For a medical student who freshly completed three years of Bachelor of Medicine and Bachelor of Surgery (MBBS), the following 365 days of internship is critical. During the internship period, which is part of the programme, MBBS students get hands-on experience and training for one-two months each in various departments — performing surgery, fixing a bone and delivering a baby, among others. However, for the students who started their internship (house surgency) early this year, have had their experience and learning upended by the COVID-19 pandemic.
“Government hospitals get at least 500 patients per day. So, as interns, we get to learn a range of medical cases in one day. However, the interns in my batch have had 500 patients over the last nine months since March 2020, all coming for the same set of COVID-19 treatment. As a result, as medical students, we learnt only one-hundredth of what we would have learnt otherwise,” said Dr Gayathri Viswanathan, a house surgeon at Bangalore Medical College and Research Institute (BMCRI), run by the Karnataka government.
Dr Gayathri and her colleagues started their internship in February 2020. By April, as Bengaluru started reporting coronavirus cases, Victoria Hospital and Bowring Hospital, which are teaching hospitals attached to BMCRI, were converted into an exclusive COVID-19 hospital, pressing the medical students, including the post-graduate or junior resident doctors, into service. Since March-April, they have been on COVID-19 duty. As a result, their academic activities and training took a backseat.
States like Karnataka, Telangana, Kerala, Gujarat, Maharashtra and New Delhi, too, roped in — or rather mandated — MBBS students, interns and resident doctors for COVID-19 duty, to cope with the dearth of doctors and rising caseload. The Gujarat government threatened action under the Indian Penal Code and Disaster Management Act, 2005 if the students did not report to medical colleges.
In cities like Hyderabad and Bengaluru, teaching hospitals were completely converted into COVID-19 treatment centres and all non-COVID-19 services were temporarily suspended. Gandhi Hospital, a state-run tertiary hospital in Telangana’s Hyderabad, was solely dedicated to treating COVID-19 cases since the pandemic began. In November, the junior doctors protested demanding resumption of non-COVID-19 services, fearing they would lose out on their academics due to insufficient training in other specialisations. The non-COVID-19 services finally resumed recently, after nine months.
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“We are happy to treat all coronavirus patients, but we are students first; we need experiential learning, too,” echoed some of the house surgeons and resident doctors TNM spoke to.
After completing their final-year MBBS exam, students start their rotational internship, loaded with practical lessons. They work with different departments, examine and perform a multitude of surgeries and procedures — all in one year. Besides gaining experience, this is to enable them to choose the branch of medicine they would like to specialise in, for their three-year post-graduate training in Doctor of Medicine (MD) or Doctor of Science (MS). “We are now confused what to do next,” said Dr Gayathri, the medical intern.
If an MBBS student cannot choose the field of speciality, National Medical Commission (NMC), the body that regulates medical education and professionals, does not allow an extension or repeating internship. After the MBBS, students have to take the NEET PG entrance exam, and depending on the speciality, they will be allotted seats. According to PG students, if there is no first-hand experience on what each department is doing, this decision is tough.
For Dr Gayathri, the only takeaway from COVID-19 duty was the mental strengthening lessons, besides learning how to maintain oxygen saturation level, intubation and ventilation.
Similarly, junior residents start their post-graduation with the motive to specialise in a particular branch of medicine. “The three years are interspersed with, inter alia, exams, research activities and submitting the thesis. Currently, nine valuable months have been already uncrated, and we have not gained as much knowledge in our subject as possible,” said Dr Ramesh SM, a junior resident doctor at BMC.
According to Dr Vijayender, who just completed his MD from Osmania Medical College in Telangana, during the first and second years, PG students are given routine or less-priority work, including examining patients and observing various cases. “They are not given surgeries until they enter the third year. So imagine if those eight months are taken away from the third-year medical students,” said Dr Vijayender, who is part of Telangana Junior Doctors’ Association (T-JAUD) that offered to help intensify the protests by resident doctors of Gandhi Hospital.
Dr Shameem, a junior resident at a medical college in Kerala, explained, “If five patients in a ward turn positive for coronavirus, it does not mean their primary disease is COVID-19; their comorbidities or non-COVID-19 condition, too, need treatment.” However, such cases are mostly attended by senior doctors from the Medicine Department. Besides, due to the contagious nature of the disease, only a handful of medical staff are allowed in a room or ward, which means, any scope for non-COVID-19 services training is further curtailed.
In Kerala, both COVID-19 and non-COVID-19 services in medical colleges and hospitals have continued since the onset of the pandemic. “Thanks to Zoom, we have theory classes and webinars for students every day, as against two to three classes per week during pre-COVID-19 times. One student will virtually demonstrate by examining a patient; other students and professors can ask questions. This is at least something to make up for the loss in practical classes,” said Dr Anil*, an associate professor at a government medical college in Kerala.
House surgeons in Kerala also get one month of COVID-19 duty, 15 days rest and 15 days of speciality duty to ensure their academics is not completely disrupted. However, there is a snag. “Many students get infected with COVID-19. About 40% of interns have been infected in this college. As a result, some will have to miss days of speciality classes,” said Dr Anil.
The students stress that they come under the Department of Medical Education, and not the Health Department. “We are paying an academic fee of Rs 1 lakh without getting the relevant training. We are serving the government by treating COVID-19 patients 24 hours. Yet, we get a paltry stipend (Rs 50,000) in Karnataka compared to other states and countries, and there are no COVID-19 incentives, too. The government can at least waive the academic fee,” Dr Vishal (name changed), a member of Karnataka Association of Resident Doctors (KARD), which recently gave a representation to the Department of Medical Education.
They have threatened to boycott COVID-19 services if the government does not accede to the demands of medical students to waive the tuition fee (for 2020-21), grant COVID-19 risk allowance and recognition for their services.
According to Dr Gayathri, the authorities concerned have promised to resume all services at Victoria Hospital by the first week of January 2021. However, it will take at least two to three months for everything to be even half of normal; but, by then, their internship will be over, she said.
Several medical students ascribed this to the fear among the public to come to hospitals that were dedicated COVID-19 facilities for a long duration. The beds are minimal as many were used for COVID-19 treatment. “We have been getting only acute and emergency cases. There are no cases of chronic pain, such as knee pain or back pain. Even consultants are affected as patients are hesitant to come to hospitals,” said Dr Anil.
Elucidating her point, Dr Gayathri said, “Bowring, which was a dedicated COVID-19 hospital, resumed non-COVID-19 services in September. That month, we had one OT (operating theater) service per day. This month, we have 10 OTs per day.”
“It is frustrating for the interns as they are gaining knowledge only on coronavirus, they are on duty from 8 am to 8 pm, and patients are infectious,” said Dr Anil. “Even if there is a vaccine, people will still have to wear masks and be cautious for another year. So, this situation (for medical students) is likely to continue for at least one more year.”
“For post-graduate students, this is their last opportunity to learn. After completing MD, they have to work in other hospitals and treat patients on their own,” pointed out Dr Vishal.
“As students of Bangalore Medical College, we were supposed to be the cream of the crop, as it is the number one medical college in the state, top 100-200 rank students get admission here, and we were supposed to get the best training. Yet, we are lagging, while private college students are getting proper training,” said Dr Gayathri. “An experience is worth thousand medical books. That can save a life,” she added.
As Dr Vijayender said, “Medical students will get their degree, but no skill.”