachers. There is no harm in doing that. But the peculiarity is that these persons often without knowing the correct answer give the answer by guesswork, by extrapolating certain knowledge or give the answer in a roundabout manner. It is not possible on everybody's part to know everything. So if somebody does not know an answer should frankly tell that he does not know, there is nothing to be ashamed about it. Similarly the students who are asking the question should not accept these answers without verifying them from the books. By doing so he will not only know the correct answer, but also he can know more about it and related topics and he will be able to know the source for future reference. So I personally discourage knowing by listening from others. However, it is worth listening from people who have original work in any particular field. Even if a teacher differs from a book he should be able to give sufficient reasons for it.

These days we see that many junior doctors particularly the interns reading a number of multiple choice questions 22(MCQ) books and preparing for postgraduate entrance examinations. It may help them in getting a PG seat but this knowledge does not help them in treating patients. Knowing answer to a thousand MCQ may not be enough to treat a single patient. Students should know that when they will examine a patient he will not give him choices what he is suffering from. So they should leave no chance to learn the practical points of patient management.

Writing a thesis is an essential part of postgraduate study. But many postgraduates and unfortunately some teachers feel that it is not required. Many take it too lightly. But they should know that thesis is required as it teaches the methodology of a medical research work. Whatever knowledge is improving in medical science it is due these research works. So every doctor with postgraduate degree should know how to do a research work. By that they can also contribute to the development of new knowledge. Research can vary from simple observation of facts to quite difficult drug trials. Hence thesis is an essential part of postgraduate study. In fact every postgraduate should learn not only to do a research work but also to publish his work in different journals. In addition to them he should also know how to write a review article and case report. Let there be small number of cases but the work should be genuine. Thesis also helps us to know the methods of biostatistics.23

Medical students may have to appear oral tests and at times different interviews. One should know that the time available in these types of tests is much less in comparison to written tests. So one should know how to answer in these types of tests. Here the answer should be brief, to the point and should include more of practical things and common things. If the student start answering by telling some theoretical things or uncommon things the examiner develops the opinion that this doctor has not worked enough at bedside. For example, if you are asked to answer the causes of hemoptysis, one should tell some common conditions he has seen in the wards and he is likely to see the same conditions when he goes to practice. Tuberculosis, mitral stenosis, bronchogenic carcinoma, bronchiectasis, chronic bronchitis are some of the common conditions the student should answer. But if he says Goodpasture's syndrome, pulmonary AV malformations, etc. the examiner will think that this boy has not gone to the wards. The common cause of hemoptysis in India may be pulmonary tuberculosis but it may be chronic bronchitis in Western countries. Similarly the commonest cause of heart failure in India may be rheumatic heart disease but in USA it may be coronary artery disease. So the candidate should know where he is appearing the interview.

It is embarrassing for a student to fail and equally embarrassing on the part of a teacher to make a student fail. But failure is a part of any examination. These days students are becoming violent after failure. They are threatening the examiners (both internal and external) in different ways. Every student feels that he should pass. Being threatened by the students, teachers are either not interested to be examiners or not failing the students. Irrespective of performance of the student if a teacher passes all and he feels of the student if himself secured. By this the administrators also feel happy feeling that their institute is performing well. The parents also feel happy as their children pass in one chance. But is it the truth? As nobody feels unhappy does it mean that nobody should 25fail? Amidst all these happiness the only person to become unhappy is the patient. And this patient may be the father, mother, teacher, administrator or the common man. If poor quality doctors are released to the society everybody has to face its consequences. Many patients will unnecessarily spend more money, diseases will be diagnosed late and at times not at all (till death), more patients will be transferred to tertiary care hospitals. I know several such examples. Even there are doctors who are not able to treat their own parents. So for the better interest of the society passing should not be liberal. At times students feel that because they have failed once they are bound to pass next time. That should not be practiced also. If a candidate has no standard he should fail as many times as needed. At times students argue that if they fail is it going to improve their standard? I feel yes. If one works hard his standard will certainly improve. Even if the candidate does not improve, everybody should know that proper punishment to one criminal prevents several criminals to develop in the society and if more and more criminals are allowed to escape more and more good people will become criminals. Similarly failing the non-deserving students will improve the overall standard of all the students and indiscriminate passing of all the students will decline the overall standard.

In a medical college there are indoor and outdoor services. Students should understand the basic principles of these works. In the outdoor the primary function is to know who are the patients to be disposed off and who are the patients to be admitted to indoor. There is little time in the outdoor. So one should try to collect brief history, major physical findings and come to a conclusion. In the outdoor also one has to decide whether the patient needs consultation in any other department or not. A patient coming to medicine outdoor, does not mean that it will 27be a medicine case; it could be a surgical or a gynecological case also. Initially people come by their choice, but it is our duty to advice him correctly. So to dispose off outdoor cases one has to be quite efficient. Outdoor is the beat place to learn and best place to assess one's efficiency. So every student should devote enough time in outdoor.

Teaching hospital is a hospital where medical students are taught. Medical councils have given several guidelines for an ideal teaching hospital. In a medical college hospital not only the would—be doctors get training, the other paramedical staff also get training. Today's student is tomorrow's doctor. The better the quality of training he 28receives the better he will serve the society in future. If his training remains inadequate he cannot serve people efficiently. To learn better he should see varieties of cases and he should be actively involved in the patient care. He should also be exposed to different type of instruments/ equipments used for investigation or treatment. All these means the better the facilities available in a teaching hospital it is better for the students and of course it is better for the public in the long run. So the authorities involved in running a medical college hospital should not be miser in investing newer and newer things in these hospitals. The patients attending a medical college should give the medical students or other trainees to examine them and take their care. By that they are doing a great favor to the society. Because of them better doctors would be available in the society in future. They might be facing a little bit trouble by being examined by the students but their trouble yields good result and the subsequent beneficiary of the services of these future doctors may be he himself or may be his children or grandchildren. Every patient coming to a medical college should at first be examined by the students/junior doctors, so that their thought process, power of judgment, power of observation will improve. If the consultants examine the cases from the beginning, then the juniors will not learn actively. The students and the junior doctors should see that they take total care of these patients (not only as patients but also as their teachers) and should look for their comfort while examining them. Whatever problems 29they face in solving the problems of the patients they must bring them to the notice of their seniors and if needed should refer the books and other recent literatures.