The centre of the life a medical teacher!

  

I watched this vessel of water boil this morning, while sipping my coffee. After about five minutes on the fire, some bubbles appeared on the surface, following which steam began appearing over the surface of the water which is what is seen the the second and third photos. Soon I noticed the water reach the boiling stage with water bubbling in waves from the centre of the water, from the bottom to the top! What a sight of surprise and message!

I went in to make coffee with some thoughts on the privilege I have had for over thirty five years to be associated with medical students. Now that I am formally retired from teaching, I was recollecting for the last one month my different learning experiences with them in seven settings.

When I saw the water boil from the centre, it became a metaphor of all that happened through the association with medical students. I felt that they were at the centre of my teaching life. It was by listening to them, understanding their thought processes and aspirations, and accompanying them, Anna and I felt enlarged to stay contemporary to the context of students. It was the group of students with whom we have had close associations, who briefed us to find the way we can support them without controlling, accompany them without taking over and enabling them in their calling without stifling their enthusiasm. They gave us energy and inspiration to make teaching relational, collaborative and formative beyond just disseminating information.  

My first experience with medical students was in the Medical College, Nagpur, when I was a junior resident. The students would come to the paediatric ward to 'see patients' and learn eliciting clinical signs. To auscultate a heart murmur or feel a just palpable spleen, or  discover papilloedema in the fundus or examine the central nervous system were exciting things for students. They devoured any information or help any faculty could offer to them. For the faculty, it was natural to be available whenever the students came in, seeking help. I grew up in the mid sixties as a medical student  watching my teachers dedicate time for students as a normal and cordial activity. Some would even take us to coffee at the end of a teaching session. The contact with them enlarged as some of them got involved with the activities of the Medico-Friend Circle, of which my class mates Dr Ullas Jajjoo and Dr Abhaya Bung were the leaders.  This was a time when we got introduced to life in the slums and villages, where medical camps were conducted through the initiative of medical students. By the time Jajoo and Bung were into their post-graduate training, the students of that time took the lead to continue the activities of the Medico-Friend Circle.  That was my first experience to appreciate the altruistic motive of some medical students and thier loyalty to the cause of service of the disadvantaged. 

When I went to the B.J.Medical College, Pune in 1976 for my post graduate training in Community Medicine, I found an equally approachable attitude from the faculty. In fact I was drawn to do post graduate training in Community Medicine by the extraordinary approachability and friendliness, I noticed in Prof. Maya Natu, who came on a transfer to Medical College, Nagpur from BJ Medical College, Nagpur. During the two years before I finished my undergraduate training, I found the approach of Professor Natu innovative as a community Physician, which was because of the two outstanding community physicians under whom she was trained, one of whom I met during a visit to Pune. Professor Sathe, looked at 'human wellness' as a bench mark in health care and not just treating illnesses. He to me in hindsight was a prophet talking about the things to come, mainly the emergence of life style diseases following the decline in communicable diseases, although we were still fighting small pox in some parts of India at that time. It was during this period of two years during my post graduate training, I realised how much teachers were keen to 'teach' and 'befriend' students. I experienced the primacy of 'calling' teachers expressed in the way they related and engaged students to give them knowledge, share experiences and dialogue on values in the practice of medicine. In every batch of students, there was a good number, who looked at learning medicine as a way of life, rather than just to score high grade in the examinations. I felt fascinated by the enquiring attitude of the students to learn bed-side practice of medicine through clinical examination and interpretation of the clinical signs. The way the students wanted to 'demystify' clinical situations in a fathomable way was certainly a refreshing experience while engaged in taking clinics for them.

Later at the Mahatma Gandhi Institute of medical Sciences, Sewagram, as a lecturer in community Medicine, I had an unusual experience of being associated with students. The community Medicine department ran the general out-patient services with specialists from all other departments, sitting in a large hall, giving instant cross-consultation as much as possible. It is from this general out patient service, patients were referred to specialties for further care, when needed. This experience of having medical students involved in examining and making decisions opened my eyes to the need of emphasising on 'hands on leaning' even when one is a student. In fact, gathering of all the primary information from patients and conducting the clinical examination were efficiently done by the final year medical students. So the students were 'doctors in training' and not just students preparing for their exit examination. 

The  faculty-student relationship developed into being co-learners and collaborators in reaching out to patients. One evening a group of students dropped into our home and surprised us by their regards and concern. Arpit was just few months old at that time. They enjoyed carrying and playing with him. For the rest of the eighteen months we were at Sewagram, this contact with students grew into a friendship level. Both Anna and I felt that there is more than just class room teaching while being engaged with medicals students. The relationship was formative for them and us. I looked forward to taking formal lectures to different batches, because it was a fellowship time and friendship building occasion. Some of the best question-answer times in the class were during this period because the subject of Community Medicine allowed a lot of lateral thinking and philosophical bend of enquiry in health care, health economics, social structure, politics in health care, etc. I returned from every lecture feeling that I was in the company of people who cared for me and received me well. 

Mr Raj Narayan, a comical person with his attire of a green head gear and 'silly' in behaviour and communications often, was the health minister in the government of India led by the Prime Minister Mr Morarji Desai. His only qualification to be included in the council of ministers in the government of India, was that he defeated, Mrs India Gandhi, the former Prime Minister in the parliamentary election. The health care planning reached a low ebb because Mr Narayan was neither forthcoming or allowed professionals to steer health care in the proper direction, but that government lasted for only for two years. So it was good to engage students and build their hope in the health care system at a difficult time when, they were appalled by a set back in health care parameters during that time. I recall this memory with nostalgia and admiration for students! 

A lot of conversation with them was on Gandhian thought and actions, because the ashram where Mahatma Gandhi lived for about 15 years before and during the independent struggle was only three minutes walk from the college. The founder of the college, Dr Sushila Nayyar, expected students to be influenced by the Gandhian life style of simple life and service. It was expected that students and faculty wore clothes made from and spun cotton as a symbol of identifying with the 'least' in the society who weaved these yarns. I was wearing such clothes for at least ten years prior to coming to Sewagram, as an expression of my resolve to live mindful of those who were disadvantaged. This itself was a good starter for conversation with students about the way one can 'condition' one's life voluntarily to live well and yet not be taken up by things which are temporal and external. The true self which resides within us is indeed 'God consciousness' and 'neighbour consciousness'! I found some students being open to explore this consciousness in their personal lives, so much so some students used to come home every week for fellowship times! 

The fourth major association with medical students was at Chennai, from 1983, when some medical students from the Stanely and Madras Medical colleges used to visit us. That gave Anna and me an opportunity to visit them in their colleges and participate in prayer meetings which they had in small groups for them to grow in the sense of call in medical vocation and engage the call of Jesus of Nazareth. Although it was not a regular or consistent contact, this gave us a new perspective about students. They being urban, seemed to be preoccupied with their further training and pursuit of career. We had a first hand experience of how the glamour of practicing medicine in prestigious hospitals and making a career path for themselves was driving some of them. During the fifteen years at Chennai, although we got to know some of them, it did not go beyond the social acquaintances. Some opportunities I had with post graduate teaching of paediatric trainees helped me to know the mind set of an average trainee, who was seeking after a 'successful career'! 

When we arrived at the Christian medical College, Vellore in 1997, we encountered a new culture of staff-student relationship. The first impressive and revealing experience about the way staff viewed students at CMC was when we watched the staff entertainment, which the faculty put up for students soon after we joined the institution. It was an occasion when the faculty recalled their student days and made hilarious presentations, through skits, mono acts, drama, music and singing! It was an occasion to 'demystify' the unnecessary 'awe' artificially created among students towards the faculty. The faculty by having 'foster parenting groups' attached to them, got involved in nurturing and accompanying students during their years of training. The students were provided with a 'missionary' appeal in the practice of medicine through the simple life the faculty chose to live and serve their patients with compassion. The next fifteen years at CMC Vellore till Anna and I retired were special years, when we had lot to do with students formally and informally. 

One special experience was the involvement in selecting students for the MBBS course as group observers, which through a two day interview process gave us an opportunity assess about seven students in a group and grade them for their all rounded sills. This was the beginning of contact with every batch of students.  The learning process for every batch of students started with them living in a village for one month as an exposure to life beyond their normal consciousness. Every batch of students visited the village where they spent a month to keep track of family and health dynamics as a result of which some students, in  batch of sixty at that time, would have made up their mind to go to a rural are at work. As a part of the curriculum students spent at least three holidays in a rural mission hospital under the supervision of a faculty for them to get familiar with opportunities and needs in a rural area. For some students this was a turning point in their lives. The students presented their experiences to the faculty after their return which  gave the faculty to be even more involved in a mentoring role with those who were 'creative and self giving' in there pursuit of the future. 

I remember, Professor Frank Garlaick in the mid sixties at CMC Vellore had a group of students visiting him in his home almost every week, to discuss existential questions. Two of them, Dr Raju Abraham and Dr Vinod Shaw from that group went on to pursue a missionary vocation which have been radical on one sense. Raju trained himself as a Neurologist, worked in National Health Service in Britain and returned to live and work in Kachwa mission hospital in response to a call to go a 'second mile' to serve others. Vinod, started his work in a rural area in Danta, went on to train as a paediatric surgeon, worked in the Emmanuel Hospital Association, became its Director and later established the Distance Education Department at CMC Vellore. There are several examples of such 'students' who moved into a life time of service in needy areas because of the 'change experience' they had during their student days at CMC Vellore.  I remember Dr Jayabalan who spent a life time of service working with patients of Leprosy; Dr Ajit Singh, who still works in a rural hospital at Khariar; and late Drs Raj and Mebel Arole, who went on to establish a pioneering rural health care service in the community at Jamkhed, which became a role model in community health in rural India.  They along with many others who have made a difference in health care were students at CMC, who received a vocation to make their profession into an opportunity to serve and live vicariously! The mentoring roles of Dr P Zachariah, late Dr Benjamin Pulimood, late Dr Paul Brand, and late C.K.Job were some of the faculty whose moving stories Anna and I heard from them or those who knew them well. In fact, in an interview I had with Dr Paul Brand, in response to a question as to why he went to Men's hostel in the evening to teach students, who missed his class, he told me, that  'A teacher is for students...it is his or her responsibility that students are looked after'! Such was the extent to which the teachers at CMC Vellore viewed their role in the lives of students. No wonder, that when an employer has to choose a doctor to work in a hospital, a person trained in CMC Vellore gets the first pick. 

During the first term of two  years Anna and I spent in CMC Vellore from 1980 to 1982 we got to know some students, Joseph Thomas, Gordon Thomas, Vijay Aruldas, Johny Oommen  and few others. They were students who inspired us with their sense of mission in life. All four of them have gone on to engage in some creative responses : Joseph was part of the team that founded the Asha Kiran Hospital, Lamptaput in Orissa and later went to specialise in Foetal Medicine with a distinguished professional contribution, Gordon went on to train himself in paediatric transplant and is a leader in this field, Vijay went to do hospital administration and served as the general secretary of the Christian medical Association of india and Johny works in a mission hospital at Bissamcuttack, where he established a residential school for tribal children, which is creating a new layer of leadership in the community! The contacts with them and some others gave us an opportunity to get a sense of what students expected from teachers and stay connected with them.

It was during the second spell form 1997 to 2010 at CMC Vellore, we got further immersed in the life of the students. A Friday Forum that emerged was a good example of the student's initiative to stay in touch with us, by meeting every week at home around coffee and chocolate cake to discuss and explore personal and professional matters. A few might have come for the cake and coffee, who later dropped out, but about ten who were regular in such meetings were enquiring about inner realities of life and purposeful living in the call of medicine! It was during that time, I became involved in undergraduate and post graduate teaching. A neurology consultant who is a reputed leader in this field, happened to mention in a meeting that her interest in neurology began with the three bedside clinics I took before the final paediatric post graduate examination on childhood neurological illnessses. The undergraduate lectures and bedside clinics too became good contacts with students in 'searching' with them the best way of making the subject matter come alive. I have had feed back that during that fifteen year period in the faculty, eleven students went on to train in Paediatrics because, they felt enthused by the specialty through those teaching sessions. Anna and I have contacts with some of them who recall the turning point in their lives. A paediatric intensivist mentioned in  a recent email, that the excitement of bedside examination and decision making made him gravitate towards training in paediatrics. It was more than a surprise to have been chosen for the 'Best Teacher award' in 2005, at CMC Vellore, which gave me a sense of direction to make teaching-learning a student friendly activity. It provided me encouragement to register four professionals for PhD, when the department was recognised for research in Developmental Paediatrics in 2006. 

The student life in CMC Vellore was an experience in internal democratic decision making as both Men's and Women's hostels had a governing committee who decided the affairs of the hostel life. Anna served as the warden of the Women's hostel for a few years during which time, the contacts with students got even more enlarged. Anna used this opportunity to encourage the women students by instituting an annual award for a best all rounder of the Women's hostel in memory of our daughter Anita Susan. This promoted some students in the leadership, to value hostel life even more as an occasion to develop long term friendships.

There were occasions when students needed personal support and discerning conversations, which made a difference in their lives at critical times. Going with them for their retreats, speaking at the Sunday worship in the chapel or at formal occasions such as college day, etc brought us closer to the formative process of the student community. The foster groups that met in our home regularly was another encouraging experience for us. They got involved freely with us  because they were also familiar with Arpit and Anandit who were also students at CMC Vellore. Our home was decorated every year for Christmas by the foster students. When Arpit and Anandit got married the physical arrangements were organised by the foster students. We had opportunity to get to know some staff children who were students at CMC or elsewhere, which made us stay connected with some staff families even after we left CMC.

We had several farewells when we were leaving CMC Campus on retirement. The farewell by the foster students and some others was a moving occasion. We felt honoured by their kind words and some recollections of gains of relationships which went beyond our expectations.    

It was with this experience, we moved to the Pondicherry Institute of Medical Sciences, in 2010. Although that was only for a short period of two years, there were some meaningful relationships during that period. The study group that met in our home was one memorable experience of watching some students grow in their value system and revise their view of future vocation. A few students  chose specialties deliberately out of this sense of mission they sensed through these meetings. By then the attitude to teaching and training was already changing among students and faculty. The reading habit too was declining. The internet and smart phones had to come to occupy time and attention. The leisure time was spent in activities of entertainment. The students preferred to read text books which were small and less in content or rely on their notes of lectures. This was a time of disillusionment for Anna and myself, as  there was an increase in the number of students to study medicine, who felt pressured to do so by their parents. This had changed the learning ambience in the college.

When we came to work at the MOSC Medical College, Kolenchery in 2012, we were already aware of the changing trend among students. Anna took an earnest initiative to introduce opportunities for students in clinical research from the very start of our time, because of which she was appointed as the Research Co-ordinator. About fifty students undertook different research projects, about half of them   qualifying for ICMR student scholarships during the last four years. Although Anna handed over the responsibility to a colleague as she wanted to move on to focus on developing her department, she is still a resource person for students in clinical research. I got involved with students  for their personal development and the foster parenting system developed out of this. We have a    group of students with whom we meet to support them and dialogue on matters of health care and professional life. However, relating to students has not been easy because of an emphasis we brought in to make them consider student period as a time to be a training period to become doctors! 

It was a new experience to offer clinical attachment to students in Developmental Paediatrics and child Neurology and during the in-between times, when they were waiting for results after first year examination or final year examination. We have had seven so far who used this opportunity. It was an encouragement to have had the students involved in doing many practical things in the department: decorating the place to make it child friendly, organising Badminton matches for staff and students, Christmas cheer annually, getting some documentation of the clinical data for research, organising an annual 'one rupee save campaign' to subsidise cost of care for children, assisting to conduct the annual meetings of the department, etc. Anna and I feel grateful to many students especially Thomas, Caren, Anjaly and Rhea who were our initial contacts in the year we joined MOSC through whom we got to know many more. We feel encouraged by their visits to our home and to our departments and all that they meant to us to get adjusted to life and work in Kerala. Anna grew up in Pune and I returned to Kerala after having been away for forty years. For both of us, student friends were companions who made us feel at 'home' in Kerala.

The season of six years in MOSC medical college was also a time of sensing some new dynamics within the student community. There have been tensions and conflicts of different types, all boiling down to the changes taking place in medical education in India. The emphasis on 'learning for life' has been less of passion; it is mostly to learning to pass examinations. The conduct and character of a a doctor in training is not necessarily a focus for the students or the faculty! Some of us who speak this language 'formation for life' while in training or represent this view to the medical students have suffered as some students react adversely to such  an attitude in the class room and outside. In fact the very students we tried to enable and befriend have turned hostile because they resist value based choices! We wish some of these students were more mindful and thoughtful of simple courtesies we are to keep in the profession! I had a special request from a responsible member of of the college union, 'let me advice you not to come for the functions even if you are invited because students might behave rudely..' To me it sounded as a consent for the students to ignore the decorum and meeting etiquette required of all of us!

At the same time we have come across many students who conduct themselves soberly, kindly and regardfully, thereby making the college life colourful and endearing!

Yesterday an intern dropped in for a conversation after he responded to the weekly quiz in the bulletin board of the department. He mentioned that most students spend the last four months of the final year to prepare for the exit examination! It is not a systematic or sustained learning process for many students. He spoke of it with concern and pointed out the 'limited' practical skills with which they complete the  course! I sensed this myself recently. I offered a batch of students a handout on long term 'management' of children with Epilepsy after my two lectures on this topic. None came to collect the handout form the office. So has 'minimalistic' learning set in!

Now that I have formally retired from the faculty, I  feel distanced from the teaching-learning events in the college. 

So looking back at the thirty five years of association with students, in seven different settings, I feel glad for having been able to keep the students in the centre of our thought and focus. They made Anna and me aware of the current realities and gave us the readiness to change and adapt. 

So watching the water boil from the centre of the vessel was the starting point of this long train of recollection of thoughts and experiences of keeping students in the centre of our teaching-learning journey!

A fulfilling and grateful ending to thirty five years of learning and growing by having the medical students in the centre of my focus!

However, I am tempted to add that the medical education in India is on a crutch, with the Medical Council of India now superseded a third time in 12 years because of corrupt practices. A profession which ought to be rooted in values of high ethical practices  for which a regulatory body is created is itself accused of several corrupt practices. I fear for the future of medical education in India and the recent turn of events in centralising control in selecting students through a centralised entrance examination. A college like CMC Vellore which has had its own selection process, and chosen students who have a feel and flavour of viewing the profession as a vocation also has to take in students on the basis of NEET score! The score does not represent the ethos or outlook of a student to study or practice medicine. Whom are we training for the profession! Those who feel the call to serve or those who want to make a career out of medicine!

Oh, Good Lord, restore sanity in medical education in India!

M.C.Mathew(text and photo)