How should a medical student use his Internship?

I got asked this question on Quora

How do i make best use of internship during MBBS in India?

It got me thinking as to what internship meant to me. I finished my internship nearly 7 years back so maybe now I have better perspective on what it meant back then. I answered and I thought it would be a good idea to share it here as well.

How should you spend your internship?
Most of my seniors said study hard for your entrance exams since its so hard to crack them. I'm sure most interns would study anyway as a default. I wouldn't stress on that aspect.

I would say use your internship to prioritize your career goals.

What do you want to be?
Sometimes this question is asked too late in a medical student's life.

To prioritize your medical career you need to use your internship as career sampling. 

More than knowing what to take as a specialty you should know what not to take.

Few things I think might help you in that

1. Keep an open mind. 
Never get bogged down by other people's opinions about what you should do. What you do is your business not your uncle's or neighbor auntie's.
2. No work is too small.
Take up every role that you come across. Cleaning a colostomy tube is as important as putting in the colostomy tube through surgery.
3. Respect the patient.
Work towards making them better always and try your best not to hurt them.  Always remember that patients are your best teachers so give them as much respect as you would your teachers.
4. Take ownership of your patient. You might be just an intern who follows your unit head's orders but the patient is still yours. Try to create a personal bond between you and your patient. It always helps you and the patient. Both sides get what they want.
5. Medicine is art. 
Work hard in the wards. Your books will only take you so far but the warfield (wards) is where you learn the craft. Never belittle any ward procedures. IV lines, central lines, urinary catheterization ,repair of emergency lacerations..... You never know what you will come across in the wards. These skills you can never acquire or experience later. I did one central line during my internship and that experience was exhilarating. Being an ophthalmologist now I'll never do it again so I'm thankful I did it then. Wards and patients will give you all the inspiration you need to propel you towards a speciality.
6. Make your peace with death and disease.
Until you reach internship you never realize how much death and disease of your patients can affect you. This is because you will have a personal investment on the patient. You will sometimes feel helpless in the face of mortality and morbidity but that is necessary.
7. Find your role models.
It could be anybody you work with and even your own batchmate who has probably figured it out better than yourself. One is never short of people to look up to.
8. Recognize the wrong people. 
You will come across people who are not good at their job, people who insult and look down on their colleagues and juniors, people who are unethical and so on. Identify those people and make note to yourself never to be like them. Do not let a bad doctor ruin a good speciality option for you. I didn't have good teachers for ophthalmology in my medical school but I didn't let it spoil my opinion of ophthalmology.
9. Maintain your sense of wonder
I feel we need to find wonder in what we do and work towards what we want to be. I would advise the same during one's internship. Never lose that wonder.

From Oculoplasty and back

“Just don’t give up trying to do what you really want to do. Where there’s love and inspiration, I don’t think you can go wrong.” —Ella Fitzgerald

Its been an incredibly long time since I've been active on this blog. Partly because I have been busy and mostly because I haven't been inspired to write in a long time. I was in Bhubaneshwar sometime back and it has kind of brought me back to a place where I almost gave up on Oculoplasty as a career. In my earlier blog posts I had professed immense interest in Oculoplasty and haven't really updated what happened afterwards. Its a huge story worth a potboiler at the very least (ha ha I'm kidding). Well I wont bore you with all the details.

But something incredible happened in the end of September 2013. I got an offer letter from National University Hospital, Singapore accepting me for their Orbit and Oculoplasty clinical fellowship program. I had applied to NUH after my residency  just like the many other institutions I had applied to. Somebody there had seen a spark in me and selected me. I was ecstatic and that hunger to get into the fellowship kept me from giving up during the protracted paperwork process to start my fellowship.

I'm now more than 4 months into my fellowship and its been an amazing experience till now and I feel I'm in the best place that I could be. I have finally found a mentor who could really shape my career the way I would want it to go. I'm learning new things everyday and things I never thought I'll be doing.

I'm training in navigational surgery of Orbital fractures,small incision endoscopic browlift, Aesthetic procedures, attending orbital fracture implant courses and a myriad things I hadnt even imagined I would be able to do.  I realize that i'm at the forefront of technology and innovation in my field here in Singapore. The real challenge will be to use the knowledge and training that I have gained here into a place like India where there are always impediments to one's growth. A lot of it is economic and most of the rest of it is politics and nepotism that thrives in my profession in India. I sometimes worry that I'm getting spoiled by all the high tech gadgetry that I see here in Singapore and I fear becoming obsolete in India. Also I'm recently married so to get the kind of solid support from my wife has been comforting but I understand the sacrifices she's making for my career and it sometimes troubles me.

But after a lot of reflection I realize that the basic emotion here is "Joy". Joy in what I am doing despite hectic schedules of this fellowship and finding happiness in an equally important marriage at the same time. This beats every fear that I'll ever have. I figure that if I'm enjoying what I'm doing I'll find a way to make a living out of it.

The Surgeon Conundrum

“From inability to let well alone; from too much zeal for the new and contempt for what is old; from putting knowledge before wisdom, science before art and cleverness before common sense; from treating patients as cases; and from making the cure of the disease more grievous than the endurance of the same, Good Lord, deliver us.”

Sir Robert Hutchison, 20th century physician, British Medical Journal, 1953

I often hear descriptions of famous surgeons as “great”, “amazing””, “brilliant”,etc. and wonder how those adjectives get decided. The corollary used in describing a surgeon is somewhat akin to a performing artist or an athlete. The problem with such an approach is unlike an athlete who can be assessed by statistics or artists who is assessed by cultural expertise of common people, a surgeon does not lend himself to such assessment. A surgeon does not have a publicly available success rate statistic nor do common people have any expert knowledge of surgical procedures to know if a surgeon is great or not.
Is surgery so hard? Yes and No.
YES because one needs to put in years and years of study to even have the opportunity to hold a scalpel and from then on has to practice relentlessly for many more years to actually master the surgeries in his/her specialty. For that relentless pursuit the surgeons usually have to sacrifice the prime years of their lives to this task, having no time of their own, decreased social and personal life and often living under debt or their parents’ financial benevolence for a little less than half their lives. 
NO because its not magic. Most surgical procedures have certain established techniques which if practiced over many years become second nature to the surgeon. So if you know the rules you are set. Of course it goes without saying that you would need a certain level of aptitude and intelligence to learn the complex machinations of the human body,decent memorization ability and a whole load of patience but essentially surgeons are human beings like the rest of us. Only that we surgeons are the lucky ones among humanity who get to wield the scalpel to help humanity as a reward for all those years of hard work.
Skill can vary of course like in any profession, they can be excellent, good, average, poor and miserable. Skill, we surgeons are often told is what separates the great from the rest and yet there are many average skilled surgeons doing incredible service to mankind which many highly skilled surgeons could not.
So does mere skill of a surgeon decide his greatness? Here its a big no. From what I see from the inside of a surgeon’s world, having started my surgical career 3 yrs back, the greatness of a surgeon has to be measured beyond just skill. Like my Professor in college used to say, “ Any fool can operate,even that cobbler on the street or that OT technician, maybe even skilfully but what should separate you from those fools is that you should be able to judge what surgery the patient needs or if he needs surgery at all?” (he had more colourful words to say, this is the watered down version of it, LOL). I recently heard an amazing perspective from a very famous surgeon (he’s a brilliant surgeon by the way) : “ The reason older experienced surgeons do lesser types of  surgical procedures than younger newer surgeons is not because they are any less fearless or capable than the younger ones its because they are tempered with the wisdom of what works and how well. The ability to cut down on trying too many things and to bring more efficiency and longevity to surgery is what experience brings”  These are two different perspectives with a converging opinion on the importance of clinical judgement of a surgeon being paramount!
Doing too much or doing too little? Where do surgeons draw the line?
For that the “art of judgement” is the crucial quality of a surgeon. I sometimes feel we as surgeons are often guilty of “surgical over-aggressiveness” . There are times when doctors operate when in hindsight just waiting would have done the trick. Sometimes when a medical treatment would be far more beneficial than a surgical one. Other instances when after surgery the patient is worse off than before. It’s not to say these doctors have any vested interests to operate. They mostly always want to help the patient and often in their zeal probably do too much. Sometimes its more harder for the doctor than the patient to accept that nothing more can be done. But again in trying to solve the “doing too much” problem, surgeons should not fall into the “doing too less” trap which so often happens in many hospitals these days where patients aren't demanding or in the know. There are several instances when doctors just chooses to delay instead of taking that acceptable risk to operate since they don't want to be responsible for somebody’s poor surgical outcome. Some don't even refer to a specialist who is capable of doing the surgery with lesser risk. In the end such a patient’s surgery is not done at the correct time resulting in handicap or he/she succumbs to the disease. This attitude is worse than the “doing too much” phenomenon. As an example i distinctly remember one little girl of 5yrs who came with multiple metastatic cancer to my hospital when the original small eye tumour which was detected a year earlier was not operated by the doctor assuming it to be benign. A clear case of doing too less and the experience is so heartbreaking for everybody concerned.
There are no definite answers to most surgical decisions because medicine is a field where results cannot be predicted with pinpoint accuracy like a mathematical model. But surgeons have to take these calls everyday and no one else can do it for them.The surgeon’s judgement sometimes lies between life and death of a patient so its not as simple as people believe it is. I am happy to say with full confidence though that for the most part more good than bad gets done in the full balance of things. The ability to do as much as possible to help the patient yet never letting one go overboard is a balance every surgeon should aspire to attain and this balanced judgement is what makes a surgeon truly GREAT.

Healthcare in India: myth busted

The other day i read that India is one of the top destinations for medical tourists.for those not in the loop this refers to foreigners mostly from developed countries like US, Russia, Germany, Singapore, Korea, etc who do not qualify for healthcare insurance in their home countries who come to India for cheap medical care so that they can get similar or better care for less than one tenth of the price in their home country.When i read this article i couldn't help but wonder whether we should really be gloating over treating foreigners for cheap while millions die in our country due to dire need for basic healthcare.We in India apparently follow a socialistic policy in healthcare. Is it really so?
I recently read an article by Dr. Devi Shetty,a famous cardiothoracic surgeon and leading philanthropist in the field of healthcare.He said only 8% of the people needing cardiac surgery actually get operated and in a country like India we have a huge backlog.In his own words this is ridiculous even for a developing country like India.He has bought down costs of heart surgery to less than Rs. 1lakh and he’s desperately trying to get it to less than Rs. 40k.He’s doing a commendable job and needs every bit of adulation and support he can get.But really where is the Government in all this? its conspicuous by its absence!
I work as a resident in the premier Govt. Eye Institute in West Bengal which incidentally is the top govt  eye inst in the whole of eastern India. we have top of the line instruments, microscopes, lasers, machines, diagnostic aids and first class infrastructure.we undertake all kinds of surgeries done in any of the top institutes of the country.This should in effect should help the masses.But unfortunately not everything is free.True cataract surgery covered by the national program for control of blindness in India is free but nothing much else is totally free of cost for the patient.the patient still has to buy consumables for surgery such as silicone oil or perfluro-gas(Retinal Detachment surgery),silicone prosthesis,sutures and many other consumables.A typical RD surgery costs the patient around Rs. 12,000 in our institute(only consumables).In other diseases for proper diagnosis CT scans,MRI,histopathology,expensive blood reports,immunohistochemistry,etc. needs to be done for which the patient has to shell out from his/her own pocket.All this and not to mention other daily expenditures in eye drops,costly antibiotics,pain killers and sometimes hospital fees.Drugs supplied by the govt. form a woefully short list or for the most part ineffective probably due to adulteration and poor quality control.So many expenditures in a Govt Hospital which is a premier institute at that in a supposedly socialised medical healthcare.This much expenditure to a man/woman who probably earns less than Rs. 100 a day.does it sound right? can our conscience make peace with this fact? if this is the state in a premier institute what is the state of peripheral hospitals.I’m not blaming the people who run our hospital for all this.they are doing a great job to the masses with the limited resources at their disposal.the costs that are being borne by the patients is due to the helplessness of these doctors and due to their endeavour to provide world class care to patients with limited expenditure to the society. In this scenario doctors are stressed to provide healthcare and the public blames them for any incident that happens. This is the reason why doctors in govt sectors are getting frustrated with the system. its not them but our healthcare policy that is to blame.It is flawed left right and centre!
I’m speaking in the midst of one hospital and i’m talking of ground realities in one govt hospital as i’m a part of one.But this is the story of nearly every govt hospital in India.it is just that the categories of expenditure changes.Our society will be judged by how we treat the weakest(read poorest) among us.And our country falls terribly short of an ideal.
As i have mentioned previously in my blogs,Indian govt. spends less than 1percent of our GDP on healthcare.Even countries like Bangladesh and Sri Lanka spend 16 and 32 pc respectively.UK spends 7pc and yet provides Universal free healthcare to every citizen and immigrant.In India 80pc of the health care burden is borne by the pvt. sector.We are quick to downgrade the insurance based healthcare of the USA but in India we neither have an Insurance based healthcare of USA nor a Socialised Healthcare like UK,France,Sweden,Denmark,etc. the common retort by the govt is India is a poor country and we do not collect sufficient taxes to sponsor universal healthcare in India.But this is a poor argument because though only 3 pc of the population pays income tax,we all pay tax in every other way.sales tax,wealth tax,property tax,road tax,service tax,luxury tax,custom tax,education cess,advertisement tax,service tax,value added tax,….phew just to name a few!!!! Only birth tax and death tax is left to be enforced.where does all this money go? We have a horrendous education system,pitiable healthcare and a treacherous bureaucracy and yet we have any non-descript politician worth his salt(not necessarily elected) being ridden across the country in a fleet of 10 cars or helicopters or jets! govt officials,bureaucrats and govt aides lead a life of extreme luxury.our politicians and bureaucrats must be among the richest politicians and bureaucrats in the world(and we are a poor country mind you!!!)No other country in the world has more black money in Swiss Banks than India.So who do you think owns all that money? the above people and also some huge businessmen. So do I still hear somebody call India a poor country. We now know who are the beneficiaries of these many taxes.
Solutions are quite often very simple but simple things aren’t done without a political will in this country.The masses don't demand healthcare because they have nothing to eat so why will anybody talk about health? Healthcare needs to be removed as a state subject and be transferred to being a union subject.Doctors and healthcare professionals need to be paid more as professionalism demands money.you can’t attract the best talent in any industry with pitiful pay packets.same should hold true for healthcare.Govt budgetary allocation to healthcare should increase to 5pc of GDP for a start and should eventually increase to at least 8pc.another 10pc to our education system because to sustain a healthcare this massive we need an educated population.All these budgetary allocation should come from defence cuts.We don't need bombs and missiles.we need medicines and medical care.there needs to be a stringent quality control body for healthcare delivery and of course for the quality of drugs and consumables being supplied.In effect we need a complete overhaul of our healthcare and education policy.Do these sound difficult. hell yes!!! because attitudes need to be changed,awareness needs to be increased and most of all corruption should be minimised.All this is easier said than done but it still is simple stuff no?
I sometimes feel really bad when patients suffer because they either can’t afford treatments or we are restrained from giving them the best treatment due to the many impediments i have mentioned above.There is a certain joy in treating patients and you need to have empathy to understand their varied problems.Its a hell of a tough job but there is nothing else in this world which gives the same high as that got by alleviating suffering of people.It is for this incredible satisfaction that most doctors work even in trying conditions,amongst apathetic govts.,and high personal sacrifices(both monetary and social).So if we doctors can treat our patients without worrying about whether the patient can afford the treatment we can at least bring back nobility to our profession.its not only the rich who deserve to get sick and be cured.even the poor have every right to lead a healthy life.So the next time you fall sick and get treated think about the millions who are not as lucky as you and be grateful for the same.Also try in your own way to do something about it.sometimes a simple thing such as a change in attitude will do.

17th April,2011                                  Raghuraj Hegde