MEDICAL EDUCATION, TRAINING AND PATIENT CARE FROM THE LENS OF MEDICAL INDIAN RESIDENT

8/12/2019 MEDICAL EDUCATION, TRAINING AND PATIENT CARE FROM THE LENS OF MEDICAL INDIAN RESIDENT

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Open Access Articlewww.njcmindia.org pISSN 0976 3325eISSN 2229 6816

National Journal of Community MedicineVolume 3Issue 4Oct Dec 2012 Page 750

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MEDICAL EDUCATION, TRAINING AND PATIENT CAREFROM THE LENS OF RESIDENT

Ruchi Sachdeva1, Sandeep Sachdeva2

Authors Affiliation:1Dept. of TB and Respiratory Medicine; 2Dept. of Community Medicine, PGIMS, Rohtak,India

Correspondence: Dr. Ruchi Sachdeva, Email: [email protected]

It was a jubilant moment to receive the newsthat I got through all-India competitive entranceexam for pre-medical test. The fruits of hardwork, perspiration and sacrifice had come

through but with a pinch of salt, as my rank waslower-down in the merit list. It was a challengeto convince my family till I proceeded to enrollfor MBBS course in a medical college from thestate very different from my native in allperspective-geographical, socio-demographicaland linguistic. Anatomy was real terror thatdisciplined us for rest of our lives. Pathology ledme to believe that I was also suffering fromsome disease for which I had to receivecounseling. Educational visits to understandliving condition and health care structure in

slums and rural area under communitymedicine was eye opening. Bed side medicineand surgery were stimulating, engaging &learning was exhaustive. During OBG posting,assisting delivery & holding newborn wasmoment that led to feeling of accomplishmentand thanks giving to natures divine.

The persona of our teachers were captivatingand were mesmerized by volume of informationretained by them but use of only chalk & boardduring teaching was boring. All through-outdegree course we kept on cramming with littleinter subject linking, critical and/or out-of-boxthinking but over time-frame subject alignmentnow appears to be perfect. Best part was patientexamination, evaluation, interaction andmanagement during internship along withjunior faculty. Healthy moments of raggingmade seniors our best friends but alas this magichas lost its effervescence in the current context.

During this professional growth, many newdimensions were being added at personal frontalso as I had to learn local language to

communicate with patients, people and friends;learnt and adapt to local cuisines, culture, and

customs. Our parents and relatives visited us onmany occasions, stayed in local hotels, travelledto tourist and archeological spots, did lot ofshopping and carried home little mementos

thereby contributing substantially in economy atmicro-level. Some of my native peers happilymarried local residents thereby adding a newdimension of experience and enrichment in life.Today, I understand the vision of policy makersand one of the objectives of all India competitiveexams be it medical or engineering is to fosterIndianness (a feeling of unity in diversity)amongst its citizens! Now let me share myhumble views as a chest resident.

Poverty, illiteracy, unhealthy practices andcompliance issues is rampant among masses(especially when 70% are residing in rural areas)in any developing society with limited access tocompetent heath system and personnel leadingto in-appropriate care. In contrast, urban class ismore aware, demanding and assertive onpatients rights, treatment risk benefit, clinicalpractices & negligence leading to increasehopping for advise, personalized care, litigationand/or attack on medical personnel.

In India, according to Global Adult TobaccoSurvey (GATS), around one-third (35%) adults

use tobacco in some form and 52% are exposedto second-hand smoke (SHS) at home with ruralarea accounting for 58% and urban (39%)respectively.1According to NSSO survey basedon information collected during 2009-10 from100,794 households in 7428 villages and 5263urban blocks spread over the entire country, thepercentage of households in India reporting useof firewood and chips was 87% in rural areasand 25% in urban areas.2 Taking the example ofHaryana state, nearly 61.8% [76.6% (rural) and22% (urban)] household used fuel other than

(LPG, electricity, or kerosene) suggestingdung/crop/fiber residue while 11% used woods


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for cooking.3 Some serious efforts to controltobacco menace in the country were undertakenduring last decade and notification for ban ontobacco product by ministry of health in 2011only therefore its positive impact would bevisible only in next two decades. With increasein longevity [avg. age 32 years (1947) to current,66.8 years] and simultaneous exposure tosmoke/tobacco & other risk factors for last 60years sizeable population is now and willcontinue to manifest in large volume at healthfacilities with chest, cardiac, cancer and/orassociated diseases. Under these circumstanceswith concomitant acute shortage of ICU beds,government institutions are negatively labeledin community as centres of mortality andentrusted with the task of issue of DC (death-certificates) only.

Influenza pandemic provided ampleopportunity to inform/sensitize communitiestowards improving personal hygiene and coughetiquettes but administrators failed to interjectnew practices. In the backdrop of rising cost ofcare, alcohol abuse, propelling graph of non-communicable disease burden, obesity,HIV/AIDS and environmental hazards it ismammoth task to drive the issue across theminds of patients & other stakeholders thathealth is an individual responsibility also with

key principle of prevention is better than cureand to attempt for positive health behaviour is astill an impossible task.

To dissect, look into microscope or take up knifeas a carrier option following graduation,personal traits, motives, hard work or meritplays the trick. Residents in clinicaldepartments especially in governmentinstitutions are apparently overworked withlittle time for introspecting on clinical decisions,improving patient care or communication.Inadequate logistics, casual approach, high turn-over of patients and poor infection controlpractices are detrimental in controlling themenace of nosocomial infection. On manyoccasions we fail to understand the basics ofquality, effectiveness, efficiency and competenceof care in an environment of limited resourcesbut still master many skills by multi-tasking,trial and error. Team work, motivation, andrespect for others are becoming dwindlingentities in society including our profession. Attimes due to in-adequate institutional &departmental protocol for case management andlack of secretarial assistance, confusion reignshigh, anger spreads like wild fire, nurses skip

consultants round and poor resident ends upbearing the brunt.

There may be lot of CTVS surgeons in the citiesbut only few with inclination for thoracic in-comparison to more glamorous cardiac surgery.

Multi-organ disease patients in-particularabdominal Kochs and infertility cases keepshunting between departments and surprisinglysome experts recommend ATT only on thebasis of positive tuberculin test. TB with apropensity for multisystem involvementcontinues to play havoc in population and its apity to observe sufferings & poor quality of lifepracticed by young patients with MDR-TB andtheir family members. Truly, nature has itsstrange blue-print of handling humans but thestruggle of science to conquer diseases continues

unabated. In this difficult but scary real lifesituation, health personnel including otherspecialty & super-specialty physicians alsorequire continued medical education onchanging dynamics and reinforcing the basics ofprimary care and RNTCP.

Gaining education (knowledge, psychomotorand attitude) on various aspect of pulmonologyrelated to patho-physiological & clinicalspectrum of diseases & management; concept ofcontinuum of care; intensive care; modernimaging technique; therapeutic procedures;interventional bronchoscopy; allergy testing;oxygen/aerosol therapy; sleep management;respiratory rehabilitation; adverse effects ofdrugs; CPR; cancer; pulmonary hypertension;lung transplant; occupational care; chestphysiotherapy; pediatric pulmonology; conduct& interpretation of PFT/ABG; preventing &diagnosing sudden death due to pulmonaryembolism; smoking cessation; genetic therapy;molecular biology; stem cell; clinical trial;telemedicine;4-10 pulmonary manifestation ofdifferent systemic diseases, public healthincluding research methodology, biostatistics,behaviour change communication,documentation, administration, financial,conflict, time and self management to name afew needs sincere efforts from residents,constructive criticism & supervision [normative(administrative), formative (educational),restorative (supportive)] from our seniors andfunctional linkages with other departments.

Internally it is satisfying to be a physician butsystem expects us to undertake many divergent

roles and responsibility including research.However, in the backdrop of intense compulsion


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for publications, originality is losing charismawith the evolving cut/copy/paste phenomenon.The sorry state of affairs is being driven eveninto the minds of very young school children asthey are required to execute projects throughuse of internet. On the corollary they tend tospeak less but share more on internet and theday is not far when these kids would be living invirtual world who are socially isolated and stillnet-connected. Communication is an art withfewer medicos having a flair for it for whichthey were neither trained nor shown the path.However with rising trend of medical tourism11,maturing of local media (print/electronic),research and publishing of new journals fromIndia, writing makes a business sense too inaddition to professional growth and personalsatisfaction.

With the exponential rise in technologicalmodalities, health insurance (proportion ofIndians having any health insurance is less than15%), unethical referral, practice of defensivemedicine in the era of consumer awareness &protection, there is higher tendency amongprofessionals to investigate first and may beexamine latter. It may lead to higher cost but atthe same time some new diseases/disorders arealso detected during this process for which wenever comprehended. However, similar practice

is unwillingly being transferred to youngergeneration as a result they do not intend totouch or observe patient for learning.Stethoscope as an element of show-piece will befound only on pictures in archives of librarybooks or models in university museum. Withchanging life equation and dynamics studentsare apparently smarter and want results in shortperiod of time; interested in learning theorywith simultaneous declining trend of physicalfitness during under-graduation and postponingpractical learning for post-graduation period

thus aiding the path of growth for water-tightcompartment of numerous specialist and superspecialist.

Instilling belief that medical profession is a life-long learning is a challenge but we hang ourboots in despair after exams enough is enough.A person can be directed to a pond but notnecessarily be lead to drink too and on the samebut critical note inspiring teacher can make adifference in the of life of students and residents.In this era, such selfless mentors are alsobecoming hard to find.12,13 To teach or trainrequires time, energy and efforts from learneras-well as guide. Our peers in developed

nations14probably also passed (or still passing!)through these developmental changes howeverinterlinked global economy can shorten thetrajectory of system experimentation andlearning. Thus we can suitably adapt & adoptthe global best practices for pulmonology andsub-specialty development in India and still notlose the subtle relationship chord of beingconsidered as family-physician.

There is overall shortage of health humanresource be it medical, nursing or alliedparamedic (respiratory therapist etc)considering population or geographicalparameters but assumes critical proportion forspecialist. Taking the example of chest medicine,current (2010) estimated need of 1010postgraduate (PG) seats fall short of 660 as

actual is only 350 seats. Further estimate for theyear 2021 & 2031, the requirement for PG seatsare 2020 and 4039 respectively. India has largestnumber (330) of medical colleges (e.g. China has188) in the world with annual production of30,000 doctors and 18,000 specialist. High levelexpert group of planning commission onuniversal health coverage has further proposedfor creation of 187 new medical colleges in aphase manner and target of one doctor per 1,000will be achieved by 2028.15

On an encouraging and positive note,Government of India, Medical Council of India(MCI), National Board of Examination (NBE),Indian Council of Medical Research (ICMR),Quality Council of India (QCI) and specialtyassociation are engaging themselves and otherpartners for enhancing production,management, regulation & retention of humanresource, enactment of legislation, conduct ofstandard entrance & exit exams, curriculumdevelopment,registration/certification/accreditation,revamping education, streamlining training,providing funds for infrastructuredevelopment/innovation/technologytransfer/patent, promoting alternative system ofmedicine (AYUSH), institutionalizing capacitybuilding for research & knowledge transferthrough international collaboration.

With the epidemiological, economical anddemographical transition being observed in thecountry and concomitant rise of mobile/internetbased technology health communication withpatient has deteriorated further. Do we need to

re-align with the changing technology withfocus on evidence based medicine (EBM) or hold


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on to historical concepts? Medical and socialparadigm is being re-structured and canlegislation play a protective and deterrent role isto be seen during coming years. On a parallelnote, considering future chronic respiratorydisease burden16will it be premature to call foran urgent national movement to combatrespiratory diseases other than TB also is amatter for introspection, debate & discussion.

Nature preserves only the fittest and the currentcompetitive era has further propounded thisphenomenon to an extent, perform or perish.These thoughts could have projected aconfusing, gloomy and/or depressing scenario.However on the face of development we areevolving, hopefully for a better future andeverything may not look as dismal as it may

sound. Flexibility in approach, overallenthusiasm in life, positive attitude, hard workand patience along with value for traditioncould be possible answers. But how much wepromote, practice and sustain the core principlesis a matter of personal choices!

Conflict of interest: Nil

Source of funding: None

REFERENCES:

1. Global Adult Tobacco Survey (GATS) in India. Ministryof Health and Family Welfare, Government of India;2010.

2. Household consumption of various goods and servicesin India. NSS 66thRound (2009-10). National SampleSurvey Office (NSSO), Ministry of Statistics andProgramme Implementation, New Delhi: Governmentof India; 2012. Report no. 541 (66/1.0/3).

3. District Level Household and Facility Survey (DLHS-3),2007-08: India. Haryana: Mumbai: IIPS; 2010.

4. T. Evans, M.W. Elliott, M. Ranieri, W. Seeger, T.Similowski, A. Torres, C. Roussos. Pulmonary medicineand (adult) critical care medicine in Europe. Eur RespirJ 2002; 19: 1202-06.

5. Froudarakis ME. New challenges in medicalthoracoscopy. Respiration 2011; 82:197-200.

6. Gerard A. Silvestri. The evolution of bronchoscopytraining. Respiration 2008;76:19-20.

7. Rodrguez FC, Alvarez-Sala JL, Gascon FS, and othermembers of the Spanish National PulmonologyCommission. Postgraduate Training Program inRespiratory Medicine. Arch Bronconeumol 2009;45:394-04.

8. GT Conde, M Miravitlles, JLA Sala, FR Castro, JAncochea.Residency training of European RespiratoryMedicine Specialists: The HERMES Project. ArchBronconeumol 2009;45:92-99.

9. American Thoracic Society/European RespiratorySociety Statement on Pulmonary Rehabilitation. Am J

Respir Crit Care Med 2006; 173: 1390-13.

10. M Polkey, T Howes, G Burns, SG Spiro. Respiratoryeducation: a dangerous drift away from academia? EurRespir J2008;32:1144-45.

11. Jose R, Sachdeva S. Keeping an eye on future: Medicaltourism. Indian J Community Med 2010;35:376-78.

12. LDH Wood. Mentorship in Pulmonary and CriticalCare Medicine. Am. J. Respir Crit Care Med2010;182:1215-16.

13. Alsultan M. What makes an effective clinical trainer?Saudi J Kidney Dis Transpl 2011;22:1229-35.

14. Mary Jo Kreitzer, Benjamin Kligler, William C. Meeker.Health professions education and integrative healthcare. Commissioned for the IOM Summit on IntegrativeMedicine and the Health of the Public; 2009.

15. Report of the working group on tertiary careinstitutions for 12th five year plan (2012-2017).Planning Commission, Government of India, NewDelhi; 2011.

16. Khaled NA, Enarson D, Bousquet J. Chronic respiratorydiseases in developing countries: the burden andstrategies for prevention and management. Bull WorldHealth Org, 2001, 79: 971-79.

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MEDICAL EDUCATION, TRAINING AND PATIENT CARE FROM THE LENS OF MEDICAL INDIAN RESIDENT