Category: education

A number of junior residents at Jipmer have raised allegations of mental and physical harassment against the head of department, medicine, and called for action against the senior faculty.
In recent complaints lodged with the Jipmer Dean (Academics), the residents alleged they were subjected to various forms of harassment at the hands of the department head during the three-year PG residency. They sought re-examination of the results of the exit examination on December 23 as they suspected they were deliberately failed in the practical segment by the faculty member.

This is from The Hindu a couple of days ago.

This is just one among the many thousands of such incidents across medical colleges. It would be really difficult to find a medical college which doesn’t have harassment and bullying.

When this came up for discussion in a WhatsApp group I am part of, there was an interesting debate. While everyone acknowledged that there is a hierarchical culture in medicine and that this needs to be rectified, there was a slight disagreement on the exacts of how and why.

One argument was that the medical college culture is an extension of the casteist culture outside and that it will go away only when caste based discrimination disappears. To this some disagreed a bit and said it is not the same in institutions like nursing colleges.

Today morning I tweeted: “If you apply the corporate workplace harassment standards to medical colleges, you’ll have to fire *all* doctors. That’s how horrible that culture is.”

I do think there’re more issues that lead to the culture in medical colleges apart from casteism. I list down the potential causative factors here.

As you might know, I believe in intersectionality and in the contribution of all these causes (including causes that’s not mentioned here) to the problem. The listing here is by no means a suggestion that “X is the reason ABC happens”. If you remove X, you’ll still have Y, Z, and so many other issues.

There is a lot of work to be done in medical colleges

A medical college (especially in government settings) has a lot of things happening at once. There’s out patient department and the rush of patients. There are new admissions being made. There are existing in-patients who need follow-up care. There are constantly new developments (new symptoms or worsening of symptoms, new investigation results). There are plenty of learning requirements to be met. There are procedures to be performed. There are resources that need to be mobilized. There is paper work to be done. There are a lot of people talking to each other, lots of communication and miscommunication. There are duty rosters and handovers. There are emotions and sickness playing beneath all of this.

Almost everything requires to be done as soon as possible too, if not stat.

There is a lot of gap in resources

Often (especially in government settings) the resources required for getting a lot of work done is simply not there. This could be things like medicine, dressing equipments, and suturing material. Or this could be human resources like nurses, specialists, doctors, cleaners, attenders, pharmacists, and technicians.

There is poor spending on healthcare in Indian budget

As a country, India spends much less than what it should on healthcare.

The science of medicine is imperfect and the art of medicine is really hard

Medicine as we practice it has only evolved in the last few decades or so. We still have no idea what’s going on in a lot of situations. It’s an imperfect science. Biology has a lot of secrets.

Add to that we’re dealing with human beings. The art of handling sickness and patient care is always complicated by the intensity of emotions.

Who wants to work hard?

I’ve left hospital based practice long ago. And I’ve not been even doing clinic based practice in the last couple of years. Because it is a lot of work.

When there’s a lot of work, some people find ways to make it fun. They focus on the learning and growth. Or they focus on the people they’re serving. If you can make hard work fun, you can do it for a while.

But it is not possible to do it forever.

Medicine is not fun

After a point, you get a lot of similar patients. There’s plateau in learning and drudgery in work.

Even when you find ways to enjoy some of that, you can’t enjoy death. People literally die. Despite all of what we do. How do you make death fun?

There are not many options for a change in scenery

It’s the same kind of work from the end of MBBS till retirement. You go to hospital. You see patients. Medical college faculties don’t even get transfer. You’re stuck in the same department of the same building for your entire career.

Lack of skills leads to insecurities

We established that medicine is hard. Many doctors lack skills – be it in the clinic, or in their life. They are sometimes aware of their incompetency too. And some of this manifests as insecurities.

Everyone loves delegation

The best way to get something done while hating it is to delegate it. Patient care is complicated. If it can be delegated, it is less of a headache.

Delegation requires power structures

The easiest way to ensure you can always delegate work is to ensure that there are people “below” you who can do your work at your command. Maintaining a hierarchy is essential for delegation.

Hierarchies are easy to maintain in a hierarchical society

How do we build a hierarchy? We just need to belittle others. There are numerous ways to belittle others when the society has trained many people in things like:

• caste
• gender
• language
• physical appearance

In medical colleges there is a much easier way to belittle people – using their years of experience. Someone who is “junior” can be belittled easily as they will have that much lesser experience.

Individuals can’t fight the hierarchy

Because medicine is hard no individual can do it alone. You can’t run a hospital by yourself. Especially if you’re a junior doctor who is still learning, you absolutely would be terrified of doing patient care without support from seniors. How can you fight someone whose support you need for your work?

There’s always something more urgent

There is no space for conflict resolution in medical colleges. Patient care always comes up. There’s no time for cooling down. There’s no time for empathy.

The individuals who get in are of questionable merit

Most doctors are doctors who have gotten good marks in an entrance examination. This is a test of their memory and cognitive skills in a very narrow domain. This makes the selection process to medical colleges be highly skewed. The skills in various other domains – like social skills, emotional intelligence, empathy – are not regarded at all.

Without these other skills, it is very difficult to even acknowledge when something wrong is happening.

There are not many role models for better culture

Where does one find examples of good work culture in healthcare in India? Very few “alternative” healthcare institutions provide such an exposure. This is not accessible to a wide variety.

Medicine is mostly seen as a job, and not as a passion by many

There aren’t a lot of people who think in terms of quality improvement, safety, etc in medicine. For many it is a job. A way to make money and live.

And hundred other reasons

These are what I quickly wrote down. I’ve not gone to a medical college in a powerless position since about 7 years. I do go to medical colleges very often as an “external” “senior” instructor. I’ve used this “power” to understand some of the power structures within medical colleges from up close. That has led to some of the insights above.

There are possible many other things that contribute to the mess. Some of the ones above could be wrong too. There are possibly many interventions one can do on many of these problems.

Whether one likes it or not, everything is getting digitized. And it is often a good idea for human beings to keep abreast of changes. This is a series of posts designed with community health folks in mind to help them develop mental models around the technologies that make up the digital world.

In this post, we will look at certain foundational terms like “information”, “data”, “communication”, and “computer”. Then we will connect it to words like “internet”, “server”, and “cloud”.

***

Information / Content / Data

Anything that is meaningful is “information”. Emails, videos, textbooks, numbers, anything that you can imagine and represent or store in some form.

“Content” is just another word for information used in specific contexts. Like if I’m sending you an email, the body of that email would be called “content”. An article has content. A youtube video has content. An instagram post has content. A tweet thread has content.

“Data” is yet another way of looking at information. If you collect information about 50 people while doing a research project and put it in a spreadsheet, you might call it research data. If a hospital keeps a medical record of a patient who was admitted there, that would be called health data. If you write a brief bio of yourself and share it with someone, it might be called a biodata. 

***

Communication

Human beings have been communicating forever. We can talk to each other. Or we can draw something on the wall which someone else can come back and read later – perhaps after a day, perhaps after centuries. We can write letters. We can write emails. We can message people.

Communication is just transfer of information/data from one place to another, from one mind to another.

It need not always be one-to-one. It can be one-to-many. Mass communication.

We will come back to the term ‘communication’ in a while.

***

Computer / Computing device 

A computer is a machine or a device which can be used to view, store, transmit, receive, and manipulate/transform data or information.

Is a physical book a computer? It can be used to view, store, transmit and receive information. But it cannot manipulate or transform that information.

What about a calculator? Is it a computer? A calculator can be used to view, store and manipulate/transform information. But it can’t really transmit or receive information, can it?

What about a smartphone? You can send and receive data/information via smartphone. You can store it and view it. You can also manipulate and transform it. A smartphone is a computer.

So is a laptop, or a desktop.

Computer as a Communication Technology

You might have noticed that in the above section, I am referring to the computer as a machine that can be used in receiving/transmitting information, or, communication. In the past people might have called a calculator a computer. But today, computers are almost universally able to communicate and therefore it is ideal to view computers as machines useful in communication technology.

What kind of communications do computers allow?

Email, WhatsApp, YouTube, Instagram, Twitter, research publication, reading journals, reading news, writing blogs, reading blogs, putting things on a website, viewing a website, so on.

(Remember – your smartphone is also a computer!)

***

Internet

The Internet is the simplest and most powerful creation of human beings in the past few decades.

It is super simple. Imagine I (A) connect my computer and your (B) computer with a cable that can transmit information. Now I can send messages from my computer to yours and vice versa. A—B

Imagine now that you connect your computer with that of another friend (C). Now, I can send a message to C through your computer.  A—>B—>C

If D connects to C’s computer, D can send a message to me. D—>C—>B—>A

Imagine most of the computers in the world connected to each other through each other. Like a huge “net”. That’s internet.

This connection need not be through a physical cable.

It can also be through the electromagnetic spectrum. 4G, 5G, WiFi.

You might have a question here. You have only one computer in your place, and it is not connected to any other computer. How are you able to browse the internet, then?

Well, actually, when you’re connected to internet (be it through wifi, be it  through mobile data), what you’re actually connecting to is a computer. That computer would be in the office of your internet service provider (Airtel, BSNL, Jio, etc). And they connect their computer to the rest of the world through massive underground cables.

Basically, the whole world is connected through cables and electromagnetic spectrum. And that’s how internet works.

***

Server

A computer is not a magical device.

If your computer is switched off, you cannot read your emails from it.

If your computer is not connected to the internet, it cannot send or receive information from the internet. If your wifi is switched off, or your data pack is over, you cannot receive whatsapp messages or emails.

But if that’s the case, what will happen to the WhatsApp messages others send to you when your phone is switched off? Where does it exist? Where is it stored? 

Let’s say B’s phone is switched off. A sends a WhatsApp message to B. A then switches their phone off. Both phones are now switched off. Does the message exist anywhere?

B switches their phone on now. (A’s phone is still switched off). Will B receive the WhatsApp message sent by A?

The answer is yes. And the answer is “servers”.

A server is just a computer that is kept on and connected to internet all the time.

When A sends a WhatsApp message to B, A’s message is not directly send from A’s phone to B’s phone. Instead, A’s message is send from A’s phone to a computer owned by the WhatsApp company. This computer is always kept on. This computer might physically be located in California, or London, or Mumbai. We do not know for sure. But WhatsApp knows. And “server” is just another word for this computer that is always on.

This server sends the message then to B whenever possible. If B is online, it will immediately send that message. If B is switched off and later comes back online, the server will send the message to B then.

That’s what a server is. A computer that’s always online.

It is not just WhatsApp. Almost everything in today’s internet works through servers. If you’re reading this through an email, you are probably getting that email off your email providers’ server (Gmail/Yahoo/whoever). If you’re seeing this on a blog, you connected to Blogger company’s server to download this post to your computer.

***

Cloud / Cloud server

Cloud is just a fancy name for servers run by big companies like Amazon/Google/Microsoft. When I run a computer at my home and keep it always online, it is called just a “server”. But when a capitalist company runs a computer at their air-conditioned, high security, custom built buildings, it is called a “cloud server”, or sometimes simply “cloud”.

 ***

We will look at some related words like “client”, “database”, “website”, “protocol”, etc in the next post.

In our primary healthcare leadership fellowship that’s been running for 2 years now, we’ve only used self-assessment by fellows as a measure of impact till now.

While self-assessment is the easiest to perform and also gives a good sense of subjective measures like confidence and readiness, bringing objectivity to the measurement of impact is important for academic rigor.

The subject of measurement here is leadership. How do we objectively measure leadership and/or growth in leadership?

For that, it becomes necessary to define leadership in some way. Fortunately, there’s an article that RK keeps showing everyone which details 6 roles of a family physician. 

The roles are

• Care provider
• Consultant
• Capacity builder
• Clinical trainer
• Clinical governance leader
• Champion of community orientated primary care

We can define primary healthcare leadership as excellence in all these roles. It is easier to develop objective measures for some of these at least.

Here are some examples:

Capacity builder – How many practitioners are being or have been mentored/supported by the practitioner?

Clinical trainer – How many workplace trainings have the practitioner conducted in the past 3 months?

Champion of community orientated services – Has the practitioner worked with the community to develop/promote any community based service?

It is important to evaluate these at the baseline, incorporate growth in these dimensions as an expectation during the onboarding process, and re-evaluate these at the end of the fellowship to get an objective metric of leadership growth.

I was trying out the Daily Rounds app on Android and came across a case description “Unilateral limb swelling in a 51 year old lady. No comorbidities. KFT normal. How to proceed to diagnosis?”

This reminded me about how clueless I was about history taking during medical school. I think if I’ve learnt anything well by now, it is on how to take a detailed history. And looking at this question made me realize how much that helps me in coming to diagnoses. So here are some super simple tips to take detailed history while building a personal connection – which doesn’t require any knowledge of pathology or medicine.

Start with the person

You might have learnt that asking for name is the way to build rapport. But that’s a lie. Asking for name is so you can write it in your notes. If you want to build rapport, talk to the person in front of you (and not the patient). I’ve found that the question “have you had breakfast?” in their language (adjusted for the time of the day) is a super simple way to build rapport. And the reason is that this is what regular people usually ask each other casually when they are on the road.

This lets the patient relax and breathe free. With just one sentence you’re telling them that you’re a human like them and you respect them like another human. That their sickness is secondary to their human existence.

Move to the patient

There are people who assume that doctors who get into medical school through reservation end up as bad doctors. They have no clue how medical school works.

I won’t go into the reasons why reservation (or affirmative action) exists. That is one of the easiest ways for governments to “do something” towards inequity in the society. This post is about the relationship between medical school and bad doctors.

Defining bad doctor

Let’s first define a “bad” doctor. An objective way of measuring that would be – a bad doctor is someone who kills the most number of patients. There’s a problem with that though. A doctor with no patients would then not be a bad doctor. And a surgeon who takes on the most difficult cases (with proportionately higher chances of deaths) would also be considered a bad doctor. So, the absolute number of patient deaths is not a very good measure of the badness of a doctor.

Maybe we can then take the subjective measure of “patient satisfaction”. The doctor who gets 1-star rating for most consultations is a bad doctor. That is tricky though. The doctor cannot keep only the emotions of the patient in mind. The doctor also has to worry about the medical issues. If a patient prefers that the doctor does not examine their abdomen, a doctor who is dealing with this patient’s “pain abdomen” may score poorly on patient satisfaction if the doctor does consider it important to palpate abdomen. Patients might be less satisfied if the doctor doesn’t prescribe them a few medicines. 

If “patient satisfaction” is measured in a longer term wherein the formalities of a consultation are forgotten and all that remains is the satisfaction of achieving good health, maybe then it is a good measure.

People in the profession can also score doctors. I could make up a criteria for scoring doctors. I could say the doctor who practices the most rational, ethical, and cost-effective medical care is the best doctor and vice versa.

A hospital can say that the doctor who generates the most revenue for the hospital is the best doctor.

Someone can say that the doctor who works the longest hours is the best doctor.

It is thus clear that who is a good doctor and who is a bad doctor is a difficult thing to have consensus on. Let us nevertheless choose a popular vantage point.

Let us call the doctors who are irrational in their care and leads to poor health outcomes as bad doctors. (I had initially included “insensitive to their patients” in that list, but apparently many of us elites think that the fictional (or not?) “Dr House” is a good doctor. So we will first talk about these “good” doctors and later come to whether there are alternate definitions of good doctors).

Medical school training

What does a medical school train doctors in? Indian medical schools (at least the south Indian universities I know about) confer MBBS degree on someone based purely on theory exams and practical exams with theory given more weight. The whole training for 4.5 years is focused on what those exams need. And how’re those exams conducted?

Theory exams are mostly single sentence questions that goes like “Write a brief note on <insert health condition name>”. (You can see many question papers in the archives of this blog). There is no “Higher Order Thinking Skills” involved in MBBS theory papers. The only skill tested is that of ability to memorize a lot and write a lot more.

Practical exams are slightly better. In the clinical subjects, there would be patients called “cases” who are examined on the spot by the candidate and afterwards an examiner(s) and the candidate discuss the “case”. These practical exams are not scored with an “Objective Structured Clinical Examination” pattern. Therefore, it doesn’t matter how you examine your patient or if you examine them at all, all that matters is that you have the right diagnosis and that you can discuss lots of points about that diagnosis with the examiner. In reality, often the diagnosis of the patient is “leaked” to the candidate before the exam and once that is known the patient is just a prop in the act.

In summary, medical school tests you on how well you can remember the textbooks – and that alone.

Does that mean all the training in medical school is towards that? No. There are some islands (in form of an exceptional lecturer, post-graduate or peer) where other skills are focused on. But to a large extent medical school training is towards what is tested.

In reality, medical school training does not help people perform good even in these tests because medical school training is literally paid doctors who have no philosophy on teaching (let alone facilitating learning) passing their time with by wasting the valuable time of learners. If medical school professors were sent to teach 12th standard biology classes, their students would dropout and re-join 11th standard in the computer science stream.

(Of course there are some really good people. And the bar is so low that even someone who talks to their students with kindness are considered good professors in medical school. Anyhow, let’s not be bogged down by exceptions)

How are doctors made then?

Doctors become doctors not because of medical schools, but in spite of medical schools. It is mostly their interaction with textbooks, peers, patients, and life in general that makes them doctors. And only because the law restricts this opportunity to the confines of medical schools, it is restricted to medical schools.

The skills involved in patient care – communication, courage, critical thinking, empathy, leadership, etc have nothing to do with medical school training.

The theoretical knowledge involved in patient care are all textbooks based.

Procedural skills are learnt by doing (on real patients) with some supervision and there are no special courses to improve or learn these skills in a setting where it is okay to make mistakes.

Where do doctors really learn their craft then?

MBBS doctors start learning real medicine towards the end of MBBS (on their own). They get really good at it only after MBBS – either by working as a postgraduate student or by working in hospitals.

And these opportunities to learn after MBBS are really diverse and heterogeneous. Some work as residents in certain specialty departments where they learn a lot about those specialties (and a bit about medical care in general). Some do this with a gap of a few years (spent in PG entrance preparation).

From then on they keep getting better at it. Because every new patient they’re responsible for teaches them something new.

In essence, the 5 years in MBBS has little to do with how good/bad your doctor is. Medical school is a place where doctors learn about the outline and the syllabus of MBBS. After graduating is where they learn to treat people – and that is what decides how good your doctor turns out to be.

What makes a good doctor?

Privilege plays a role. If one has the privilege to get trained abroad (or in India) in medical schools that are interested in pedagogy, ethics, and rationality, there is a good chance that they learn to become better doctors. Also if one has the privilege to afford to work with lesser known good doctors within India, again there is a good chance that they learn to become better doctors.

Scientific temper and critical thinking plays a role. I’m not really certain how one gains these skills. Life experiences that makes one skeptic may help, perhaps? Or reading about science might help too.

Empathy and emotional intelligence plays a role. Understanding one’s patient and their context is critical to be able to understand what they’re saying. Often the patient is telling the doctor the diagnosis, but the doctor can’t hear because they cannot connect.

If you’re under the impression that performance in an entrance test is what makes a good doctor, you’ve gotten it completely wrong.