I know it’s like setting a cat loose amongst pigeons but this has been on my mind for quite some time.

I have taught in a private medical college for close to 25 years and I have noticed this disturbing trend amongst students. It begins in the 10th standard, by then students have either decided or the decision has been taken for them, as to what career they will pursue. It’s a limited choice, either Medicine or Engineering and anything otherwise is considered sacrilegious. Even before the 10th results are declared the students are admitted into coaching classes, which prepare them for the premedical or pre engineering exams. There is a ‘setting’, as known in local parlance or nexus between these coaching classes and some schools and junior colleges. The student admitted in these schools/junior colleges are not expected to attend classes. Instead they spend the whole day in ‘swot’ or coaching classes. The main focus is on the pre-medical or pre-engineering exams. The schools/colleges themselves don’t encourage their pupils to attend classes and their staff moonlight by teaching in these coaching classes. So they are not available to take regular classes. Some students don’t even enroll in coaching classes in their home city, but in famous towns whose names have become synonymous to quality coaching classes, like ‘Kota’. Kota has become a brand name in itself and many wannabe classes in the town have sprung up which have no connection with the original Kota classes but encash on the name. Kota being the name of a town cannot be trademarked. Even for getting admission in the original Kota classes the students have to undergo a pre-pre-entrance exam and only the best are taken. If you are take the best you are guaranteed a good result. The challenge would be to take the average and make them the best.

The students return to write their boards in their home town and as they were enrolled in local schools/colleges that’s no problem. They can now avail of the domicile of the state while applying for admission. Regarding domicile only Delhi is truly all inclusive and anyone can apply in the state medical and engineering colleges. Most other states have quotas for domicile, even for domicile in regions within the state then rural and urban. For clearing the board exams the student has sufficient knowledge to get passing marks and is guaranteed 100% marks for the practicals and of course class attendance. Thanks to the coaching-class-school/college setting.

The students through various permutations of caste, quota and capitation secure admission in a medical college. The students of today are farsighted. They know where their priorities lie. They glimpse the future through their own crystal ball. They realize that a mere MBBS doesn’t amount to much. This is true because the days of a family doctor is over, जिनके पास हर मर्ज की दवा थी, or who had the panacea to all illnesses. The general practitioner field has been taken over by graduates of the alternate-pathies or Ayush. No self respecting MBBS would allow himself to be a general practitioner. So now begins the quest for a post graduation degree. Once again admission is sought into specialised coaching classes for post graduate admission tests. Many of the students miss the morning lectures in college because they are attending the coaching classes. Students posted in surgery sometimes request me that they may be excused on Saturdays. Usually on Saturdays an expert on a topic flies down and delivers a lecture. I ask them what can he teach you which is different from what is taught in regular classes. They have no answer. Possibly ‘घर की मुर्गी, दाल बराबर’, or you don’t value what you have. Since the expert has flown down from a metro and has the aura of a sawant, it is believed that his teaching would be like the revelations of an Oracle.

“To study the phenomenon of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all” (Sir William Osler) and “The ward is your library, the patients are your teachers”. I must have quoted these adages from the Surgical textbook, Bailey and Love, to students, ad nauseum but with no avail. Unfortunately it is possible to pass MBBS without ever having seen a patient and passing is all that is required. Because admission into post graduation depends on how you fare in the entrance exam and not on your MBBS marks. What is taught in the coaching classes? How to approach the entrance exam and how to score in multiple choice questions. Question banks with questions from previous years is distributed and studied as the questions repeat, sometimes almost upto 20%. The theory taught is related to these multiple choice questions. Internship in hospitals where presence in spirit and not in flesh is required is sought. The flesh can attend the coaching classes while the spirit does the internship. This has resulted in MBBS graduates with zero practical knowledge and selective theoretical knowledge.

So the student cracks the post graduate entrance exam and gets admission in a post graduate seat. The most sought after seats are the ones where ‘practice’ or patient footfall is good. For example orthopedic surgery, trauma is increasing and not decreasing thanks to the fast pace of life, there is always trauma and people are breaking bones. A broken bone is obvious even to the untrained eye of a patient on an x-ray. Not much persuasion is required regarding the need for surgery. In contrast in general surgery a patient with appendicitis, intestinal obstruction or perforation peritonitis would not show much in his x-ray which would be discernable by the untrained eye.

Gynaecology is another all time favourite because every married lady will become pregnant sooner or later, preferably sooner. She will have to deliver and a Nursing Home close to home is preferred. It is convenient for delivering tiffin and accommodating visiting relatives. So there is a ‘friendly neighborhood obstetrician’ in every locality. In our days suction cups, forceps and manipulations were used to ensure a vaginal delivery. These days the Obstetricians take no chances, if there’s even a slightest doubt then it’s safest to do a Cesearian section. What surprises me that these same ladies who have undergone multiple Cesearian sections when told they will require an appendectomy, baulk and say they are scared of operations, can’t it be fixed with medications? When asked how they endured the multiple Cesearian sections, they retort, “that was many years ago”.

Dermatology is another sought after speciality where there are plenty of patients and no emergencies. These days dermatologist are packaging themselves as cosmetologist. Their plethora of services along with consultation includes beauty treatment.

Radiology used to go abegging when I finished my MBBS, because in those days x-rays were the only diagnostic tool in the hands of the radiologist. Now there is a plethora of diagnostic tools like sonography, CT scan, MRI and PET scan. Interventional radiology has also taken in a big way. Now radiology is in the great demand for the same reasons, plenty of patient footfalls, no emergencies. However being a dependent branch it involves schmoozing specialists but once the chain is established it is all hunky dory.

Medicine is another sought after speciality because physicians are the gate keepers. Almost all patients initially land up first to a physician who in turns decides where to send the patient. Somebody describes them as Kings because “जिसके पास प्रजा, वो ही राजा” or the one who has a following is the King. The physician can manage the patient initially till relevant specialist sees the patient. The physicians also always have a gaggle of chronic patients suffering from diabetes, hypertension and heart disorders. These ailments cannot be cured and can be merely controlled, hence the physicians have patients for life. Physicians fitness is mandatory for patients posted for routine surgery. It’s their job to optimize the patients for surgery.

Ophthalmology is another speciality where footfalls are guaranteed. All of us require glasses after 40 and cataract surgery after 60 is all part of the aging process. This speciality has few emergencies and plenty of patients.

Coming to my speciality, surgery, it lies somewhere in between. The surgical field has also been encroached by the superspecialist depleting the field. Now a general surgeon handles purely general surgical problems, leaving the cancers for the surgical oncologist, vascular to the vascular surgeons, endocrine to the surgical endocrinologists, urinary problems to the urologists, head injuries to the neurosurgeons, gastrointestinal problems to the surgical gastroenterologists and lower gastrointestinal problems to the Colo-rectal surgeons. He is left with hernias, hydroceles, abscesses, wounds, lumps and bumps.

Finally the real value of a seat is determined by the market forces, which is most sought after and which attracts the highest capitation. Capitation fee or sometimes euphemistically called donation is uniquely an Indian term, refers to an illegal transaction in which an organisation that provides educational services collects a fee higher than that approved by regulatory norms.

Now once a student gets his speciality of choice or had no choice, just had to take what he gets. If he gets surgery than his goal now is to get a super speciality seat. No one except fools like me would be happy being a plain general surgeon. But I can say because I have worked in all specialities of surgery, I can teach the superspecialists some practical things.

The students we get from premiere institutions are solely lacking in practical knowledge. Some don’t know how to take the blood pressure others don’t know how to start an i.v. line. One student introduced an i.v. cannula into the vein in the wrong direction, pointing distally. After starting the i.v. the patient’s hand got swollen up. But now the focus is studying for the superspeciality pre admission test and the cycle begins again. After that they will be studying for a foreign degree.

Someone said “When I finished my studies I began my education”. The question is when will the studies end and education begin?