Introduction

Marcellus’ observation in Shakespeare’s Hamlet (1) that “Something is rotten in the state of Denmark.” (Act 1, Scene 4) could well be applied to medical education in India today. and could be followed up by repeating another statement earlier in the play, “and I am sick at heart.” (Act 1, Scene 1). I was fortunate to have studied medicine in Mumbai at a time when we were keen to learn not only the science of medicine but the art of practice from teachers of the calibre of Drs Minocher Mody, J G Parikh, Noshir Wadia, C G Saraiya, W D Sulakhe, N G Talwalkar, and Noshir H Antia at the Grant Medical College (GMC) and Rustom Jal Vakil, Rustom N. Cooper, AV Baliga, Nathoobhai D Patel and PK Sen at the Seth GS Medical College (GSMC). We would move from one college to the other, eager to listen to them teach and demonstrate how a patient should be examined and a diagnosis made. Our teachers deserved our respect and homage. Although termed “Honoraries” and expected to work in the institutions for 4 hours each day, we saw them in the wards and laboratories from 8 am to 4 pm. daily. They taught us all they knew, sincerely and diligently. I recall approaching Professor P K Sen at GSMC, whilst I was a postgraduate student at the Grant Medical College, with some trepidation, to request permission to attend his clinics for postgraduate students in surgery. He instantly and graciously granted permission with one proviso, “You can listen but do not interrupt.” Likewise, Dr S D Bhandarkar, the eminent endocrinologist at GSMC, told me how he attended Dr Noshir Wadia’s clinics regularly each week at GMC and benefited greatly from them. When individuals such as Drs Sir Harold Gillies, Robert J Last, Michael de Bakey, Denton Cooley, Victor McKusick, A Earle Walker and M G Yasargil visited, we would take pains to find out when and where we could listen to them and ensure that we learned from them. We would even travel to arts and science colleges to learn from visiting atomic physicists, astronomers, botanists, and zoologists… This was apart from attendance at the occasional readings of great works of literature at the British Council and the SIES. College and, when we could afford the cost, shows such as The Tintookies (aboriginal term meaning “little people from the sandhills”) by the Australian group led by Peter Scriven; foreign actors and dramatists like Emlyn Williams; plays staged by the Indian National Theatre; groups featuring local stars such as Alyque Padamsee and Gerson da Cunha and classical dance and musical performances. We borrowed books from the libraries of the British Council, American Center, the J N Petit Library and other repositories of wisdom and heritage. Our teachers and these activities engendered in us a love for medicine and empathy with our patients. Equally important, we developed a breadth of vision and were on intimate terms with the humanities. Contrast this with what obtains today.

Lessons learnt from a senior resident doctor

In a recent exchange of emails, saddening truths were brought home to me by my young correspondent – a final year resident in Cardiology in one of our public sector teaching hospitals. I reproduce the comments below:

• Everyone knows the status of medical education in our country.
• The pattern of the entrance examination has systematically destroyed any urge to learn. It’s an open secret!
• When will your generation wake up to save medical education and the future of healthcare in India? Why should our generation be victimised?
• Why do our teachers not take ward rounds and teach at the bedside of patients? We learn from our teachers that taking a history and conducting a detailed examination are unnecessary as they place all their faith in investigations
• I wish to learn interventional cardiology but am frustrated by the fact that few life-saving procedures are carried out by teachers in my hospital, because they want to carry them out in private hospitals where they have been allowed to practise although they are full-time professors here.
• There is no accountability for medical teachers.
• There is no place where we can go and complain with certainty of redressal.
• Why is promotion in professorial cadres based on fake research articles and on quotas? What about merit? Why is feedback from the students they are teaching not considered at all?
• Do you know that our guides use our theses as weapons of attack and defense? I can assure you that 99.99% theses are based on manipulated results and are of no practical importance.
• I find it strange that medical graduates feel an overwhelming compulsion to attend coaching classes.
• Most of my teachers have placed their offspring in medical schools in US as they have realised that education in our medical colleges is worsening day by day

  From my own enquiries I learn that this situation prevails in many departments in our teaching hospitals. Ward rounds and bedside clinics have almost disappeared from the teaching arena, as have autopsies and clinico-pathological correlation in weekly brain-cutting sessions or study of autopsied lungs, hearts and great vessels. No lessons are learnt from the dead on the natural history of disease, missed diagnoses and errors in medical and surgical therapy. Lectures are often a bare recitation of facts, lacklustre and bereft of personal enthusiasm. No examples from studies by the lecturer and others in the department are provided to back up statements. Stimulation of thought, the spirit of enquiry and discussion are not encouraged. Having completed his spiel, the lecturer walks out. As noted by my correspondent above, no lecturer or department ever seeks or values feedback from students. Forced to attend such talks by mandatory roll calls, students are quick to tune out as the lecturer drones on. Presentations on the internet – as exemplified by those from the Khan Academy (https://www.khanacademy.org/science/health-and-medicine) – and tuitions are used to replace what should have been taught in the medical college and hospital. Since Indian medical education is driven by diktats from governments – in Delhi and the states – and those issuing orders are not famed for their progressive or principled vision or action, there are few grounds for optimism about change. Attempts at inculcating the humanities in medical students and postgraduates are few and amateurish. We lack professionally run, well-financed departments manned by respected, competent and highly motivated individuals. Administrators of medical colleges and hospitals do not see the need for them.

Some promising attempts at improving the present sorry situation

Despite these huge odds, efforts are being made by concerned individuals and groups at improving the situation. St John’s National Academy of Health Sciences, Bengaluru, the University College of Medical Sciences and Guru Tegh Bahadur Hospital, Delhi, GSMC, Mumbai, and the Christian Medical College and Hospital, Vellore, are some examples of institutions striving to inculcate the humanities in their students. A variety of means are used to instil into students and residents the principles of medical ethics, the spirit of empathy, courtesy towards patients and their families and a love for the arts. Plays, The Theatre of the Oppressed, films and talks by the likes of Drs Farokh Udwadia, Prakash Amte, Abhay Bang, Mario Vaz, Satendra Singh and Himmat Bawaskar, are some of the means used. There are some common handicaps faced at all these centres. The organisers, working in an honorary capacity, have to confront the crushing burden of lectures, laboratory sessions and tuitions on students and hospital workload on residents. They must beg heads of academic departments for slots when students can attend the programmes set up by them. They must hunt for funds for their activities. They must sustain interest and enthusiasm in the programmes in their own teams, and then in students and residents.

Needs for the future

In the great teaching centres of Europe, America and Australia, medical colleges are ranked not only on the basis of their scientific excellence but also on the achievements of their departments of humanities. We desperately need such a culture in India. In order to enhance the importance of the humanities, our medical colleges must, first of all, improve their standards of teaching medicine and caring for patients. These are the foundations on which the humanities can be built. Towards this end, we will need a major revamping of our educational system. Our teachers must be selected and promoted on the basis of a single criterion: merit. The selection of students to be admitted to our medical colleges must be based on vocational aptitude as much as on academic excellence. The system of evaluating the latter must change from numbers of marks to assessment at a systematic interview. The large number of applicants cannot be used as an excuse for the perpetuation of the existing hopelessly inadequate system. An intellectually stimulating and professionally challenging medical curriculum must include strict measures to enable each student to acquire clinical expertise at the bedside and in the autopsy room. These principles championed by Drs Herman Boerhaave in Leiden, Thomas Sydenham in London, Pierre Charles Alexandre Louis in Paris, Charles Morehead in Bombay and William Osler in Canada and America remain of paramount importance. Creation of departments of the humanities must follow. Each department must be adequately staffed with a head, professors, assistant professors, lecturers and office staff. Each of them must possess impeccable qualifications, proven enthusiasm and sincerity in promoting the goals of the department. The department must have a significant presence in the institution’s library, archives and museum. A curriculum for the humanities must be laid out with care and aim at cultivating in students and residents a life-long interest in ethics, history, philosophy and the arts. Such a curriculum must, of necessity, be devoid of compulsion, learning by rote and stressful tests and examinations. Some foreign medical colleges offer the following modules to their students:

• Classics
• Comparative literature
• Film studies
• History
• Liberal Arts
• Music
• Philosophy
• Theology and religious studies

In our country, we also need to lay strong emphasis on respect for and care of women and children, the differently-abled and the poor.

Conclusion

We are fortunate in having exemplary mentors who have made their departments reach, and at times, surpass international standards in every aspect of patient care, teaching and research. They awaken in their junior colleagues a passion for learning and hunger for knowledge; but such mentors are few. We need ALL our teachers to reach the heights they have scaled so successfully. In a recent oration, Dr Nalini Shah, Emeritus Professor of Endocrinology at GSMC emphasised some neglected truths (2). Our students must be convinced that education is a continuing process that ends only when we breathe for the last time. The best teachers are perennial students at heart. Learning any new subject must start with an understanding of history, the works of pioneers and the means by which they overcame the many obstacles they faced. Our best teachers are our patients. Inspired and passionate residents and students are invaluable members of the clinical team. Research is an integral part of learning and leads to our making an addition, howsoever humble, to existing stores of knowledge. If and when we can meet these needs, the young cardiology resident referred to above will rest content as will all the others aiming at “the practice of medicine as an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head.” (William Osler)(3).