What ails our Medical Education? Few suggestions

Let us face it straight; all of us have this question, but dodge it for various reasons.

What is the purpose of medical education in India? How is the curriculum decided? Why is it structured the way it has been running for last umpteen number of years?

This is twenty-fifth year of my joining MBBS. Throughout my graduate, post-graduate and super-specialty years, these questions have bothered me. I can vouch the questions have bothered all of us at some point of time.

One of teachers in P&SM had told, "The purpose of MBBS in India is to make a doctor to carry out all functions of any PHC (primary health centre - the basic unit of health delivery at government level) on completely independent basis, covering all essential medical needs and decide appropriate triage."

With this idea in mind, added on by exuberance of service orientation of youth, few of us take our internship very seriously. We want to make ourselves very useful to society by being good Doctors who manage the best PHCs! Whereas, most of our colleagues work hard on solving MCQs of PG Entrance exams.

After internship, forget getting a job in PHC, we are unable to get a job in any private nursing home also! Turns out our MBBS is no good at city level. No medical institute would give a permanent post for MBBS pass. Government service is ridden with reservations, nepotism and political influences. Only options are either work for a pittance in nursing homes/private hospitals (working mostly as clerks to senior consultants) or have clinic of our own (finance is a major issue) or go for PG course.

This was when we understand the futility of mere MBBS! We slowly lose all the fine skill acquired as interns! It is of no use if we do not get job of medical officer in PHC! MBBS is actually a certified qualification to write PG entrance exams!

Our friends were in the right track. Most of them did not take internship seriously. They maintained enough attendance and did minimal work to get completion from each department! They invested their time better by preparing for PG entrance exams. How stupid of us!

After horrifying competition and travelling across the nation by cheapest modality of transport to write various entrance exams (shamefully spending hard earned money of parents), we finally land with some PG seat. Many a times, the available PG course for our rank does not match our aptitude. But, we cannot be very choosy. Every year the competition increases. Even this seat may become a premium later! No chance-taking here! Just grab a seat and be a specialist!

This is, in short, what happens! Why is that the course pursued by the brightest students of this country so shabby and disorganised?

Five-and-a-half years of MBBS and now, government adds two years of rural service to it! No guaranteed job; no respectable income; no promise of safety; no assurance of secure future; no streamlining into PG courses! What's happening?!

Who decides the curriculum of MBBS? How many of us can remember what we studied in pre and paraclinical period? Was loads of information worth it? Applied courses should have an objective. What is being served for practitioner? When MD medicine Physician can be penalised by our court for treating myocardial infarction patient, why teach about complex surgical techniques at MBBS level?
Isn't it the time now to re-structure our medical curriculum to suit the present needs? Shouldn't we raise the voice for doctors of future? Just because we were given an unjust deal, should it pass on to every generation?

Some suggestions are enumerated here. This is an invitation to add all relevant suggestions.

The MBBS course should be cut short. One-and-a-half years for pre and paraclinical subjects put together. These subjects should be taught using visual imagery and 3-D teaching techniques. It should be interactive with periodic assessments. No anatomy dissections, no pithing the frogs, no instilling drops into the rabbits' eye and measuring pupils!
The next two years should be exclusively clinical. Didactic classes should stop. Small dynamic groups should be created to encourage group discussions and interactive discussions. The rotation should be similar to Family Medicine curriculum of DNB, but at basic level. After exit exam, 6 to 9 months of intense internship and 12 to 18 months of rural posting with pay of at least 75% of what the MO in PHC gets.
The overall duration including rurals should not exceed 5.5 years. The curriculum should include practical tips on how to establish a clinic or small sized hospital including economics and legal regulations.
Those who wish to stop here and practice should be offered interest-free bank loans for all the social service they have done by abiding to government policies (which no other professional in India does). They should form the first-tier of health care and should be encouraged the same way. This will lead to strengthening the family physician aspect of health care, which is glaringly lacking in India.

Post-graduation should be 4 years. First year exclusively for anatomy and physiology of concerned specialty. At this level, learning is super fast due to all the knowledge of MBBS. It should be on simulation and problem solving basis. For example, MS General surgery PGs should learn surgical anatomy and basic surgical techniques on cadaver. MD pathology PGs should learn histology and histopathology in great detail. The next 2 years should be spent on actual specialty learning.
The last year should be for developing practical skills or getting oriented for super-specialty, depending on the aptitude of candidate. They should come out as competent specialist to take on any challenge at their level of training.

Super-specialty should be for 4 years again. Three years of actual super-specialty with additional year of further sub-specialization. For example, a Cardiology super-specialty student should use last year in either coronary work or electrophysiology or transplant related heart failure and so on. They should come out as full-fledged specialist who can take on any centre confidently.

We are a huge country. Our health needs are diverse. We cannot just copy-paste the systems prevalent abroad. We need to make our own protocols. We need to have our own methods to ensure health-care delivery and check quacks. At the same time, we need to ensure an honourable life for doctors. The change cannot come by intervening half-heartedly at some random point of health-care delivery. It should happen at grass-root level - right at medical education. There needs to be a drastic restructuring.

Please pen in your views. Constructive criticisms of all variants are welcome! Please speak your minds. This forum should turn productive as it is meant and envisioned by its creator!

WHY ARE PEOPLE ATTACKING DOCTORS? THE MOCKING BIRD THEORY.



Yes; we are debating, quite fiercely!

How to prevent people from attacking doctors? By legislation? By police action? By employing bouncers? Or by not allowing our children from getting into this profession?!

We are scientific people! We detest quacks who treat on symptomatic basis. We seek an etiology, establish a pathogenetic scale and intervene at appropriate level using best of our discretion. Its all when we treat the ailments of others.

But, when it comes to tackling a serious question of our own safety, we never try to get into etiology; we are simply offering solutions at preventive level, damage control and rehabilitation!

The question that we need to ask and answer ourselves is, "Why are people attacking doctors?"

Didn't people attack doctors in the past too? Yes; but the incidents were extremely rare. Most of the times such attackers were not because some patient died.

But now, the reason for attack is the death of a patient. That answers "people attacking". Still, WHY and DOCTORS need answers!

WHY is a complex question to answer. Still worth a try.

Earlier when people moved around a hospital, they would see doctors at all important places. The chief of hospital, Medical Superintendent, CMO, Chief Physician, Chief surgeon etc were doctors. Most of the fees they paid were going to doctors. When a doctor wrote concession in bill, patient used to get it without much hassle. Doctors were most powerful part of the entire hospital system. Obviously for a patient, doctors were face of the system. The perception was fixed.

As of now, we are replacing hospitals with HEALTH-MALLS! Huge buildings, impressive interiors, expensive artefacts, eye-catching advertisements, discount coupons on health packages/lab tests, massive machineries, ultra-luxury wards, suites and what not!

These health-malls are managed by MBAs! Most of the decision makers are from business management background. They need not even know how a hospital looks like (let alone how it functions) before managing the complex system of healthcare delivery! They look at balance sheets, profit-loss charts, pie-diagrams instead of diagnosis, treatment charts and discharge summaries. They do "hiring and firing" instead of building a team of healers and counsellors.

But, unfortunately, for the patient, the doctors are still "face of the system". They do not realize that doctors no longer get bulk of the amount in their bill. They do not know doctors are not allowed to decide the cost of their treatment or to write concession. They do not even know doctors do not decide brand of medicine that patient should get! In the name of cost cutting, most of the Health-Malls ask doctors to write the molecule and will get the most profitable brand available in the market, irrespective of its quality or credibility of company! How would a patient ever know these things? How can doctors talk about such issues with all patients? Its neither professionalism; nor practical.

The moment an MBA is running a health-care delivery system, it is no longer a service oriented firm; it is a business organization! The priorities of such organizations are different from a humanitarian institute. So, the rules change. Doctors realize this and keep quiet. However, patients do not know this yet. For them, doctors are earning a lot from exuberant bills they pay! They think doctors are greedy that the cost of health care has soared to sky! They feel they deserve value for money!

This "value-for-money" in health care is ill-defined! For MBA admin, it is profit margin compared to other industries! MBAs feel that the profit margin of Health-Mall is less than other Malls! So, customer is getting more value for money! Simple economics.

For the patients, it is end-point of their treatment. "Don’t worry about the expenses; I just want my patient cured" is a common sentence used by patient's kin. That defines their "value for money". This "consumer mindset" which has replaced "care/service mindset" makes huge difference in perception.

When "value for money" is not met, Health-Mall MBA admin is unhappy. As earning members of system, doctors take the brunt. They fire doctors, break treating teams, lure few morally weak members to take up unethical stands, get a new consultant who is capable of drawing more patients into the system, change the pay-package structures of doctors and so on. The entire equilibrium in system turns chaotic and makes every doctor jittery and insecure.

When "value for money" is not met, patient party gets violent. They destroy property of Health-Mall, attack doctors/nurses, gather a crowd and manhandle hospital staff, threaten consequences, take legal course, go to consumer courts, hire a shrewd lawyer who picks at every loophole in the system; or worse, they blackmail the system to extract huge sums of money. As "face of the system", doctors are again at receiving end. The entire equilibrium in system again turns chaotic and makes every doctor jittery and insecure.

This explains "Why people attack"! But the question remains. "Why DOCTORS?"

We doctors have lot to blame and lot more to be pitied. We could do nothing when hospitals were replaced by Health-Malls. We could do nothing when power was taken away from us and given to MBAs. We could do nothing when money-hungry admins arm-twisted us to accept changed rules. Most of us were meek and weak to just nod our head to deteriorating standards of humanitarian consideration. Many of us just felt happy that we would earn more money and would be taken off the headache of managing "concession seeking" bunch. We had no idea of how future would turn against us!

Added to the woes were unscrupulous media and irrational policy-makers of Governance. Media has a huge role in demoralizing doctor profession. Even a 12th pass reporter or anchor gets judgemental without even making an attempt to understand reality. In fact, they don’t need reality; they just need "breaking-news", sensationalism, material to fill their 24 hour sojourn. They are not bothered about long-term impact of their stupidity and irrationalism over the society.

Government on the other hand cannot be left behind. With most of the politicians having a meaty portion in Health-Malls, the policy makers make sure their investment is safeguarded but a scapegoat is ready for blaming for any mishap. Doctors are such inevitable scapegoats! We are neither empowered to resist nor given an opportunity to explain our plight. We are just at receiving end of scathe. The worst part of the entire picture is that even the judiciary understands none of these nuances.

So, with no support from internal system, no understanding from media, no sympathy from policy makers or judiciary, we doctors are overexposing ourselves to angst and fury of the patients' kin. We have nothing to protect ourselves with. Our job makes us vulnerable.

This probably explains Why DOCTORS?

Overall, the scenario is complex. At one extreme is the vulnerability of hapless Doctors/Nurses; on the other end is the delirium and hysteria of patients' attendants. Given the complex nature of economic dynamics running the health-care today, conflicts are inevitable. Civilized conflicts like legal option damage the doctors personally and financially. Uncivilized conflicts like manhandling, assaults, media induced infamy harm us physically, emotionally and psychologically.

The most painful aspect of entire equation is that the actual culprits are not even in the scene. Business managers who run the Health-Malls and Policy makers of health care are the actual causes of conflict of this complex nature. But, they are not made accountable; no one asks them any questions; long term impacts their decisions are not even brought to the book. No one bothers to get into the roots of the problem to find a long-term solution.

By making counter-attack groups, asking for laws against attacks, asking our kids not to join this profession, we just applying Iodex over the abdomen for Appendicitis! It is either too short-living or being irrational. What we need is something as drastic as an emergency surgery to deal with a potentially life-threatening condition. There is no point in killing a mocking bird.

The million dollar question is: Is the government ready for taking any long-lasting action? Can we have a solid health-care plan that assures quality health-care at affordable prices for all segments of society? Can we regenerate the faith of public on the doctors? Can we restructure hospitals by deconstructing Health-Malls?

Can we? Can anyone?

Open criticism and caustic suggestions are most welcome!

Dr Kiran welcomes all the readers to the blog of Pediatric cardiology department, Narayana Hrudayalaya Hospital, Bangalore.

Recently I met my primary school-mate. Discarded as “mediocre” by my teachers then, he is a successful entrepreneur today! He runs a software firm with 80 people working under him! His company develops custom-made computer softwares and high-end smartphone apps for medium to large scale companies.

“Managing 80 employees must be quite difficult. How do you deal with problem of recruitment and attrition?” I asked him.

His answer was eye-opener. He has simple logic. “I believe in them!” he said. “I select my employees through known circles, mostly through the existing ones. That leads to better accountability and indirect control. But, I assign job responsibilities for everyone as per my assessment. I don’t care about their legacy, the institute they have graduated from or certificates of credentials they carry. CVs are the easiest to fake nowadays and getting references cross-checked is cumbersome. I just want to make sure that they understand what they are doing and how good they are at that work. We pay one of the best packages in this sector. So, I am all about what I want from them.”

“Not that alone”, he continued. “I don’t allow back-biting or speaking negative of anyone. We address workplace problems through a confidential information system where the identity of whistle-blower is completely safe. We have works meant for individuals and groups. If a person does not qualify for either, I fire him! I hate parasites who do not know the work and who live only on the ability of others. To sustain that status, such people usually cause rift between one-another. Their entire existence is dependent on such ill-wills. When one of their hosts realize this, such parasites simply shift their host! Such people are blemish to civilized world. We don’t lose anything by getting rid of them! In fact, on a long run, their absence caters growth of the company.”

“Even better would be sending them to your rivals!” I said jokingly and we laughed.

I was smitten by his insight. He is of my age and how much of worldly sense he has gained by self-industrious path! I was wondering how big time corporates can make use of this principle. After all, ergonomics is the key for eventual profit.

I came across an article in the June 2014 issue of “Journal of Cardiothoracic and Vascular Anesthesia” titled “Extubation in the Operating Room After Cardiac Surgery in Children: A Prospective  Observational Study With Multidisciplinary Coordinated Approach.” Matter of pride is, it is from Narayana Hrudayalaya! Our senior pediatric cardiac anesthesiologists, Dr Rajneesh Garg and Dr Keshava Murthy have authored this.

This was a prospective observational study with controls taken from past, on historic basis. They have studied 1000 patients in the “study group” (age: 1 day to 18 years) with another 1000 historic controls, comprising “before study group”. The study group had undergone cardiac surgery with combination of general anesthesia and neuraxial analgesia with a mixture of caudal morphine and dexmedetomidine. These patients were planned for extubation in the operating room after completion of the surgical procedure. They were compared with historic controls for impact of extubation in operating room on ICU stay and resource utilization.

The authors have been successful in extubating 87.1% of study group patients, including 40% neonates. Of these, 45 required reintubation within 24 hours. The authors observe that overall ICU stay was reduced by 50% in the study group as compared to control group with positive impact on resource utilization.

The authors give a detailed yet lucid account of the patient groups and sub-groups undergoing surgery. They have also documented the factors that lead to deferring extubation in OR. High risk category demanding reintubation has been discussed. They have done detailed statistical analyses of their observations and findings.

The main limitation of this study is utilization of historic controls. This point is acknowledged by the authors. Also, such studies need to be properly blinded to enhance their value and neutralize the bias. The authors have also observed this limitation. But when the number is so large, the chances of bias are not very high, especially when standard protocols are applied as a rule. The cost-benefit analysis is an extrapolated conclusion in this study, with no actual measurements. The authors have acknowledged this fact.

Can this be followed in other centres with lesser numbers and lesser resources? The authors recommend that if early extubation within 2 to 4 hours in the ICU can be practiced, then the re-intubations for re-exploration for surgical bleeding and diaphragmatic palsy can be avoided. They also recommend that perioperative course can be planned in such a way that many patients can be extubated safely at the completion of the surgery either in the OR or early in the ICU, depending on the applicability in that particular center, instead of planning elective ventilation. This helps in keeping a custom-made approach than a blanket version.

The study does not inform the age and weight related mortality in the study group. Weight or Body Surface Area, being an important factor in pediatric ages, could have found a place in their otherwise detailed analysis. Extubation failures related to age and weight/BSA can carry more practical message. Also, if the authors had risk-stratified the patients based on diagnosis and pre-operative conditions, it would have has better impact for those who would like to emulate. Such large numbers are not easy to study. The authors should be applauded for their commendable work. Equal credit should go to the intensive care team for managing the aftermath!

With that, let us get back to few learning scenarios:

306.    CUTTING OFF THE HIGH-WAY

In children with single ventricle physiology with pulmonary atresia, PDA forms the highway for pulmonary circulation along with some collaterals. In cath study, entering PA through PDA is risky. We take reverse pulmonary venous wedge pressures as correlates of mean PA pressure. How much reliability can be attributed to this correlation? We at NH had done a small observational study a couple of years back and found a difference of 2 to 3 mmHg between the two. The question remains, is the cath study required for pre-surgical hemodynamic data in such cases? Wouldn’t interrupting PDA enough to bring down PA pressures to normal? How many centres still follow doing cath studies in such children before single ventricle palliation? Does any centre “not practice” cath study in such scenarios? What is their experience? Please let us know your learnings on this.

307. PROXIMAL COMPLIANCE

We speak of compliance of ventricles a lot. But, we largely take the compliance of atrial cavities for granted. Can there be issues in this regard? Let us take Mitral stenosis or Mitral regurgitation as example. The progress of high PA pressures and RV dysfunction varies in different patients. Can LA compliance be used to explain this variation? Logically, if LA compliance is good, the progress of PAH should be slow. On the other hand, the progress would be faster if LA compliance is poor. Is there any study looking at this issue? What is the personal experience in other centres? Please share.

308. TO CROSS OR NOT TO CROSS

One of the feeders for perpetual tussle between pediatric cardiologist and surgeon is on the coronary crossing RVOT in children with Tetralogy of Fallot. Acts of both commission and omission are held accountable here. Even after advent of CT, this tussle hasn’t doused off. Despite all this, is there any systematic study on the actual disparity between the data on echo report and on-table occurrence? It would be interesting to know this data in high volume centres. Has any centre studied this? It would be interesting to know.

309.ANYTHING LEFT OTHER THAN LEFT?

We have earlier discussed various possibilities of great artery relationship in TGA. We have seen d-malposition, L-malposition, antero-posterior or side-by-side in children with TGA. However, in children with congenitally corrected TGA, we hardly see any relationship other than L-malposition. Has anyone come across any other malposition of great arteries in CCTGA? What is the explanation for this rule? Please let us know.

310.BREATHLESS AFTER SURGERY

What is the incidence of diaphragm palsy after cardiac surgery, which mandates intervention? Diaphragm palsy offers significant morbidity in the post-op period. It also increases the ICU stay, overall expenditure and cumulative mortality. But the actual incidence reported seems quite different from what is usually seen. Is there any reliable data on this? What is the break-up incidence for different lesions? Is there any correlation with CPB time? What is the usual outcome? How many such incidents require placation or other interventions? Please let us know your observations.

That brings us to the end of this post. Please pen in your comments in the comments section. If you find any problem in posting comments, please mail it to my email id kiran.vs.dr@nhhospitals.org I shall post them on your behalf.

Regards

Kiran

Dr Ravi Ramamurthy has done it again!

This time, he is talking about the statistics part of the erstwhile article we discussed in the previous post: "Risk stratification at diagnosis for children with hypertrophic cardiomyopathy: an analysis of data from the Pediatric Cardiomyopathy Registry". He explains some of the jargon related to medical statistics for the understanding of those who can just spell the word!

Here we go: 

“There are lies, damned lies and statistics” …..

Mark Twain certainly did not have medical biostatistics when he popularized this phrase.

The contribution of statistics to medical science cannot be said in the same light. The weight of a study is determined by its statistics. So let us just take a breather from just satisfying our intellectual taste buds by tasting only the abstract of an article and proceed to actually looking at the entire cooking process.

I was exposed to statistics when I accompanied my mother to the vegetable market.  The potatoes were “sampled”; by size, freshness, color etc. Then they were screened for “predictive markers” indicating their likely shelf life before they reach their “end point” either cooked or rot. And the inevitable remark that out of the last purchase, what percent of the potatoes went bad (“failed to survive”) within a fortnight (“period of observation”). These observations helped us predict and pick the best potatoes.

 In the article under discussion, “Risk stratification at diagnosis for children with hypertrophic cardiomyopathy: an analysis of data from the Pediatric Cardiomyopathy Registry” the clinical implications and its applicability is quite obvious. So the million dollar question would be “Why do we need statistics to prove it?” The answer is simple. Any data needs to be authenticated before it can be applied in practice or replicated. This authentication process is done by statistics.

In this study, two important statistical analytical methods were employed. Let’s discuss them in brief.

Cox proportional-hazards regression:

How important is it?

 It appears in one in ten papers.

How easy is it to understand?

Aim to understand the end result – the “hazard ratio” (HR).

When is it used?

The Cox regression model is used to investigate the relationship between an event (usually death) and possible explanatory variables, for instance observe table 3 & 4 in the article in detail: “Idiopathic, diagnosed at age less than 1 year; Idiopathic, diagnosed at age more than or equal to 1 year; Malformation syndromes; Inborn errors of metabolism; With restrictive cardiomyopathy; With dilated cardiomyopathy.”

What does it mean?

The Cox regression model provides us with estimates of the effect that different factors have on the time until the end event. As well as considering the significance of the effect of different factors the model can give us an estimate of life expectancy for an individual.

Regression and correlation are easily confused.Correlation measures the strength of the association between variables.Regression quantifies the association. It should only be used if one of the variables is thought to precede or cause the other. Interpreting the Cox model involves examining the coefficients for each explanatory variable. A positive regression coefficient for an explanatory variable means that the hazard is higher and thus the prognosis is worse. Conversely, a negative regression coefficient implies a better prognosis for patients with higher values of that variable

The “HR” is the ratio of the hazard (chance of something harmful happening) of an event in one group of observations divided by the hazard of an event in another group. A HR of 1 means the risk is1 × that of the second group, i.e. the same. A HR of2 implies twice the risk.

Kaplan–Meier estimate of the survivor function

To determine the Kaplan–Meier estimate of the survivor function for the above example, a series of time intervals is formed. Each of these intervals is constructed to be such that one observed death is contained in the interval, and the time of this death is taken to occur at the start of the interval. A plot of the Kaplan–Meier estimate of the survivor function (Figure 1) is a step function, in which the estimated survival probabilities are constant between adjacent death times and only decrease at each death. Figure 1 of the said article depicts a step wise graph of the surviving subjects in the study upto five years where the number of surviving subjects can be seen on the Y axis of the graph.

I have tried to simplify these statistical tests, probably a bit too simplified. The intricacies regarding a test lie in deciding where and when to use a certain test. This narration cannot dwell in these details. Secondly the calculations are quite enormous and confusing. But thankfully suitable software are available to carry out these tests. It is imperative for a researcher to be conversant with the various statistical software packages available before embarking on a study. A few examples are Epi 6, SSPS, SAS etc. A researcher should have his statistical test decided before embarking on a study, therefore it is prudent to discuss with a biostatistician beforehand.

So much for now. 

That is Dr Ravi Ramamurthy for you! If you have any doubts or applause, please email  them to kiran.vs.dr@nhhospitals.com or write a comment in the comments box below. It will be honored!                                               

Hello to the readers!

Our new fellowship student Lt Col Dr Ravi Ramamurthy has agreed to contribute his video presentation on “Natural history of ASD, VSD and PDA” for the readers of blog. Please find the same attached. It can be downloaded from here, but any use of material in the video should be with consent of author. You can write to my email (kiran.vs.dr@nhhospitals.org) for the same.

Please comment on the contents of this video.

Regards

Kiran