Sunday, June 12, 2011

Reforming Medical Education in India: Do we Alumni have a Role?


Reforming Medical Education in India: Do we Alumni have a Role?

Eighteen is this the time to be confused. Some say “yes” and some say “no”. Yet others say any time is fine to be confused. Biologically, 18 is the peak age for endocrine changes in the human body, the time for all sexual energies to be expended on romance and love and the time for “experimentation”. Is this the age to begin a professional course whether it be in engineering, law or medicine?. The Indian academic system largely influenced by the British legacy has copied the notion of 10+2 of higher secondary schooling followed by professional courses. This system of education has generated some outstanding engineers, lawyers and scientists. On the other hand there have been some fantastic mismatches: these include IIT graduates like L. Subramanian and Fusion Guitarist Prasanna who are outstanding Carnatic Instrumentalists of the highest possible caliber and no longer engineers and physicians like Deepak Chopra who have become holistic gurus rather than practice his subspeciality as a trained endocrinologist.

On the other hand are these true mismatches? Are these these "mismatches" the consequence of the confusion that comes with "forcing" teenagers to choose professional courses when they are "confused"?

One could argue an education of the highest quality is never a bad thing and regardless of what happens in life later, such education will hold one in good stead. While this is true, the success of nations like USA, Russia and United Kingdom can be attributed to their talent pool of intellectuals that cultivate and grow their talent further in a particular discipline and a system that encourages the cultivation of talent in individual disciplines among their youth. The highest quality of medical professionals in USA did not come as sheer accidents from engineers and lawyers changing their disciplines of study upon completion of their professional education. Same is true for engineers in Russia and Lawyers in England. The cross fertilization of disciplines could occur as a minority outcome but cannot be expected as the majority outcome in any professional educational program. Just imagine if the majority of management schools in any nation churning out outstanding diplomates that never end up as managers, but choose to become doctors, engineers, cooks, carpenters and accountants. Would such a management school be considered a success? Surely by any standards this would be considered a colossal failure.

In a similar vein, medical schools have the mission of generating the highest quality of physicians. This is their stated mission. If a very small minority of graduates from a medical school become politicians, movie actors or home makers, this would be quite acceptable. But if greater than 10% of any graduating medical student class were to become homemakers and never practice medicine anytime in their life, would it be acceptable? Most medical administrators and educators would consider this an enormous failure of the medical education system. Either this represents poor selection process or a poor mentoring process. Either way, it is a failure and should be recognized as such. The lack of anyway to track what happens to medical graduates exiting medical schools in India is a major handicap. This leads to the inaccurate an often unrealistic notion that everything in medical education in India is okay. 

If our goal is to produce the next generation of physicians that provide the highest quality of medical care to Indians, then the time to act is now. We need to have accountability for medical education, educators and administrators. We need to track everyone that enters medical schools from the time they send in an application to enter medical school. We need aptitude tests and interviews no matter how subjective they may be to complement entrance examinations. Even if we use only entrance exam scores as the sole criteria to admit students to medical schools, the aptitude tests and interviews will be helpful to mentor and guide these students in medical school. So, at times when the 18 year old is confused and has excess sexual and romantic energies, they can be channeled in positive direction by medical educators, psychologists or other support personnel. A complete psychosocial profile of every medical student must be confidentially obtained and available to school counselors to help medical students. These are things we as medical school alumni can provide to our alma mater. We need accountability in numbers. How many students succeed in their ambitions that form at the time they spend completing their MBBS?. What can we do make sure that these dreams come true and that these dreams form the nidus of realistic achievable goals? In particular the more vulnerable groups like women, minorities, economically disadvantaged and the physically challenged must get more support from medical educators and administrators. Everything must be done to ensure that no medical student fails to accomplish their dream. Afterall, these are the brightest and best among our youth. If they cannot achieve their goals in life who else will be able to in our society?

There must be goals and targets for each medical school. A certain percentage of students need to choose primary care (family medicine, general practice, etc.), a certain percentage become specialists, a certain percentage become physician scientists and a certain percentage become medical administrators. These careers must be discussed and explained to students and they must choose them willfully rather than sheer accident. The next generation of medical students must not be products of accidents that happen due to confusion that occurred at the age of 18. They must be an informed generation of smart choosers who know everything that need to be known at the stage of choosing a career.

Let us start with some accountability ourselves, let us at CMC set the example of providing accurate numbers to our administrators on the success of our graduates. Fill out the survey that I developed if you have not yet done it. Here is the link


Ask all your friends to complete the survey. We need a minimum of 5% of all CMC alumni  to date (~50 years x 200 students = ~10,000 CMC alumni) to complete this survey to get any accurate statistics. As of today (June 10, 2011) only 49 Alumni have completed. We need at least 500 Alumni to complete the survey. So, let us start with you if you have yet to complete it and get your CMC friends to complete the survey as well if they have not done so.

If you have ideas on how we can implement change medical education at CMC come forward, participate and give your ideas more voice and act on it.

Let us goad our medical administrators to act on our data, Let us encourage additional accountability. Let us provide mentorship opportunities. Knowledge is power goes the old wise saying. So, let us enpower our current generation of CMC medical graduates with the knowledge and wisdom that we gained over the years. It can only make them stronger. Enpowered youth will take care of themselves. Our job is simply to enpower them for the future. Let not the “confusion” of an 18-year old lead to accidental careers and accidents that end careers. Although all of life cannot be planned, a bit of planning can never hurt in life. Moreover, the brightest and the best in India should have “ambition made of sterner stuff” than mere confusion of the 18-year old. So, let us get together, participate and goad medical education in India to a new frontier.

Friday, October 29, 2010

Horizon at CMC






Horizon at CMC
by
Thyagarajan Subramanian

All characters appearing in this work are fictitious. Any resemblance to real persons, living or dead, is purely coincidental.

It was the winter of 1980. Onam had come and gone, its festivities buried in the excitement of new enrolment into Calicut Medical College (CMC). A sea of new classmates, some familiar, most complete strangers, large class rooms with intimidating professors and the new stench of formaldehyde that overpowered the perfumes worn by neatly dressed girls in the class, the masala dosas at India Coffee House (ICH) or the smell of the lovely flowers in bloom in the college courtyard. The rains had stopped spraying itself into the two sets of stairs that took us up to the Anatomy dissection hall on the third floor. Yet, the whitewashed right stair well was smeared with bat excreta and damp as the sun never set its rays there and able bodied students never went up the right stair well, leaving treacherous surfaces that permitted no traction for my arduous climb up and down each day. The 2 sets of elevators in this 25-year old building never worked consistently. Moreover, the elevators were in 2 corners of this large square 3-storey building with a superb large open quadrangle in the middle that had one of the best urban gardens in all of Malabar. Getting through this building was no easy job for the able bodied let alone the disabled. The building planners thought of the aesthetics but not its accessibility. The walk for one classroom to the other was arduous long corridors that often filled with rain water as one side sprayed in from the quadrangle that was exposed to the elements. Thus walking through the corridor meant dodging many puddles, leaks and natures many gifts that came in from the quadrangle. The beautiful garden in the quadrangle attracted numerous small birds, butterflies and insects that in turn provided food for hoards of bats that made the rafters in the college their home. The many frogs that got dissected in experimental physiology, the rabbits that got their hearts harvested in pharmacology and the sheep blood from human physiology laboratory provided crows and ravens a chance to scavenge. These avians had their favorite nesting on the large rain trees that arched over from both sides on all campus roads. These birds also created the much-maligned bombing zone, were they practiced with infinite precision nocturnal defecation on all pedestrians on campus roads. Planned or unplanned, the CMC was a complete habitat with its own providers, hunters and scavengers.

Getting to CMC from Kozhikode town was no easy task either. CMC is strategically placed up a series of hills 6 kilometers from town, as far away as possible from any easy modes of private or public transport. Autorikshaws, the cheap taxis of India were literally out of question as very few would successfully make it up the hills and were too expensive and scarce to make it worthwhile. About 10 city public transport buses and a dozen long distance buses came up to the medical college junction, a road stop that was half a mile away from the CMC classrooms. Day scholars like me had to walk through the busy hospital corridors filled with doctors, nurses attendants and patients, climb down a secluded and dingy set of stairs besides a decrepit classroom in the first floor of the back of the hospital to exit and cross-over to the CMC building and into the first year classrooms. Alternately, we had to walk through a campus road that bisected the 2 hospitals, NMCH and IMCH dodging hoards of patients and families to enter through the front of the college. Either way, handicap access to CMC was never a priority of the builders or the administrators. Ironically, sometime within 5-10 years before I entered this cathedral of medical learning in Malabar, the administration had chosen to create a “reservation”, a set-aside seat for the disabled student. A very interesting side-bar to the story at hand is that although I never took advantage of the “disabled seat” in medical colleges in the state, it intrigued me through the years when I had seen other occupants of this “disabled seat” who chose to join CMC were either not greatly physically challenged or that they simply choose to join another medical college in the state that was more accessible to the disabled student.

Despite these physical challenges, first year at medical school was fun. I heard horror stories of how certain professors would take infinite pleasure in torturing medical students in their oral exams, how some others would literally help you forge a perfect kymograph in the experimental physiology practical exam, and how certain romantic opportunities exist in the quadrangle, the library, the ICH in the evening and in the anatomy dissection hall. I scrambled through different dissections, memorized pathways in biochemistry and sat through thoroughly boring impassionate lectures in physiology. Osteology, histology, dissections, biochemistry lab, physiology lab, things were coming in all directions. But all in all, I loved it. The white coats, the excitement of this large building and 200 classmates, it just gave me a catecholamine boost.

After finishing classes for the day it was my habit in those delusional days to walk into the college library pick up the brand new copy of “Nature” and “New England Journal of Medicine” to peruse in my favorite verandah that connected the 2 segments of the library. This long corridor had neatly placed wooden desks with chairs on each side open to the elements on each side (liberally sprayed with rain water) via a contiguous meshed window on each side. Through one set of windows one could appreciate the multitudes of beautiful large trees with red flowers on each side of the campus road that circumambulated the college. The windows on the other side opened to the long barren hot segment of earth that was condemned not to grow a single plant of any kind for mysterious reasons and separated the college and the library from the favorite hangout on campus, the ICH. Thus, strategically located in this corridor, you got a birds-eye-view of all the happenings in the most significant part of campus.

Hordes of lady medical students in their fine evening wear descended into ICH for the famous masala dosa especially when the mess manager was amassing personal wealth. While on the other window, one could watch nursing students walking back from their classes to their bus. Thus, a strategically placed seat would afford the best of all worlds, a nice indoor seat with the evening breeze, beautiful flowers in bloom, multicolor magazine with the latest in medicine and science and the best seat to watch all the beautiful women in campus without attracting any attention to yourself.

It was one of these days in December that I first heard about the “Horizon at CMC”. I was curious to see several women who normally ascended the steps that lead out of ICH, making a sharp detour away from their normal route back to the ladies hostel and instead walk along the campus road behind the library towards the staff/faculty quarters. While this afforded an even better view of these pretty women, I became curious and asked my friends Ramesh and Chacko where were these women going?

“Oh, did you not know? This is the hot spot in campus, the Horizon at CMC”, they replied in chorus. I pleaded my ignorance and asked them to tell me more. They described the “Horizon at CMC” as the edge of the campus, an end point of the vast CMC campus, where virgin land of green expand below a sheer cliff, nothing separating the unobstructed view of the sky, the sun and its descend to the other worlds each evening, gentle breeze blowing across the viewers face, while surrounded by women in all their liberated finery. No hair buns, no stifling white coats, scalpels, stench of formaldehyde and no faculty watching each of your moves. Ramesh said, “Man, this is the happening place, it is the place to be if you had romance in the air. All the chicks come there to check out the sunset and the guys”. “We are going there ourselves today, would you like to come?”

I was thrilled and immediately agreed. “Yes, yes,…I want to go with you”. I was all thrilled about seeing these girls up and close that I could only spy from afar from my seat in the library. That afternoon, soon after classes, I hobbled out to the third block hostel in rapt anticipation. As I put aside my books and coat in Ramesh’s room, Chacko said, “Hey Subban, are you sure you can walk up to horizon?”. I asked him why not? I walk from the medical college junction to class and then up to third block, how much more difficult would it be for me to get to horizon. Chacko knew that “Horizon at CMC” was simply too far for me to walk. It was way past all the different staff quarters more than a mile from where the college building was located. If anyone knew about it, it would be Chacko as he had lived all his life in campus as a child and grew up there and knew every building and tree on campus. Chacko also knew that all these facts were not going to get me discouraged. He had known me since I was in grade school and Chacko knew that I would not giving up without trying at least once. He also knew how foolish and unrealistic I was in those days and how he had to bail me out of trouble on more than one occasion. But, Chacko and Ramesh were friends and what are friends for if they do not put up with each other’s eccentricities. I was determined to see “horizon” for myself. The thought of missing out on all the romantic action in the most happening place in campus, was just too discouraging.

Soon, all 3 of us started walking towards “the horizon”. Within 300 feet, I knew things were not going to go too well. The tarred road gave way to pure gravel. I struggled to get a good foothold. Soon enough, I was simply struggling with my steps. I was not about to give up. Chacko gave me a hand and with his help I kept walking. Another 200 feet and my leather knee belt that held my polio affected limb in the “locked position” in my ankle foot orthosis snapped. Now I was in real trouble. I had barely made 500 feet advancement toward “Horizon at CMC” and my dreams were shattered. I also had no real way to get back. I also managed to ruin the evening for my 2 friends. With their help, I hobbled back to third block and eventually home. For the next few weeks, I was terribly depressed. I thought to many different ways that I could get to the “Horizon at CMC” without walking. But nothing was really practical. The pathway I was told was only suitable for walking, may be it could accommodate a 2-wheeler, but certainly not a 4-wheeler, opinioned Ramesh and Chacko. So we discussed the possibility of using a bicycle, scooter or a motorbike. But, I cannot ride it myself. Someone else will need to take me on it. It seemed an impossible track for a safe ride. Too many small rocks, too much uncertainty.

The next few years, I kept thinking about “Horizon at CMC” and its mysteries. I saw an enchanting picture of sunset at horizon against the silhouette of one of my classmates and her boyfriend on ladies hostel day when the boys were invited to check out the girls in their hostel room. The picture and the background taken purportedly at the “Horizon at CMC” were hauntingly beautiful, bewitchingly romantic and irresistible. I kept longing to see this elusively beautiful place. But my attempts to reach there were simply too complicated. Walk was the only real way to get there. No vehicular traffic was entertained. Moreover, the notion of me making it there in a vehicle even if it were possible will simply kill the idea of romance associated with this place.

To seek a glimpse of the “horizon”, I tried an indirect method. One day as I was sitting in the front porch of CMC with Ramesh and Chacko, watchman Balakrishnan told us that the clock tower was the tallest point in campus barring the water tank. Immediately, my face lit up. This could be it. I could go up the clock tower and get a view that is equally romantic as the “Horizon at CMC “. After much coercion Balakrishnan told me that if I could climb stairs he would let me go up the clock tower with him. Although the idea of romance simply vanished as soon as he said that he had to accompany me, I still thought it was worth a shot. May be it was promising, I could create my own private handicap accessible “horizon” up on the clock tower and I could take my romantic date up there one day!! So, one evening, up I went the clock tower with Balakrishnan in tow. I firmly grabbed the banister that had 25 years worth of pigeon excreta with both hands as I ascended the steps up into the clock tower. Finally, I was on the top right next to the clock face. I could see all the surrounding buildings, the quarters and all the hostels. It was a beautiful sight. Yet, the sunset in the horizon, the romance that Chacko and Ramesh promised, the beautiful picture I saw in the ladies hostel remained elusive. Besides the poorly kept environment, pigeons, bats, crows and other creatures seemed to habitate the clock tower. The idea of a private romantic and handicap accessible “horizon” simply vanished after this brief trip.

The following year or the year after, I was told that “Horizon at CMC” was going to be ruined. A tall forensic laboratory was planned at this nature’s wonder. Once this was built, I was told that all the natural beauty of this place would disappear and the romantic charm of the place would be gone. I grew desperate. I knew the time I had to appreciate this nature’s wonder was limited. I was now in doing my PG course in general surgery and a colleague, Sojan had a motorbike. I was told the years of walking along the path to “Horizon at CMC” had now made it a little better pathway and that Sojan had rode to the “horizon” in his bike at least once. I immediately approached Sojan, “Hey man, can you take me up to “horizon”? Sojan said he would. But days went by, we got busy, minor op day, major op day, casualty duty, rounds, studying for ECFMG, GRE, TOEFL and the umpteen applications to US universities, trip to Delhi to get my visa to go to Lahore all simply took time away. I never took the bike ride to “Horizon at CMC” with Sojan.

As I looked out the window at the sunset in the western horizon on my maiden airline flight from Delhi to Lahore, I saw the reddish pink canvas in front of me that had the myriad colors from blue to deep red and the hot sun was quickly dipping out of view. I thought to myself, this must be it. The “Horizon at CMC” must look like this. For a second, I dreamt that I was in the “Horizon at CMC” checking out all the pretty ladies with romance in the air just like Chacko and Ramesh had described. Alas, reality rudely broke in when the airhostess announced, “We are now reached an altitude of 15,000 feet above the ground…, this flight will take 55 minutes and will land in Lahore at 6:55PM”.

My visit to Lahore, ECFMG exam, short tour of Pakistan completed, soon, I was back in CMC and I was told that construction of the forensic lab had already been completed. Horizon at CMC was ruined. But, I heard that there was a “new horizon” equally enchanting as the first one. I longed to go there and was conspiring with Sojan to make the trip. Within days, I got news of my successful admission to join the PhD program in Neuroscience at University of Pittsburgh with a full scholarship. University of Pittsburgh was the place where Jonas Salk discovered the polio vaccine and it was my dream since childhood to go there to pursue medical research. I was overjoyed. I took the next available train to Madras for my visa interview and breezed through it. I had no doubt about going to University of Pittsburgh although my parents were skeptical. Many of friends were simply puzzled. Is this guy crazy? He got his MS seat and now he is abandoning it to go for a PhD program. But, I was sure. This was my chance to find a cure for paralysis and weakness. I knew that this would never happen if I remained in India. I simply did not have the appropriate training as a MBBS student and I had no hope of getting any research training by staying in India for completing my MS or the ultimate goal of getting into Mch Neurosurgery. I knew very well that these training programs did not have any true research components and did not prepare the student for scientific discovery. I did not want to miss the chance to be at another “horizon” and I would not want anyone else in my position to miss it either. Over the next 2 years doing intense laboratory-based bench research and taking many tough graduate level classes, I sat many evenings looking at the west facing Salk Hall wondering what it was like on that winter evening in CMC horizon? What was that piece of youthful romance that I missed forever? A slice of time that will never be back. Was that a missed opportunity to date and fall in love with one of the many beautiful women in CMC campus?

Since then, I have thought of the “Horizon at CMC” on over 100 airline flights at sunset during my travels around the world. When the sky seemed boundless, miles and miles of blue, pink, orange, red and all the colors in between. The soft rays of the sun penetrating the glass panes of the aircraft window without the heat. For a moment, I imagine the tranquility of the “Horizon at CMC” that Chacko and Ramesh described in their youthful exuberance.

I think of the elusive “Horizon at CMC” whenever I am up tall buildings that give unobstructed views of the skies. The many times I have been up the Empire State Building and the World Trade Center (before it disappeared) in New York, the Sears Tower in Chicago, the Space Needle in Seattle, CN tower in Toronto, Eiffel Tower in Paris, the leaning tower of Pisa, Pisa, Italy and the numerous other lesser known tall buildings around the world, I am reminded of the CMC clock tower, bird excreta-covered banisters, the secluded cauldron on the top and the fantastic view of the campus.

I tried to imagine romance in “Horizon at CMC” whenever I visited romantic sites around the world. The Grand Canyon at dusk, with its glorious colors that transcends prehistoric times, the Victoria gardens in British Columbia, the Nigara Falls in USA and Canada, the Taj Mahal in Agra, the Shalimar Gardens or boating in Dal Lake in Srinagar, the walk in Champs-Élysées in Paris, the La Rambla in Barcelona, Trevi fountain and Spanish steps in Rome, Tivoli in Copenhagen, Sofia Hagai in Istanbul and the Thames river cruise in London. I wonder the emotions that one feels at these places are similar to what all my lucky classmates experienced in the “Horizon at CMC”?

Ah! Wish I knew. But, I do not and how badly I wish I could compare. The unseen “Horizon at CMC” haunts me, ever beckoning and taunting my imagination. I am jealous of my classmates who enjoyed the sights of the “Horizon at CMC”, experienced the romance and cherish their memories. I pray for the invention of the time machine and the jet pack so that I can go back in time and share their experience!! I pray for my youth to return sans paralysis where access is unlimited and no opportunity is denied.

The horizon denied to me has kept my pursuits alive. The search for a cure for paralysis though incomplete has been very rewarding. Much advancement has been made in bench research and translational medicine. I am optimistic that the days are not far when no horizon will never be ever out of reach of any human. Until then I hope many more Ramesh’s, Chacko’s and Balakrishnan’s remain on earth to give hope to the disabled, foster exploration of alternatives that let the disabled enjoy what the able bodied are able to do and make friendships that remain lifelong.