A curios case of moral hypocrisy

The British Raj created a special service to rule the undivided India after the rebellion of 1857. The sole purpose of this new service was to rule, control and extort taxes, on behalf of the British monarchy. It had nothing to do with serving common people. The commonly known Indian Civil Service (ICS) was actually created in 1958 as the Imperial Civil Service. Sooner it became the steel backbone of the British Raj. At one point, a small cadre of little over thousand people ruled more than 300,000,000 Indians. Each officer had an average of 300,000 subjects, and virtually controlled every aspect of their subject’s lives. Hence, with a handful of clever, shrewd and rather ruthless people, a small country like England was able to control a vast and populous country like India.

At the time of the partition, there were 980 ICS officers consisting of 468 Europeans, 352 Hindus, 101 Muslims, and the rest from other communities. The service was divided into the Indian Administrative Service (IAS) and Civil Service of Pakistan (CSP). The British Empire has gone but it left behind one of its biggest legacies or curses. The first Prime Minister of India is known to have ridiculed the service and noted that someone had defined the service as, “with which we are unfortunately still afflicted in this country, as neither Indian, nor civil, nor a service”. Gradually, the service became untouchable and all-powerful, taking the shape of a coloniser within. The governance and democratic institutions having become its slave, we have thousands of monarchs in today’s time working on the same old colonial principles with total domination. Has the British legacy succeeded and brought the country to its knees? Has the service maintained its glory till date by doping the common people?

A friend from Bihar told me that parents are happy to fund their children as long as they are preparing for the civil services exam. The brightest brains with professional degrees from institutes like IITs, IIMs, and medical schools are sucked in. What makes IAS so prestigious? Is it the average salary? No, I do not think so. Professionals can make much more by honest means. Does the type of work and contribution to society make it desirous? One has to be a fool to believe that. The perks and the secondary, side sources do make it attractive as long as one is ready to compromise one’s integrity. Any graduate, with an average intelligence, can perform the said duties as there is hardly anything professional or technical about it. With a few months of training, you are supposed to run any department and that is why any graduate from any background can apply to join.

This brings us back to the societal hypocrisy contrary to the values we try to teach our children. We still love and respect people who rule us than those who serve us. There are unlimited opportunities for corruption once you are an alleged civil servant. A recent survey showed India to be among the worst corrupt countries due to this rigid and self-serving bureaucracy. The crony capitalism is another gift of the service. The service still commands the power which it had during the colonial times and has made sure that every aspect of your life is hostage to its interference. The power strangely comes with respect, maybe out of fear or the hangover of the slave mentality. Hence, professions like teachers, nurses and academics hardly matter in our kind of society, as corruption and power is what people aspire to. By qualifying an exam, a person suddenly becomes a VVIP, an elite and ultimately out of reach to a common man. Why is that? And how is it compatible with justice and principles of democracy?

How can you afford the lavish lifestyle of one class of employees and fail to pay even basic salary to the front line workers? You may be able to punish politicians by sending them out of power at the next election, but there is no way of holding Babus accountable. The failure of various public services and institutions run by these generalist elites is no secret. They may have been relevant and effective a century ago, but in the current age, institutions and services ought to be run by technocrats, engineers, scientists, and academicians, who actually have the knowhow of respective fields. Is it not scandalous that important services like health and education are failing us for this simple reason? If by some chance a department is managed by experts in the field, they are hardly allowed to function independently. All this is done to command power and keep control, doesn’t matter what the cost.

“Time and again, questions have been raised about the imperviousness, wooden-headedness, obstructiveness, rigidity, and rule- and procedure- bound attitude of the bureaucracy. Indian bureaucrats are said to be a power centre in their own right at both the national and state levels, and are extremely resistant to reform that affects them or the way they go about their duties’’, notes a study from IIM Ahmedabad. Hence the business of never ending files finding it hard to move from table to table. What is the contribution of the civil service to society? Try to make a guess. Are we not losing best brains to a service which is meant to do more harm than good? The same job can be done by an average graduate on a much less expense and better efficiency. If the service was any good, why didn’t the British take it home?

I am in no way trying to take a dig at those who join the service and why wouldn’t one aspire to be elite more so when there are hardly any jobs around. The problem is with our collective hypocrisy, the societal attitude and how it has glorified a service beyond its merits without any real reason. Our Media goes amok for weeks once someone, as they call it ‘cracks’ the said exam. A public figure and celebrity is born overnight. But I wonder why? What do people think will change by someone qualifying an exam and taking a managerial position? Compare this to a scholar, who is awarded a degree. The poor fellow has to pay for a small press release on page three. No one is ready to write a few lines unless in exceptional circumstances and people hardly take notice. Some employees being special than others just because the service used to rule on behalf of a monarchy centuries ago is preposterous. Doesn’t it speak volumes about our collective moral bankruptcy?

In the context of Jammu & Kashmir, it is not hard to imagine the service doing exactly what it used to do for the British. A local Babu with whatever beliefs and values, signing the detention papers of a juvenile, supervising and at times covering up incidents of human rights abuse is no secret. I read recently on social media that one of the Deputy Commissioners has a fetish for using PSA on local youth. The argument that locals in the civil service is good for native population is mere rationalisation as they have to prove loyalty to their masters by going the extra mile which at times means legitimising the brutalisation and occupation. It hardly matters how well-meaning one may be, the system has to be obeyed without any ifs and buts. It demands absolute surrender, loyalty and there is no room for doubt or questioning. Guess who is pulling the trigger and who is in command?

So when people talk about serving humanity, earning an honest living, the betterment of the society, ending poverty, the alleged civil service is hardly the way to go. I am no way against people joining the civil service, but it should not be at the cost of false morality, making role models of people who are simply an extension of a failed and corrupt self-serving service. I do not have to explain how various departments function once such officers take charge no matter how well-meaning they may be. People need to think long and hard how they make gods out of ordinary people and in return make their own lives hell. It is time to rethink this colonial system if the society has to come out of the clutches of corruption, crony capitalism, and VVIP menace. You may be thinking how will the system function without these elite officers? But THE question you should be asking instead is; is anything working now?

http://www.risingkashmir.com/news/a-curios-case-of-moral-hypocrisy 

KASHMIR WHATABOUTERY

Kashmir has been simmering with violence for a long time now. The recent escalation and killing of civilians in Handwara brought in a fresh wave of grief for most Kashmiris. The feelings of helplessness, hopelessness and frustration again surged to a peak. As usual, the deliberate apathy from authorities, criminal silence from most media houses and hardly any noise from international community came as no surprise. While all this was happening, there were many people who started condoning the brutal acts. Some could not hide their joy as evident from the social media responses and sadly among these people were some fellow Kashmiris.

One could understand that Indians who are constantly fed lies by the media and politicians in the alleged national interest may not show any sympathy but it is hard to understand why would a Kashmiri of any faith, knowing what is going on, even think of condoning cold blooded murders. People take to the propaganda channels and shamefully defend what is being done under the garb of draconian laws. Surprisingly, most of these people are well educated and liberal in their beliefs when it comes to matters other than the plight of common Kashmiri. Before I say any further, let me make it clear that I am not trying to generalise or paint everyone with the same brush. Most people irrespective of their faith are humane and feel the pain of other human beings. There are many Indians and fellow Kashmiris from every background who condemn the brutality on civilians and share the common grief.

The army and state machinery actively shifted the blame and attention to the minor girl and all sorts of excuses started coming through. But whatever the situation, there is never any justification for killing unarmed civilians that too by armed forces of a democracy apparently proud of its secular constitution. It is not the first time when gross excesses and use of undue force has been excused by the very same reasonable people who leave no stone unturned to seek justice, provided it is not about Kashmir. By using various buzzwords like global terrorism, Pakistan, Islamophobia, and whataboutery every attempt is made to justify the brutalities on the civilian population.

One can still understand or dismiss such evasion by those ignorant of facts or those with malice of any kind. But things really get bizarre when some fellow Kashmiris start with ‘as you sow, so shall you reap’ argument. Lately, this has become a common discourse on social media. This has put me in a moral dilemma. Should I respond using the same very rhetoric, what bad things have you done that lead to migration from the homeland? Would that be a reasonable argument? I do not think so and I believe few of bigoted minds do not represent the whole community. What are they actually trying to achieve by telling a mother that your son died because of your sins and not a bullet from Indian army? Many things can be disputed but the fact remains that Jammu and Kashmir was divided amongst themselves by India and Pakistan and the local population on every side of the divide deprived of a dignified existence. They are even excluded from being a party to their own destiny. Hence this mouthful of ‘as you sow, so shall you reap’ does not hold any ground as lives of Kashmiris were taken over long back by neighbouring countries and whatever is happening now is just a manifestation of a long unresolved dispute.

All Kashmiris have suffered whether Muslims, Pandits, Sikhs or others. We are being used against each other and some of us are so gullible that we fail to see the deception. Whenever there is a brutality by the armed forces or police against common people, many armchair intellectuals come up with counter arguments of whataboutery to justify the acts. What about Kashmiri Pandits? This is the most abused question in our history. It is often asked for justifying de-humanisation, brutal attacks, rape and torture of common Kashmiris. Do you not think it is the time tested divide and rule policy? Does it not trivialise the suffering of Kashmiri Pandits that they are being used to defend horrific human rights abuses by the Indian forces towards a particular population? Unfortunately, many of the Kashmiri Pandits themselves have become victims of this whataboutery and refuse to see beyond hate and revenge politics. I do not understand how the suffering of one human being can be used to justify atrocity on another human being. Do these champions of whataboutery think of those Pandits who decided to stay in the valley? During the devastating Kashmir floods in 2014, when people were crying for help and millions were submerged under water, the same argument of ‘what about Kashmiri Pandits’ was often used by some of our brethren to cover the failure of state machinery. Sadly this question has been asked so many times even on petty issues that probably people do not take it seriously anymore. I wonder how long will the well-educated and intellectually rich community allow such people to belittle their suffering and continue to act as a political punch bag. Is this not creating further division among Kashmiris? Are they not poisoning the thoughts of their own children? How would there be any trust if people are not mindful of each other’s pain?

You do not condemn what happened to Pandit community is another common rhetoric to condone whatever is going on. It is a fair question and no words are enough to condemn the black spot on our history. But can you talk about it every time some brutality is inflicted on Kashmiris? Leaving one’s home is terrible and hard to put in words. At the same time living in a perpetual state of fear not knowing when the next bullet may hit your son is not easy either more so when you have nowhere to go even if you want to leave your homeland for the safety of your children. Should a grieving mother first condemn other wrongs before being allowed to mourn her loss?

I fully respect if someone wants Jammu and Kashmir as part of India. But how does it justify brutality on those who do not share the same vision? Just brushing everything as a creation of Pakistan in Kashmir is obviously an absurdity. A Pandit Prime Minister of the erstwhile Jammu and Kashmir was dismissed as he favoured joining Pakistan and a Muslim leader chose to trust India for help because he wanted the state independent and hoped a democracy will do justice and keep its word. History is witness to how we got here and how tactics of deceit, corruption and brutal means left us with nothing. Let us not mislead out children by giving a religious colour to the historical dispute.

Is it not time the two communities try to bridge gaps than create further division? The generations born in last few decades may fear each other; see others as monsters and probably murderers. Not that it is their fault but it is the lies which have been fed to them for one reason or other by the hyper-nationalist Indian media and confabulating writers. Some grew up away from Kashmir seeing their elders longing for homeland and some grew up under the shadow of the gun under dehumanising circumstances. Our elders have a big role to play in educating the future generations that we share same past and future.   Unless people meet and mix, talk to each other, reflect and empathise, this divide is not going to get any better.

The rhetoric of healing touch for Kashmiris living across the state and outside has failed as India is still not sincere in resolving the long-standing dispute. But let us not kill more of our children and at the same time get used by the Indian propaganda machinery for justifying such acts. Let us be fair to condemn what is wrong and give up blinding sympathy of any kind, may it be nationalism or religion. Hope Kashmiri Pandit suffering is not trivialised anymore to justify brutalities of the army and let no more blood be spilt to remove a bunker. It is time that some cogent steps are taken to recognise the human rights abuses and the dispute resolved peacefully by respecting the aspirations of the people of Jammu and Kashmir. India and Pakistan cannot play with lives of people of the Jammu and Kashmir just to keep their naïve voters busy with politics of hate forever. The resolution of the dispute is the only way all Kashmiris can get justice otherwise, the blood game is going to deprive countless mothers of their children and many more of their humanity.

Originally published in RAIOT.in

http://raiot.in/kashmir-whataboutery/ 

Time to change the way medical education is delivered, Comparisons between India and Abroad

Looking Inward

I don’t have to explain how hard you worked to get here.  You are academically bright and after competing with thousands of aspirants, you finally made it to medical school.  From the first year to final year, from one exam to another, there is only one thing you do, read huge medical books, if I am not wrong.  There is hardly any time for life, the world or even sleep.  You do not have any time for hobbies, fun, exercise, family or other enjoyable activities! You are mostly apolitical and at times rather asocial.  Do you ever wonder what exactly it is that you are trying to become?

Having completed my MBBS a decade ago, I am sure nothing has changed except that your books must be even bigger than what I read.  But that is not something unusual, if you talk to your professors, they would have a similar story.  Nothing has changed when it comes to medical education, the same long answer questions, long and short case, quiz and viva.  There is no curriculum and mostly teaching is based on guess work or what a standard book has in it.  Even the subjects taught in various academic years are not based on any real evidence. The subjects are there purely by chance or because the person who was in charge then was from that very speciality.  One spends months learning subjects which hardly matter once you pass the final year exam.  Similarly, subjects that are essential for day to day clinical practice hardly find any space both in the classroom and in clinical experience.

Looking Out

The delivery of medical education has completely changed around the world. The teaching based on organ based system is nearly obsolete and has been replaced by systems based teaching, integrating the pre-clinical subjects like anatomy and physiology to the real world clinical work.  Hence, students no longer study a limb or heart in isolation, but are taught systems like cardiovascular, respiratory etc. which makes more sense than studying anatomy and physiology of the heart in isolation.  Students are not expected to amass knowledge significantly removed from clinical relevance.  Instead they do more than just read thick books and pass exams.  This would mean engaging in audits, research, charity work, sports, and other interests to give them a broader perspective and develop their overall personality. They are expected to undertake special study modules (SSM) wherein they may have to write a review essay every few months or do some work experience outside the hospital setting and present the work to their peers.  This gives them a chance to work on the skills of writing, critical thinking and getting in touch with real life.  Students undertake other degrees while doing MBBS like an intercalated BSc in some other subject.  Some students spend time doing basic research and taster sessions in specialities to gauge whether they are interested in an academic career in the future. This helps them to build a strong portfolio and face any future challenges.  Students are also expected to go on an elective to a different country in their final year which helps broaden their horizons and outlook.

Reflecting Back

Coming back to the situation of medical education in India, all I said above seems an alien concept and you may be thinking how can a medical student do all these things while studying for the hardest degree ever known? The reason they are able to do all these activities while completing a medical degree with all the competencies required to become a safe doctor is because the curriculum has been thoroughly reviewed and tailored. Students are not required to cram fat books, but to work around a syllabus which is clinically relevant. Exams are conducted mostly as multiple choices questions (MCQs) rather than long answer essays. The practical exams are conducted with the help of actors and are tailored keeping in view the essential practical skills which a doctor should have once they become an Intern. Teaching is aided with modern technology, simulation, professional actors and specialised aids. Students have to maintain a logbook in every clinical posting and learn prescribed skills and get them signed off once they have demonstrated that they are able to perform them safely. This can range from simple history taking; cannulation, blood pressure measurement, mental state examination, and catheterisation just to name a few.

With the delivery of health care changing worldwide simply knowing too much theory does not make good and safe doctors any longer. How many of us know the actual techniques once we have passed our final year? How many of us are mindful not to infect a patient while putting in a catheter? It can be argued that clinical skills examination is essential for a reason.

Rights for Patients and Doctors

 In addition in other countries there is also an emphasis on human rights, dignity, privacy and confidentiality. I am sure we are very behind when it comes to these things and our patients often feel we do not treat them with respect and dignity. The fact of the matter is that we never learn any communication skills which form the core of medical training in the current age. Although we all become doctors to do good for humanity, it is not difficult to become mechanistic and lose that human touch if we are not mindful of our actions. There is an emphasis on building compassion and empathy and medical schools are supposed to inculcate such traits in budding doctors.

Many students struggle and find it hard to cope for various reasons once they join medical school. This may be due to work pressure, bullying, stress and we are aware how many leave and some even attempt to end their lives. Struggling is not a sign of weakness but a normal response to everyday life in medical school. It is high time that medical schools put in place measures to support such students and have close supervision. The culture of bullying needs to end and treating students with dignity would enhance their output and help make good and safe doctors.

Who to Blame, and How to Change?

The Medical Council of India (MCI) has proved a failure for various reasons and does not seem to be doing much when it comes to the reformation of medical education in the country. Technically, MCI is responsible for maintaining the standards of medical education and make it appropriate and relevant to the current times and demands. Unfortunately so many bright minds lose so many skills as they find themselves unsupported in a disorganised system. It is no surprise if you try to log on to the MCI website and fail to find what a medical student ought to know at various stages of training. Here again it is hard to fix the blame, is it the prevalent corruption in the country or the lack of interests from senior doctors? Students as the future of medicine will need to think long and hard, and try to bring about changes. There is no harm in approaching your teachers, asking for help, demanding to engage in research and teaching or attempting to do things beyond books and exams.

Finally with changing sociocultural values, doctors need to adapt accordingly.  The paternalistic approach is no longer workable and people expect a service which is safe, collaborative and friendly.  Many doctors find it hard to adjust to the real life practice once they leave the medical college and it becomes more imperative that they are trained with holistic skills so that their talent does not go waste. We have to be compassionate, responsible, safe doctors and treat our patients with respect and dignity. The relationship between teachers and students in college needs to be friendly though respectful and not based on fear and bullying. The faculty needs to work on such issues and unless the budding doctors’ work in a friendly learning environment, it is hard to expect any progress in the college working culture and academic excellence.

It is not impossible to bring the change but it needs some determination and toil, with channelling of effort and energy in the right direction. Never forget that you are the future scientists, researchers, teachers and leaders and that there is so much to do and explore. The future belongs to you so do not give up and be that change.

To give you a taster of how a medical student goes through the training in another part of the world, or more specifically in a developed setup, I am sure you will enjoy the excellent write-up by Dr Camilla Tooley. Here she describes her own experience of a medical curriculum within the UK in reflection of some wider comparisons. Developmental changes are necessary here too, but we can see that the approach may offer refinements in structure enabling greater breadth in personal and professional experience.

From the Dissection Table to Clinic;

A whistle-stop through the UK undergraduate Medical Curriculum

Dr Camilla Tooley

One size does not fit all

When asked to review the current medical undergraduate curriculum in the UK my first thought was which medical school and which course? Curriculum’s can vary dramatically across the country with differences ranging from the approach to learning, to the length of course and method of assessment. Currently taking a Postgraduate Certificate in Medical Education I have become even more aware how subtleties can shape an entire learning experience. My undergraduate medical school was voted last year to have the highest rated student satisfaction, so offers insights into a well-developed curriculum. I will in turn discuss the typical timeline of this undergraduate programme reflected to the commonalities and differences of other curriculum strategies that I am aware of.

Selection

The Selection process for medical school has changed throughout the years. Current requirement include three full A levels, examinations taken at 17-18, with at least one science subject, typically Chemistry, and occasionally two. UK applicants must also typically take one of three additional tests- the UK Clinical Aptitude Test (UKCAT), the Biomedical Admissions Test (BMAT) or the Graduate Medical School Admissions Test (GAMSAT). As competition is high it is also critical to show a widened perspective with work experience and evidence of other extracurricular activities. An interview will typically follow, which attempts to review whether an individual’s nature is fitting. Interestingly the terminology itself on selection panels has changed over the years from highlighting importance in conscientiousness and compassion to resilience, a highlight which is sure to match the changing NHS culture.

Early Days: Years 1 and 2

My medical school focussed on an integrated systems approach where the body was separated in to areas and essentially all detail in that region was discussed together. For example ‘Heart, lungs and blood’ where the anatomy, physiology and clinical cases were taught in unison. Learning experiences were shared between the lecture hall, the dissection room and small group work. Examinations taken at the end of each module to review knowledge acquired (every 4-6 months) combined with viva’s at the dissection table and written assignments. Clinical contact also started early with time spent in community family practice and projects focussed on this work.

Other medical school’s focus primarily on format of knowledge content in what many refer to as a ‘Traditional’ learning approach. While this may prepare the student with all information in one discipline (e.g. anatomy), the lack of contextualisation could hold this form of learning back. Equally at the other end of the scale where ‘contemporary learning style’ may be focussed on entirely student led practice with Problem Based Learning(PBL)  the student can lose some of the detail required by contextualising too early. This is an example where a tool can be used well or be problematic and a balance of both approaches seems the most logical as was offered where I studied. Pure knowledge was integrated and contextualised with some problem based learning techniques.

Midway Exams and Intercalation: Years 3 and 4

Clinical practice took a jump in Year 3 when ward work began within the hospital setting and integrated system learning was built in to integrated management understanding. Student’s spend placements supervised by consultants and are assessed throughout on basic competencies from taking histories to undergoing physical examinations. At the end of this course year there are again set knowledge tests in addition to an Objective Structured Clinical Examination (OSCE), where the student is expected to carry out histories and examinations observed and marked by senior clinicians.

On passing this year the student will then have the option to intercalate, taking a degree or masters in a year before returning to the final years of the curriculum. I took this experience for the variety it offered me at the time, and as I was keenly interested in Psychology and wished to obtain a degree in this field. Other student’s took a range of other degrees from Ethics and Law to Neuroscience.

I believe anyone who was asked about this year would reflect positively about it, although it did come at a price to reengage in clinical practice in Year 4. This year in essence continued on clinical placements, together with a designated research project whereby students could begin to explore academic interests under supervision, and again as a marked component.

Finals: Year 5

A further year of clinical placements arranged around different specialities such as Paediatrics, Obstetrics and Gynaecology etc., for which student’s would be reviewed during ward assessments on completing certain skills and demonstrating clear competencies. Students would also be required to take written knowledge tests and a number of OSCE’s focussing on the different specialisms, split by Medicine and Surgery and subspecialties for example Elderly care and Psychiatry.

I noticed in reviewing other doctor’s experiences the variety of assessment methods at the end of the final year in different medical schools varied significantly. While I had a few written papers and up to 40 clinical stations in combination for my OSCE’s, students from other medical schools had significantly fewer. We could conclude from this variability that final OSCEs could fall a year earlier in other medical schools, or this assessment method may be replaced by other clinical review. Regardless this shows the disparity between learning experience and assessment throughout the UK.

Student Choice within the Curriculum

Electives and Student Selected Components (SSCs) form a platform to students exploring their own interests within medicine further, or experiencing areas that they may not otherwise encounter.

SSCs are held throughout different years and last around eight weeks. A small group meet for a few hours and discuss or explore different topics. For one of my more memorable SSCs I explored ‘The History of Medicine’ and went to a record office to review documents and identify if any epidemics may have existed from the middle ages according to information from church records. This work was again assessed by a written assignment.

In comparison the Elective tends to occur at the latter stage of medical school and offers the potential for travel together with in depth specialism for a two month period in the break between years (3 and 4) or at the end of finals (end of year 5 or 4 comparatively). While I took my elective in New Zealand others decided to take theirs across all continents including experiences in South East Asia, throughout Africa, the United States and Canada.

Societies and Extracurricular activities through medical school

Students are encouraged to continue extracurricular activities throughout their time at Medical School to broaden their learning experience. These additionally develop a student’s mind-set and build confidence outside of examinations and the evolving clinical setting. From my own personal experience I tried a variety of activities while at medical school from mountaineering to drawing classes and co-founded the Psychiatry Society there that continues to this day.

Pastoral Support and Advocacy

Students can experience difficulties throughout their studies, in their work or through emotional or financial pressures. In addition to considering the general curriculum it is noteworthy in considering the support services that are in place. Firstly students will have a consultant lead that they can approach if they are experiencing any problems on the ward in their later years.

There are also module leads, whom are other consultants within the faculty that can offer advice on the learning experience and direct students as needed to other staff. These may include generalised student support on the University campus that can offer financial and emotional advice.

Applying to the Foundation Programme

At the end of medical school students are ranked and apply for ‘foundation posts’ as junior doctors across the UK. Students apply for different regions according to a number of considerations such as geographical location, to specialisms offered by different regions or other opportunities. In my scenario I selected to work within Wessex, as it was both close to where I had studied and new friends I had formed. This area offered junior doctors the opportunity to travel abroad for work in their second year, which I applied for and acquired in New Zealand. Notably some new doctors do not get the opportunity to work where they may choose. This offers insights in to the first limits of autonomy at the start of one’s medical career.

Conclusion: Shorter stays and New Roles

On concluding my review of the undergraduate curriculum I thought it worthy to briefly discuss variants of the five year model. Firstly at many institutions mature students whom have taken a previously science based degree or profession enter many medical schools in a four year rather than five year programme. This shortening of the curriculum seems complimentary when someone has already compounded a wealth of knowledge around biochemistry. In medical schools with a more contemporary rather than traditional format however shortening the course length could result in vitally missed clinical experience.

A new breed of healer the Physician Associate has also been developed in the UK. These individuals essentially try to fit the entirety of medicine in to two years and complete their studies able to diagnose and assess patients, although remain non prescribers. In a system where the volume of knowledge covered is often considered to amass greatly it is worthy to consider how are these curriculums used to cover the same information? Could we be covering too much knowledge base still to UK undergraduates, or be repeating knowledge in too many formats? Should we consider a more ‘apprentice’ like craft again within Medicine?

On these points, as with all the changes thus far from traditional to contemporary styles the answer may lay somewhere in the middle. As great analysers the doctors who educate will review and get back to you on the next improvements.

The article was originally published in KASHMED, the yearly magazine published by Government Medical College Srinagar India.
http://www.indiamedicaltimes.com/2016/04/07/opinion-time-to-change-the-way-medical-education-is-delivered-comparisons-between-india-and-abroad/ 

Just MBBS, No Beyond!

Regressive policies, Failing system and Medical education-The Ugly Business of Headcount

The Department of Health recently issued a circular that in-service doctors will not be allowed to pursue higher education.  After criticism from doctors and pressure from the media, the circular was falsely claimed to be withdrawn.  It was argued that higher education is a fundamental right of everyone including doctors and the order was regressive and dictatorial.  The department seems to suggest that leaving doctors for further training will worsen patient care.  Let us be clear, it is not just about right to education, but it is about the greater good of society and benefit to patients when their doctors are properly trained.  Half-baked doctors are unsafe and likely to do more harm than good.  Taking such decisions without any evidence by ill-informed pen pushers is surely going to put more lives at risk.   

The J&K state has currently four medical colleges, two in each province providing training in both undergraduate and postgraduate courses.  There are plans to open more medical colleges and also a rumour of setting up a medical university in the state.  The J&K State Medical Council (MCI) registers the doctors who practice in the state. In theory, the MCI is responsible for making sure that quality medical education is imparted and doctors produced have some minimal basic standards.  The MCI also decides upon the intake numbers of the medical schools, staffing levels and other necessary infrastructure.  The MCI is mandated to make doctors accountable, making sure those doctors who indulge in malpractice do not go free and face the consequences.

There has been a growing concern about the quality of medical education and the type of doctors being produced over the years.  Many factors are responsible for the degrading education in the medical schools starting from admission, teaching, examination system, and more importantly, the quality of practical training.  It is hard to blame a single factor or agency.  It is no exaggeration to say that the MCI is good for nothing.  MCI has made a name for scandals and corruption at various levels.  Apart from inspecting medical colleges for registration purposes, it has hardly shown any leadership and interest in improving and modernising the medical education.  Hence, it is hard to know what the basic requirements or standards for a safe doctor in India are.  Even being there for nearly a century now, the MCI is yet to come up with a proper curriculum or syllabus for MBBS and other post-graduate degrees.  There is no uniformity and everyone seems to be doing their own thing based mostly on hearsay.  The medical education is still delivered by the archaic methods devised by the British well before 1947.  In short no one has bothered to review the methods of training and teaching.  On the other hand, medical science has evolved beyond imagination.  The size of the textbooks has gone beyond reason, but students are still expected to cram everything to pass the exams.  It would make sense if the medical curriculum is updated and tuned to the practical training so that when doctors pass MBBS and finish internship; at least they are safe to practice. 

Most countries around the world have made it mandatory to have further two to three years training after MBBS to be able to practice as general practitioners.  But we are still stuck with the myth of MBBS doctor knowing and doing all, and put people’s lives in their hands in a badly run and underfunded heath service.  Just passing MBBS is not enough for a doctor to practice independently at least for first few years.  We need to train doctors further and allow them to acquire the required competencies if we want to be treated safely and not come to any harm.  Not only should doctors be allowed to pursue further education in various specialities, those who are recruited as medical officers in the health department should have further training for few years before they are posted in the periphery as general practitioners and allowed to work unsupervised.  The General Practice as a speciality ought to be started sooner so that doctors get the required qualification to work as independent general physicians.

As for the shortage of doctors in the health department; it is no mystery why despite producing hundreds of doctors each year, most find it hard to get a job in the state.  Those who get lucky, find themselves in a whirlpool of a badly run system, poor work culture and unnecessary bureaucracy making sure they are unable to function to their potential.  The focus is always on headcount than the expertise and training of the doctor.   One of the doctors who trained as ophthalmologist was posted to a place where he could not treat any eye problems due to lack of equipment.  When he went to higher officials begging that he is losing his skills and is not doing justice to his patients, he was told to collect his monthly salary and stop bothering about people.  Similarly, another surgeon found himself in the same boat and finally decided to leave the job.  There are many such examples and state is losing good and competent doctors, when in reality they want to serve but are frustrated to the extent of no return by the current policies and nepotism of the health department.

To fool the vote bank, a mere statement that a doctor has been posted, does the trick.  No one bothers about the credentials of the doctor.  Although the health system is supposed to provide treatment based on evidence-based medicine, people with alternative degrees are posted in hospitals and there is no way for the patients to know who is treating them.  Even in the district hospitals, one cannot be sure about the doctor’s competence and background.  People come in good faith and want to be treated by competent and qualified doctors, believing that they are in safe hands.  Would it not make sense that specialists are allowed to do the job they are trained and competent in?  We produce enough highly skilled doctors in specialities like medicine, surgery, orthopaedics, paediatrics, obstetrics & gynaecology etcetera.  If all of these specialists are allowed to run their units with proper setup and least interference, they would not hesitate to work in the periphery.  The truth is no doctor wants to harm their patients and when they are forced to perform what they are not competent to do, they usually chose to leave or use all means to be posted where they can function.  If they are not able to get away, they get disheartened and in the process are not able to function to their potential and ultimately can become unsafe doctors.  This also breeds malpractice and corruption among doctors.  I am not suggesting that doctors should not be held accountable.  Let the MCI take action against corrupt and irresponsible doctors so that others tread carefully.  But please don’t leave it to the revenue or police department to unnecessarily harass health professionals.

If the authorities are really serious about providing safe and equitable health service, they need to review the archaic policies.  It is time to move beyond the idea of headcount and focus on the training and competence of doctors.  Doctors are usually highly driven people; they would not stay if they are not allowed to do what they are good at.   Let surgeons do surgeries and ophthalmologists treat eyes, do not push them to perform what they cannot.  Remember demoralised workforce is no good and that applies to doctors as well. Patient safety comes first and there is no place for the Babus to play with lives of common people.  Hope some sanity prevails in the health department and they start thinking beyond the lucrative business of postings and transfers.  The answer to staff shortage is to recruit doctors and then let them work.  Banning would not stop them pursuing higher education but would deprive common people of safe and competent doctors.  So, it is for the greater good that doctors get proper training and those regressive policies are binned. 

http://www.greaterkashmir.com/news/opinion/story/209013.html 

Kashmir: The epicentre of rumours

The recent rumour of child deaths due to polio vaccination created a situation of fear, anxiety and anger in entire Kashmir. It got so bad at the end that thousands of parents with their little ones ran from pillar to post for reassurance and in the process some miscreants victimised the doctors and damaged hospital properties. Let me make it clear that there was no death because of the polio vaccine. In fact, India including Jammu Kashmir is polio free because of the said vaccine.

Rumours are not new to mankind and have played an important role, positive or negative, throughout history and are known to peak during conflict, disasters and epidemics. Rumours have been described as public communications that are infused with private hypotheses about how the world works, or more specifically, ways of making sense to help us cope with our anxieties and uncertainties. Sometimes rumours can be the only source of entertainment when boredom peaks due to conflict situation and other sources of leisure are banned or prohibited. The prohibition can be due to cultural or religious reasons or simply enforced due to the prevailing situation. 

A lot of work has been done on rumour and rumour control during World Wars and other conflict situations. It is thought that rumours influence the morale of people and can threaten national interest at times. Various theories and laws about rumours have been formulated.

As per the ‘basic law of rumour’, the rumour strength will vary with the importance of the subject to the individual concerned times the ambiguity of the evidence pertaining to the topic at hand. People came up with criticism of this ‘basic law’ suggesting that the factor of importance is hard to define and it does not take the emotional context of rumour into account. 

A modified theory of rumour mongering was proposed which suggested rumours as an attempt to deal with anxieties and uncertainties by generating and passing stories and suppositions that can explain things, address anxieties, and provide a rationale for behaviour. Rumours can be ‘wish rumours’ invoking hope and ‘dread rumours’ invoking fear and disappointing consequences. 

People tend to spread rumours that they believe as credible (even the most ridiculous stories), but if the anxieties are intense, rumour mongers are unlikely to ponder on the logic or plausibility of what they are trying to pass to others. 

Research suggests that rumours serve as a window into people’s uncertainties and anxieties. Rumours might be projections of societal attitudes and motivations. Three categories of rumours have been suggested including pipe or dream rumours, bogies or fear rumours, and wedge-driving rumours.

Kashmir can be called the epicentre of rumours in the current age.  From seeing Sheikh Abdullah’s name on leaves, children will die unless seven bowls of rice are donated to Makdoom Sahab’s (RA) shrine or seeing thousands of dead bodies floating in recent floods, are just a few examples. What could be the reasons for the rumour epidemic in Kashmir?

Keeping in view the above discussion, it is not hard to imagine why rumours have a special place in our society and how many times all of us, irrespective of our background, have played into rumour propagation.

Have rumours helped us to safety at times?

Thinking about the last few decades, how many times have you run for your life, directionless not knowing why and where based on some rumour?  How many times the driver refused to go further when he was told the people are getting a beating? Rumours often played a part in getting people together, building cohesiveness and brotherhood.

I am not trying to argue that rumours are good or bad. But do rumours play a role in building the resilience of the society against the onslaught of disasters is another debate? It is interesting to note that death is a common theme of most rumours which speaks volumes about our fears and day to day experiences.

The never ending war like situation in Kashmir explains it all.  The valley has hardly any means of entertainment, everything which used to be done for leisure vanished with time. I remember the on street stage plays in villages when I was young, the folk tale etcetera often being played in the paddy fields during harvest season. There are no avenues of entertainment for children, no parks, sports grounds or safe spaces. Most of the open land is now fenced by barbed wire for various reasons. There are no theatres or libraries. Important of all, it is the safety and sense of insecurity, which does not allow people to do anything but to stay indoors.  The children are hardly allowed to wander free and explore and rightly so. There is a perpetual sense of insecurity and burden on shoulders of all, be it young or old. One can simply describe the entire population of chronic dysthymia, where pleasure and joy have become an alien concept. Any expression of happiness is seen as immoral or wrong for various reasons.  Hence, we have lost the usual cultural defences over decades but have not been able to adjust to the changes that have come with time. Even faith has become a matter of abuse than contentment.

With little to do, lack of employment, and ample time on hands, what else can one do but to play the rumour game? With the advent of social media, rumours have gained a high ground and it spreads like wildfire, not in days or hours but in seconds and minutes.

In addition, one does not need to leave the safety of the home, to be on social media. Everyone, old or young has a smartphone with internet connectivity and it is the only source of entertainment for all practical reasons. It gives a sense of false security for people in the conflict zone, to login and do whatever without thinking about consequences. One often forgets that this virtual world comes with its own realities and can lead to anarchy and chaos. It also leaves a record, unlike the traditional rumours.

Take the recent rumour about the polio vaccine, started by someone either out of boredom, malice or mere ignorance. Within hours, Kashmir was in frenzy and it was hard for any parent not to worry. People flocked to hospitals, worried sick about their young ones, seeking reassurance. We all know what happened. Authorities were too late to respond to the state of emergency created by a rumour.  In the process, many people lost their cool attacking doctors and ransacking hospital property. Who is to blame here? One can say it is the first person who started the rumour, or all those who passed it on without verifying. But do we ever verify anything, be it mouth to mouth or now mobile to mobile? As a result, what happened, everyone had something to do and talk about. Did it actually matter at what cost? Lakhs of parents probably did not sleep the night watching their children anxiously.  Many on social media went on abusing the parents of being ignorant, but seriously, do you really think it was their fault? One of my doctor friends messaged that although she knew it was a rumour; she couldn’t stop herself from checking the temperature of her little one for about hundred times in few hours.

It is fair to say what parents did was right and they deserved to be reassured. But at the same time, nothing justifies beating up the doctors or damaging public property. There is no reason to blame and take a dig on parents and calling them ignorant. In such situations when thousands of people throng hospitals looking for answers, it cannot be left to the doctor on duty to deal with the chaos. 

In a civilised system, it would be the head of the state, who will immediately use all the means of communication possible like TV, Radio, social media etcetera, and address the people putting them at ease. If not the head of the state, at least, the Director Health Services and other officials of the health department would take the front and deal with the situation. Unfortunately, in spite of so many disasters and tragedies over the years, our health system is yet to come with a plan or protocol for dealing with emergencies of any kind be it manmade, natural or simply as a result of rumour mongering.   Here the blame lies wholly with the health officials who not only failed worried parents but also their own employees.The administration has also failed to keep pace with the social media revolution to use it for the benefit of common people.

What is the solution to rumours in current age? There is no easy way out. Conflict is not a choice and may not end any sooner.  We all need to be responsible with the social media and use it rationally. One has to understand that it is as real as two people talking face to face and has same or even worse consequences if wrong things are said.  Rumour mongers need to reflect and find some other avenues of entertainment or seek help for their misery if required. Something needs to be done about leisure and entertainment other than social media. Let the social media help us to build a better society than create chaos and anarchy in an already disturbed and paranoid society.

http://risingkashmir.com/news/kashmir-the-epicentre-of-rumours/

Doctors, on strike

Jeremy Hunt, the Heath Secretary for the United Kingdom is trying to change the contract terms & conditions for the 45000 junior doctors working in the National Health Service (NHS).  These changes will apply only in England. Scotland and Wales are not bringing the changes and Northern Ireland is yet to decide.

The dispute dates back to 2012 when the Department of Health (DoH) called for changes and after many years of talks with the British Medical Association (BMA) which represents the junior doctors, the negotiations broke down in October 2014 with the BMA complaining about then ‘heavy handed’ approach of the government and the threat of imposition by the Health Secretary.

All doctors, who have qualified MBBS and are training in various specialities to become consultants come into the category of Junior Doctors. The basic starting salary of a junior doctor is around £22 636 per annum.  As per the current contract, doctors working between 7 am to 7 pm weekdays are paid basic rates and working beyond these hours including weekends called as ‘unsociable hours’ are paid additional money by a complex system called banding. 

The government wants to expand plain time to 7 am to 10 pm Monday to Saturday, meaning that an hour worked at 9 pm on a Saturday would be worth the same as 9 am on a Tuesday. This would mean in practical terms reduction of around 30% in net salary if the new contract comes into force. The guaranteed pay increase linked to the time in the job are also scrapped with proposed changes and replaced with a system of progression through set training stages. This would mean doctors going for breaks from job e.g. for research or pregnancy will lose out in the long-term.

The Health Secretary has been trying to sell the idea of contract change to public as providing 7 days NHS service which is misleading as the junior doctors already work 7 days which includes the weekends. There is a concern that if these changes come in, the hospitals will rota doctors for longer hours as the penalty to do so under the current system will be removed. This would mean overworked and tired doctors who are more likely to make mistakes, putting the safety of patients at risk. 

With the negotiations failing, the BMA balloted for industrial action and more than 98% doctors voted for strike action. The strikes were planned for December 1st, 8th and 16th.  Just a few days before the strike action, Jeremy Hunt proposed to give a hike of 11% in the basic salary which was rejected by the British Medical Association (BMA) and was termed as a media spin to mislead people.

Even with this 11% pay rise, the doctors’ calculated that they would have net pay loss if the new contract is imposed. The main demands from the BMA to call off the strike and join the negotiations were:

·   Withdraw the threat of imposition

·   Proper hours safeguards protecting patients and their doctors

·   Proper recognition of unsocial hours as premium time

·  No disadvantage for those working unsocial hours compared to the current system

·  No disadvantage for those working less than full time and taking parental leave compared to the current system

·  Pay for all work done

The junior doctors took out protest marches in various cities of England. Ultimately, with severe pressure from many organisations and the Opposition, the Health Secretary agreed to the intermediation by the independent Advisory, Conciliation and Arbitration Service (Acas), between the BMA, NHS Employers and Department of Health (DH). Finally, after 5 days of severe negotiations, Jeremy Hunt withdrew the threat of imposing the new contract just a day before the strike was about to go ahead.  The BMA responded within no time and called off the strike in the interest of patients.  The Health Secretary was heavily criticised about delaying his decision which resulted in the cancellation of routine surgeries and appointments.

It is hoped that with the mediation of Acas, the talks will progress and the two parties will come to some agreement so that junior doctors do not lose in the process and ultimately patient safety is not compromised, which is at the heart of the NHS.

There are allegations that the current government is trying to privatise the NHS and pushing the junior doctors to the edge is one way of destabilising this wonderful institution which is free to all, from the entry point.

It is often claimed in the media that this is about providing a 24/7 NHS, but this could not be further from the truth.  In reality, it is nothing but a gimmick which will lead to destabilisation of the free NHS and ultimately to privatisation.

http://healthanalyticsindia.com/health/doctors-on-strike.html