Although it is very late to be sharing events of the previous year today, I consider that the correct timing of posts is also important for the proper reception and comprehension of their relevance. Especially in the coming days of huge change in the Indian Medical School Curriculum which is now to involve a one year Rural Posting, I thought sharing my work experiences in a quasi-rural quasi-urban environment would generate some ideas as to the nature of the challenges that students might face in the outside world we call “Bharat” (an euphemism for the less developed rural/ semi-urban areas of India).
As a part of an initiative called the National Services Scheme (NSS), I had a chance to be a part of a series of Health camps organised in various suburban and slum areas of Delhi, thanks to my friend Saurabh. Students of Delhi University have been organising these camps for some time, involving students of our Medical School along with Doctors working in Private facilities who have come forward to help.
Each camp day needed us to travel to the interiors of Delhi, which very few people can imagine to exist, spanning shanties behind university area to distant Jahangirpuri slums. Walking down the streets, one could not possibly miss the almost 300-400 metres high mounds of “Kooda” (rubbish) lying on either side. Utterly surprising was that at places, a whole slum would be situated right behind the huge mounds, hidden, as if protecting it from the eyes of the civil society.
A team of students would be seated at the Registration desk and another team of volunteers would go about the community creating awareness for the camp and mobilising people, while I and my Medical school friends would be posted at the drug dispensing counter. Our work involved making copies of a line-list of drugs available for the day to be given to the Doctors. Every person who has been seen by the Doctor would come to us with the Doctor’s prescription and we would search in the not-so-scanty supply of drugs to cater to it. Finally it would be our duty to counsel the patient on usage of the drug, when to consume it, how much and till when.
The prototype patients that I would counsel:
1. A very elderly man/ woman, having scanty vision, dry skin, pyoderma, complains of piles, these being a few of the long list of complaints
2. A pregnant woman in her early trimesters
3. A 5 or 6 year old girl/ boy with fever, ear discharge or scabies
4. A mother carrying her one year old infant who has complaints of nasal discharge, fast breathing and cough
In the above cases, the Doctors would be ordering oral antibiotics, eye drops, ear drops as and when required and vitamins in almost all cases. Funny thing was that a Vitamin would be given even if the person would not have any medical needs.
This is because:
1. For the satisfaction of the patient. This in a way increases the trust of the person in the Doctor and enables repeat attendance of the same person in the next camp or to any medical facility per se in case of valid complaints.
2. Most of these “patients” belong to the lower classes which suffer from common yet often overlooked problems of iron deficiency, vitamin deficiency, worm infestations, etc.
Certain aspects of this mode of treatment which I found could be harmful was the evaluation and treatment of children aged less than 1 year within this facility. It is not uncommon of such young children to catch pharyngitis or sinusitis which after a few days convert into lower respiratory infections namely pneumonia, abscess, etc. The time when the Camp Doctors are seeing the child, the infection might be at its earlier stage, but if the mother is not counselled regarding the natural progression of the disease in the child, she would be late in bringing the child back to a medical centre for proper timely intervention. And not just in Camps, but it holds true for Primary Care system present currently at the grass-root level.
Every now and then, a woman would get restless standing in the long queue, waiting for her turn for the Doctor to comer, and would start expressing her dissent wailing and waving arms, as if they would come by and ransack our supplies any moment. But nothing like this ever transpired. We could control the crowd by taking an authoritative attitude and despite knowing that refusal of treatment or drugs to patients would be unethical, we had to resort to such “Dhamki”s (threats) more than once; although always remembering the fact that we weren’t going to resort to such lows ever.
In consideration of patient satisfaction, we could never ascertain the status of the compliance or the ability to follow instructions in the community. The basic problems that I could identify were:
1. People were not aware of the disease conditions that might affect them in daily life. [traditional knowledge of the elderly was falling short of the modern knowledge obviously
2. They had little idea about adding leafy vegetables to diet and cooking in iron utensils for adolescent girls and pregnant women. [Basically the felt needs of the community were very less, mostly due to lack of knowledge and absence of any timely educational activities trying to reinforce their knowledge regarding health]
3. They had almost no orientation as to when they needed to go to a Primary/ Tertiary care centre and when to just stay restricted to the local Primary Health Centre or a Private practitioner. I remember advising all those who weren’t satisfied with the treatment received from Local practitioners to give a visit to the bigger hospitals around the place, Hindurao Hospital for example. Any modern health system would mostly require a Tertiary care Centre to look at referral cases from lower centres. But, in our communities, the situation is grossly the opposite, majorly due to non-availability of local medical practitioners, lack of ability of the practitioner to reach out and connect effectively with the community, etc.
More than once, my friend would have a discussion with the Doctors regarding advice of unnecessary drugs (e.g., antibiotic drops for dry eyes) and the fallout would be an unwanted altercation of one person trying to understand the intricacies of drug prescription and the other party trying to explain his stance of doing the same. What obviously transpired from such discussions was that we as students had a lot more to learn not just about the Pharmacology part but also about why, how and when to dispense drugs. After completing my final year Med-School, I have finally realised why Medicine has been time and again referred to as a Pseudo-Science and an extension of Arts in Science.
Coming to the issue of the Rural posting; the logistics are still under review and the doubts regarding allocation of centres, budgeting and the pay scale remain unanswered. Leaving all of that to the policy-makers, as a Doctor who has just completed a 4 and 1/2 year long rigorous clinical training and awaiting a 1 year Internship in the multiple branches of Medicine, and as one who strongly believes in serving people at whatever cost, I would expect the policy-makers to also consider the difficulties that a new-comer might face when he is appointed as a Medical Officer in a community. The expectations of the community are going to be huge and in order for the system to work, logically there should be a mentoring program running alongside this, to ensure the proper acceptance of the new young Doctor by the community. For this mentorship program, the Govt. may hire professionals from branches outside Medicine who have a better idea regarding handling the socio-cultural aspects of people.
At present, to the would-be Indian Doctors, the crisis at hand is the selection in the Post-graduate entrance examinations based on whether or not he has served in the rural community for one year. But a lot of people fail to understand that even after Super-specialisation, once a Doctor goes out into the community, he is insufficiently equipped to deal with the non-medical needs of the community. Their needs are not only Medical in nature; a lot of times they need plain and simple counselling; like in cases of non-communicable diseases, proper explanation of diet, physical activities and lifestyle changes, which altogether is not possible by the treating physician alone and should involve a social worker and a dietician, who would help bridge the gap between the busy Physician and the patient, who does not need to visit the doctor for every minute question regarding his lifestyle. And this is just an exemplary situation that I’m talking about.
Currently, the Govt’s plan is to decrease absenteeism of Doctors at PHCs by making this rural posting compulsory. But I fail to understand one simple thing. Isn’t anybody concerned about the social relevance of such a step? DO they expect hard-core urban-mentality Doctors to suddenly go into the community and then understand how to deal with socio-cultural aspects of the community on our own? Another aspect which is of mention is the sensitisation of Doctors towards gender and religion which as of now is absent in the Medical school curriculum. It is a matter of debate as to how to impart such practical training in the curriculum, whether practice-based, i.e. along with the demonstration of clinical signs on the patient by the demonstrator, or as a separate subject dealing with patient psychology. I am sorry to accept that such sensitisation training is lacking in all of Indian Medical schools.
We are left with basically our own instincts and intelligence to learn to handle the outside world at large.
Only time can tell what shall be best for the betterment of the situation.
Until next time,
Peace.
Restless Wanderer 