Monday, November 18, 2013

The 6 missing Es in Medical Education

Medical training can be arduous. It comprises years of concentrated training, to ensure that the professional knowledge base of graduating doctors is sound , allowing them to efficiently and effectively take care of their patients . While medical school does a good job in inculcating sound professional theoretical and practical skills so that doctors can do a good job as medical professionals , there are still some glaring lacunae in medical education today. These gaps are one of the reasons the medical profession finds itself in the sad state it is in today.

Some of these gaps were well articulated by Dr. Reddy of the PHFI in an article published in the Hindu in 2009. This is my updated list !


This is a topic which is rarely discussed in medical college . I guess one of the reasons is that it’s very hard to really teach ethics . It’s something you imbibe from your parents, and if your ethical base is not sound by the time you enter medical college, then no amount of lecturing or preaching will help to fix the problem.  Unless we have medical college professors and teachers who are ethical role models, we can talk about ethics until we are blue in the face , but nothing will really change .


The two things which a patient comes to a doctor for are his professional skills and his compassion . If the compassion is missing , then no amount of professional and technical competence can make up for this. Unfortunately, polishing a doctor’s bedside manners and honing his humanistic skills is something which is given short shrift,  simply because there is so much academic content to cover within the four years of medical school , this is an area which is neglected and ignored. Some medical students are fortunate to be exposed to outstanding , who are empathetic , and serve as great role models which they learn to emulate.


Medical schools are usually so focused on teaching students how to make sure their patients get the best medial care, that they often don't factor in how much the treatment they prescribe costs the patient. Money is still a taboo topic – and not one which most doctors bother about.  It’s only when they actually start practicing that doctors learn that many of their patients find it hard to make ends meet ; and that medical care can sometimes be a luxury which a lot of them simply cannot afford . There needs to be more emphasis on the importance of exploring inexpensive alternatives ( such as generics ) during their prescribing thought process.


Doctors take pride in providing great one-on-one medical care – after all, this is their core competence ! They are taught to focus all their energies and attention on the patient sitting in front of them , to the exclusion of all else. While this is extremely important doctors , can't lose sight of the fact that they simple  cannot look at the patient in isolation. Patients come with cultural  baggage and this needs to be factored in when formulating a treatment plan. Unfortunately, students are not taught to think about the patient’s literacy levels or his socio-economic status . While epidemiology that way it is taught today is an extremely dry and boring topic , it is something which pervades all of medicine , and needs to be carefully considered to ensure that the patient gets the care which is right for him .


Lots of doctors enter private practice; and while medicine is a profession, every medical practice is also a small business . While its primary goal is to take care of patients , unless the business is profitable and the doctor is earning money , he will never be able to focus his energies on his patients. Unfortunately, practice management is a completely foreign topic for most doctors; and they often do a bad job at managing their finances, thus hurting themselves and their patients in the long run.


The purpose of medical schools is to educate doctors , and while they do a good job of cramming their students’ heads with tons of information ( which they are forced to regurgitate during the exam in order to graduate), the fact is that a lot of this knowledge will evolve and change as medicine advances. Ironically, most doctors will find themselves out of date within a few years, as medical knowledge today has a very short half life. The most important thing we need to teach future medical doctors is how to educate themselves , so they become efficient lifelong independent adult learners,  and remain up-to-date.

I shared this post with my friend, Dr. Sachin Ganorkar , works in the areas of primary care , family medicine and health administration. He is a proponent of patient centred care and is working on enabling Healthcare through social capital and Information technology platforms .

He had some interesting insights to add.

Doctor Malpani , you have left out some Es  !

This is one of the pillars of medical ethics, but one we aren't taught to factor in. Doctors focus on maximising personal benefits, but promoting equal and free access to heathcare should be at heart of medicine. Doctors are a pampered lot, who are educated in cities and surrounded by amenities they take for granted. The thought of spending even 3 months in a rural area makes all medicos take up arms. They need to be sensitized about the caste, class and economic realities of the country.  We are technically trained professionals, but have become cut off from the social milieu our countrymen live in. Empathy can only be kindled when a doctor spends time in these places - and understands first hand the economic , social and political forces which cause health inequity today.

Education for the Patient
This should not only be for themselves , but for the patient who has come to them to seek help. Doctors are very disrespectful of patients, and they need to learn to treat them with care and attention.  This would prevent over half the medical negligence cases we see today.

Young doctors need tools , and they should be able to be exposed to a skills lab and mentorship. Start up accelerators and incubators in the healthcare space can help to catalyse remarkable changes in this space, and these should partner and collaborate with medical colleges.
Entire Journey of the Patient
The physician should be taught to provide care and hand-hold the patient during his entire journey . Today's care is very episodic and patients often fall in between the cracks of our system. Specialization has lead to fragmentation ; and patients are desperately in need of a family doctor who can act as friend , philosopher and guide during his complete journey - from home to specialist to hospital and back !
E- Health
Everybody seems to be in the E-Health space today, except for doctors ! Physicians can leap frog traditional hurdles and improve their productivity in this technology driven era by participating in the e-Health boom . This can help them to reach out to many more patients much more cost-effectively.

Physicians need to be taught to tackle their egos. Most doctors today live in ivory castles of their own making.

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