The “practice” of medicine!

Medical students who finish their last round of undergraduate medical exams face a strange mix of happiness and anxiety. Happiness because they have finished the exam and are now almost certified as doctors, anxious because they don’t feel like they know enough to manage complex cases independently.

Medical students don’t seem to know enough of anything! Anesthesiologists feel that medical students don’t know enough about spinal anesthesia and central lines, Radiologists feel students can’t read an x-ray well enough. Cardiologists feel that students should be reading ECG’s better, Palliative Care feel pain management should be taught better. Why is it that every specialty flat out believes that nothing from their field is being taught in medical school?  Is it fair to say that nothing is being taught in medical schools?

However, this notion cannot be further from the truth. In India, students join for Undergraduate Medical Training in medicine straight after high school via an extremely competitive exam. They are arguably some of the brightest students in the country. MBBS covers the basics of over 19 subjects with more subjects beating on the door to be let in. A fundamental knowledge of Anatomy, Physiology, Bio-Chemistry Pathology, Pharmacology, Pathology, Microbiology, Forensic Medicine, Community Medicine, ENT, Ophthalmology, Internal Medicine, Pediatrics, Obstetrics, Gynecology ,General Surgery, Psychiatry, Orthopedics and Dermatology are covered. (phew…. you skipped the list didn’t you?). That is a LOT of knowledge – in a very short period of time! – Time is a luxury.

Theory classes in medical school are usually designed to spark an interest in students. Classes are ONLY for signposting and what is absolutely essential. The rest is expected to be read by the student in their own time. They are usually free to read any book of their choice.  

Real learning happens in the wards. From second year on, students spend time in the wards. “Shadowing” interns and residents and professors. Learning the basics of collecting a history by talking to the patient, learning to examine a patient, learning to put theory and practice together, make a differential diagnosis and order relevant tests. This is almost a sacred process where skills are passed over from one generation to another. Many clinicians love teaching and passing on their knowledge, many couldn’t care less about teaching. It is variable and depends on how much the student wants to learn and the teacher wants to teach. A good teacher makes all the difference.

The ward is where attitudes and skills are picked up. These interactions at the bedside make the difference between good clinical skills and bookish knowledge. An extension of this practical learning process is internship. Procedural skills – starting IV lines, ascitic taps, conducting deliveries, catheterizations, managing an emergency room, breaking bad news etc. are all learnt by doing. However, it may be difficult to quantify everything learnt in internship. For procedures students sometimes keep a log book but how do you quantify the learning you get after you watch death for the first time?  Break bad news for the first time? Face a mob in casualty for the first time (so common that is quickly becoming a rite of passage)? All these experiences teach so much!

If you are a medical student reading this. – Relax! You have made it so far crossing many tough exams. Keep working hard with honesty. Get your basics right. If your attitude towards your subject and your patient is right your skills will improve. Keep hustling. Mastery will come with time.

The idea of MBBS/undergraduate medical training is to make a physician who is competent with basic skills. You HAVE to meet a minimum standard. You may not be able to solve every problem but you must be able to identify red flags and refer. You may not be able to characterize a cardiac murmur but you MUST be able to identify that it exists and refer! Spend time in the wards. Do as many procedures as you can during internship. Don’t throw away the opportunity to be in the ward to solve MCQ’s. The pressure of the upcoming postgraduate residency entrance exams may be massive but the opportunity to spend time in the wards and rotate through all the specialties is unlikely to ever come again. In the future you may choose to work in one specialty but the broader your overall view is the better it will be when you specialize later.

When in doubt – Call for help! There is NO shame in calling for help.

MBBS certification is not an endpoint in itself. Learning will go on – during residency and further practice and then for rest of our lives – that is why it called “practice” to begin with. Because you keep learning and getting better.

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