Year : 2016 | Volume
: 20 | Issue : 1 | Page : 123--128
Arjuna's recollections – Part III (or) an endocrine version of the “Motorcycle Diaries”
V Sri Nagesh
Consultant Endocrinologist, Care Hospital, Hyderabad, Telangana, India
V Sri Nagesh
Department of Endocrinology, Care Out-Patient Centre, Road No 10, Banjara Hills, Hyderabad-500034, Telangana
The ultimate dream of every young student stepping into the hallowed portals of a medical college is to achieve the holy grail of medical education, a DM seat. However, the real battle begins only after the DM seat is won. The residency is a veritable roller coaster ride all through the three years, with the student alternating between exhilaration and despondency, wisdom and foolishness, hope and despair and ecstasy and agony. The long working hours, logistic difficulties, interpersonal conflicts and resource limitations are the anvils on which the callow postgraduates are beaten into shape, to bring to fore, their inner steel. While the DM residency does succeed in shaping the students into capable and empathic healthcare professionals of the highest order, on quite a few occasions, it leaves behind a host of bittersweet memories, that prompt the student to look back often , not with fondness, but with a sense of regret and heartache. Encompassing all these experiences, is an unvarnished first-hand account of my peregrinations as an endocrine resident at Osmania Medical College.
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Nagesh V S. Arjuna's recollections – Part III (or) an endocrine version of the “Motorcycle Diaries”.Indian J Endocr Metab 2016;20:123-128
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Nagesh V S. Arjuna's recollections – Part III (or) an endocrine version of the “Motorcycle Diaries”. Indian J Endocr Metab [serial online] 2016 [cited 2020 Nov 26 ];20:123-128
Available from: https://www.ijem.in/text.asp?2016/20/1/123/172271
Over the past few months, I have read with great interest the articles written by Dutta  and Das  in which they have laid bare their experiences, trials, and tribulations in getting a much coveted seat in endocrinology and in the completion of their course. When I was asked by the editor of IJEM to reminisce about my sojourn in endocrinology, it set me thinking. Ihave very little to add to the exquisitely detailed accounts of my friends, save a prosaic repetition of what has already been narrated by them. So, for a change, I decided to go off the beaten track and share a few pages from a whimsical diary I had maintained during my days as an endocrine resident. My diary is for the most part banal, filled to the brim with blood (most of which was not mine), sweat (buckets), toil (a lot), tears (occasionally?), and not the least bit glamorous. The brickbats outnumber bouquets and the successes are far and few in between, for such is the lot of medical students everywhere.
Day 1–august 5Th , 2009
It was a bright, warm day in August in Hyderabad, and the clocks were striking not quite thirteen, but nine, as I sauntered into the Endocrinology Department of Osmania General Hospital. Situated on the 2nd floor of the eponymous new block built on the occasion of the golden jubilee of the venerated hospital, it seemed to me to be a calm riposte to the chaos which was in progress, one floor below, in the outpatient departments, where on an average day, a few thousand patients waited in straggly lines for the doctors' consultation. Iwas no stranger to the department, having attended a peripheral endocrinology posting during my MD in pediatrics. Today, August 5th was a Wednesday, a free day reserved for academics and in-patient care. The rounds were already underway and the Professor and Head Dr. Rakesh Sahay asked me to wait in his room to present my joining report.
As I waited in his room for the rounds to finish, my mind rambled back to my first brush with endocrinology. It was during my 1st year in MBBS that I was first exposed to endocrinology, through my physiology internal exam. Unlike my peers, I actually found endocrinology quite interesting and had a vague idea that endocrinology could very well be an option for a future specialization. After completing my MBBS, I decided to opt for the physician stream and had to choose between general medicine and pediatrics. A lot of my seniors and friends advised me that general medicine was the better option because it was more likely to offer more options for DM. However, I chose to take the road less travelled and opted for my first choice, pediatrics, and I got an MD seat at my home base, Hyderabad, in Osmania Medical College. Niloufer Hospital, the Pediatric Hospital of the college, has always been considered one of the most prestigious adolescent and childcare institutes in the country. Right from the first day, the faculty emphasized about the importance of super-specialty care and kept exhorting us to try for the Holy Grail of medical education, a DM degree. By the time I had finished my MD, I had a clearly enunciated goal of trying to secure a seat in DM Endocrinology. In 2008, there were around 15 seats in DM Endocrinology in the country, and securing a seat was an uphill task. I opted to join Endocrinology Department of Sri Venkateswara Institute of Medical Sciences as an Observer/Resident, after narrowly missing a DM seat. The posting was a true epiphany with my first exposure to quality endocrine academics. Both the faculty members Profs Alok and Suresh had a rare passion for teaching endocrinology and also enough kindness to put up with and correct the mistakes of the students. They grounded me well in the basics of endocrinology, which enabled me to face the DM entrance the second time round with greater confidence and knowledge and secure a seat in Osmania.
As I came to the end of my musings, the rounds also concluded and the professor came back to his room, accepted my joining report, and gave me a brief orientation talk about the department, its long history and his expectations from the students. Then, to my immense delight, he gave me the day off. I was dreading having to work full tilt on the first day since I could instinctively sense the gargantuan workload that would be my lot over the next 3 years.
Day 38–september 11Th , 2009
It has been over a month since I have joined the department and I have gradually become accustomed to the work, as much as Sisyphus is, to rolling the boulder uphill. My work was made easier by the fact that I had been acquainted with both my seniors right from my MD days and Dr Neelaveni, the associate professor is also very helpful.
Moreover, interdepartmental cooperation at the postgraduate level is very good, since most of us have been classmates right from the pre-med and MBBS days. Osmania has the advantage of being the largest Tertiary Referral Unit in the state and also gets fed a lot of cases from many associate hospitals. This has resulted in a case spectrum that spans the entire gamut of endocrinology, be it adult, pediatric or gynec endocrinology. Further, almost all the super-specialties are present in Osmania and its affiliate hospitals. However, laboratory and imaging facilities are poor. Moreover, the long work hours and relatively lower pay scales have resulted in a saturnine outlook among most of the support staff. Interestingly, today Prof. Sahay asked me to pick my preferred thesis topic. I wanted to focus on obesity in the adolescent age group and he immediately agreed to it and asked me to start working on it and finish it by the end of my 1st year, so that I could leave the next 2 years free for other work. However, like any other postgraduate who has spent a few years in the groves of academia, I knew that finishing your dissertation in the 1st year only translated into more grunt work down the line. So, I gave him the tried and tested spiel that I wanted my dissertation to be the magnum opus of my student career and hence wanted some more time to plan and execute it in right earnest. I am sure he did not fall for it for even a minute, but being the good man that he is, he gave me the benefit of doubt and decided to play along.
Day 60–october 3Rd , 2009
Today was the day I got an introduction to a time honored tradition in Osmania endocrinology – “the ultrasound guided FNAC.” In most departments, either we order for an u/s guided fine needle aspiration cytology (FNAC), or it is done in-house in the Endocrinology Department. But in Osmania, the administration believes in living a life less ordinary. So, the upgraded Department of Pathology, to give its full and respected title, stipulates that the endocrinology resident has to be physically present for the FNAC. So, full of zest, I geared up to do my first FNAC. However, my presence was superfluous and the procedure was completed by the radiology resident, who refused to trust a pediatrician/physician with a sharp object, and the slides were immediately prepared by the pathology resident. Over the course of the two other thyroid FNACs scheduled for the day, I learnt that the primary duty of the endocrinology resident was to hold the cotton, in addition to lending gravitas to the procedure. I finally understood why the Pathology Department is labeled “Upgraded.” Any department that has an endocrinology resident playing Saki to its Omar Khayyams, deserves the honorific, the only difference being that I was not a cupbearer, but an exalted cotton holder.
Day 275–may 6Th , 2010
The dog days are here and the entire city is suffused in a miasma of sweltering heat. The OP is packed to the rafters, and the Electricity Department has chosen this very day to go ahead with one of its regular maintenance drives, and the power is off. All in all, a scene which seems straight out of Hieronymus Bosch's Garden of Earthly Delights. We finally managed to extricate ourselves from the teeming millions and headed back to the wards. Today has been a good day as far as clinical cases are concerned and we have managed to pick up a possible Cushing's disease, hypopituitarism, hypophosphatemic rickets, and thyroid carcinoma from the OP. Admissions are out since the indoor temperature in the ward is approaching 40° and it would be cruel to expect the patient to stay back in that heat. By the time I finish evaluating the cases and reach home, it is past 9 PM.
Day 366–august 5Th , 2010
Today, I completed my 1st year in endocrinology and I have to say that the feeling is underwhelming. True, I have got used to the routine of having 4 OP days, though the free days seem busier than the working days because we have to fit in the ward rounds, academics, discussions and also prepare for the week ahead. My overarching impression of the system in Osmania Endocrinology is that it involves massive duplication of work, with the main culprits being lack of provision of sufficient support staff for collection and distribution of reports and inadequate nursing staff with more emphasis being given to the surgical specialties. The time a postgraduate spends in the hospital should be solely dedicated to patient care and academics, and anytime spent in humdrum work is a waste of skilled professional resources. Furthermore, our hospital pharmacy provides free medicines only for one week per every consultation, and while I do understand the logistic limitations of providing medications for one full month, it has to be made mandatory, because otherwise, the same patients keep visiting the OP on a weekly basis for the medicines, which swells up the OP numbers. Also, even though a lot of MBBS students and interns have expressed interest in endocrinology, postings are not allotted to our department, thus robbing us of some useful hands and the students of a rich training experience in endocrinology. Perhaps the biggest peculiarity in our department is the excessive emphasis on writing onerously detailed case sheets. Although I do understand that a thorough case sheet is important and forms the basis of our evaluation and treatment, expecting all the postgraduates to write all the case sheets in triplicate is akin to reinventing the wheel. And given the number of pages all three of us postgraduates have devoured over the past 1 year, we seem to have accounted for a fair chunk of the dwindling Brazilian rain forest and India's fiscal deficit.
Day 506–december 3Rd , 2010
It is past 9 pm and as I am writing this, I am now at the Endo Club, the monthly meet for the city Endocrinologists. My senior Sridhar has just finished his DM practical final and has crossed the finish line. The exam has been very anticlimactic, with none of the fire and brimstone that is usually expected. I felt good for him since he has been an exemplary senior who has always handled more than his share of work and on many occasions, even taken up my workload. A case of aldosterone-producing adenoma is being discussed in the Endo Club, and Dr Ammini and Dr Ganapathy, who are the external examiners, are also providing their valuable inputs.
Day 670–june 10Th , 2011
Got back to the diary after a long time. The 2nd year has been fairly uneventful, and life has been a long series of OP days, ward days, and thyroid FNACs, occasionally interspersed with interesting cases. Osmania Endocrinology has the obvious advantage of being the referral unit for Niloufer hospital that manages to throw up at least one interesting case every day. The other departments and the maternity hospital also chip in with many cases. On the flip side, the chest hospital also chips in with its little all, and we have had to face a constant barrage of open tuberculosis cases. We are worried, not only for ourselves but also for the other patients in the OP, who are at a great risk of tuberculosis. Of late, the chest hospital seems to be firmly determined in sharing its bounty with the other hospitals and we are reeling under the onslaught of this generosity. Making the situation worse is the alacrity, nay eagerness that is exhibited in admitting open cases in the endocrinology ward. The situation has turned so bad that the current running gag in the hospital is that the Department of Endocrinology should be renamed as “Dept of Tuberculosis and Endocrinology,” in that order. Most of the other residents have started maintaining a 3-meter distance from us, and just yesterday, our usually thrifty canteen boy started serving the endocrinology residents in paper plates and cups, at no extra charge. We have taken to wearing masks 24×7, and hopefully, this will suffice. Awelcome break was afforded by the course in Clinical Endocrinology conducted at Amrita Institute in Kochi. It was a comprehensive course with lectures by eminent endocrinologists, both national and international, an introduction to foot care and case scenarios that gave us a feel of the endocrine exam. And thankfully, there were no open cases from the Chest Medicine Department of Amrita, and we were not served lunch in paper plates. We also had a case presentation contest at the end of the course and the adage “Great Minds Think Alike” was again brought home. Out of the 18 postgraduates who presented cases, 15 presented cases about Disorders of Sexual Differentiation (DSD), perhaps each thinking that they had the rarest case of the lot. Once you spend sufficient time in a medical college, the herd mentality starts kicking in.
Day 774–september 23Rd , 2011
Today was the day we had The Torrent Young Scholar Award (TYSA) for the final year DM students at Ahmedabad. The contestants were only 10, a reflection of how a few seats we have in endocrinology countrywide. We started off with a few MCQs and then had the Big Debate. I spoke for early insulin therapy. This was later followed by another round of journal scans and a case discussion and a simulated exam viva. The judges were drawn from faculty and eminent endocrinologists across the country, and this was my first brush with quite a few big names in Indian endocrinology. I got a true feel of the exam at the highest level and the experience was very helpful. ESI TYSA and ESI AV Gandhi Award are counted among the marquee events of the ESI academic calendar and I now understand why.
Day 834–november 22Nd , 2011
The dissertation submission deadline is nigh and I am scrambling to get blood samples from the chosen ones. Ihave approached a few schools for getting samples from adolescents and enough students are on board. Presently, I have to go to the schools during the regular hospital hours and I have been asked to arrange for medicine postgraduates in my stead. The current exchange rate is three medicine residents for one endocrinology resident, but it fluctuates like the dollar during the oil crisis and can sometimes go up to four medicine residents. I never knew that I had such a great intrinsic value! You realize how indispensible you are to your department only when you ask for a leave. Dr Sahay has helped me immensely with my dissertation, be it with planning, organization, leaves or even phlebotomy. He has also helped me in preparing a successful research grant proposal that I submitted to the ESI. The blood sampling is drawing to a close today, and I should start the statistical work soon if I have to beat the deadline.
Day 1020–may 20Th , 2012
My dissertation has been submitted and I am home-free. Today, I was back at the annual Amrita Course in Endocrinology, and as always, the learning has been sublime. They seem to have learnt from last year's experience, and this year we did not have a case presentation, but in its place, a medical curios quiz by the ever popular Drs Sanjay Kalra and Unnikrishnan.
I was rearing to go, at the mention of a quiz, like an old warhorse does at the sound of a bugle, and in a short while, we were off. Over the next one hour, most of the contestants had more fun than they probably had over the past couple of years and given the infectious enthusiasm, it set me thinking whether there was a hint of a future for quizzes in endocrine academics. But now the time for fun is past and I have to get down to the biggest challenge of all, the final exam.
Day 1071–july 10Th , 2012
I have just finished my 4th theory paper and surprisingly, the experience has been good. It was a grueling week and frankly all of us expected the worst. However, the examiners were kind and papers have been relatively easy. In NTR Health University, the exam pattern is slightly different and we have only 6 questions in each paper: 2 essays of 30 marks each and 4 shorts of 10 marks each. Missing an essay would be disastrous. However, no such calamity happened and the questions were framed in such a tenderhearted manner that we were given every opportunity to be at our verbose best. For a brief while, the neurosurgery resident and I were in competition as to who would demand more additional sheets. She was helped by two things: One, the fact that there are more diagrams in neurosurgery; and two, by my absolute disdain for anything pictorial, other than linear B. For a while, it was closely fought, but in the long run, class always tells and I managed to outlast her and ended my innings at 240 pages for the 4 papers. She came in a poor second at 224. Yes! I was counting! All those 110 slide seminars we used to present in the academics definitely helped my last gasp at depleting the Brazilian rain forest further.
Day 1109–august 17Th , 2012
Results are still not out and as is my won't, as soon as I got up from a restless sleep punctuated by the darkest dreams, I logged onto to the University of Health Sciences (UHS) website. The server was down, which augured well. That can only mean the University is trying to upload some results online. Just as the Mayans, who have devised the millennium calendar, have never got around to inventing something as basic as the wheel, the UHS, in spite of being a medical education pioneer has still not perfected the art of uploading results onto a functioning website and generally lets the cat out of the bag by shutting down the server every time they upload results. The tension was palpable and all of us waited with bated breath to listen to the news that could “Harrow up our souls, freeze our young blood, part our knotted and combined locks and make each particular hair to stand on end, like quills upon the fretful porpentine”. When he spoke those lines, the ghost of Hamlet Sr. must have been reflecting upon the day he had been waiting for his final year exam results. Even as we were consoling ourselves with the oft-quoted words of Ralph Waldo Emerson (especially in the vicinity of exam results) “All life is an experiment. The more experiments you make, the better”, the Andhra Mayans were at work and the website went up again. Thankfully, after the results were out, none of us had to make any further experiments in life.
Day 1200–november 22Nd , 2012
I have almost reached the end of my chronicle and as I sit in the clinic, waiting for patients like a Vladimir or an Estragon for Godot, my mind harks back to a question posed to me quite often, mostly in a spirit of enquiry, but on a few occasions, with malice. “As a pediatrician, do you find it difficult to practice adult endocrinology?” My answer has always been an emphatic NO. Indian endocrinology, unlike in the West, is not split into pediatric and adult camps and rightly so. The two subjects are not discrete from each other and to be a good adult endocrinologist, you need a firm grounding in pediatric endocrinology and vice versa. Gone are the days when diabetes in children was Type 1 and diabetes in adults was Type 2 and thyroid cancers were diagnosed only in adults. As the seams between subjects tend to blur, it has become imperative to retain a holistic view of the subject, and this is where the 3-year DM course takes center stage. The 3 years might initially seem too much, but over the long run, you realize that the lengthy duration and exhaustive training give you the nous to develop a deeper perception of the subject, something that cannot be imparted in a 1-or 2-year fellowship. Furthermore, cross-pollination of ideas from either specialty gives rise to newer treatment paradigms. A deep knowledge of anthropometry as a pediatrician helps you in all aspects of endocrinology and you bring a good knowledge about puberty, diabetic ketoacidosis, growth, DSD, and insulin therapy to the table. Residents with a degree in internal medicine are more facile with thyroid disorders, Type 2 diabetes, and PCOS. Over a period of 3 years, the disparities become less distinct and the focus centers on endocrinology and not on the primary specialty. It might come as a surprise to many that pediatricians are almost as numerous as physicians in the Indian endocrinology and are quite adept at internal medicine, as are internal medicine residents at pediatrics. However, just as a matador focuses only on the bull at the moment of truth, or to give due credence to our title, Arjuna focuses only on the eye of the bird and nowhere else, the primary focus should be on endocrinology. A working knowledge of pediatrics and medicine is necessary for optimum patient care, but the primary degree should not be used to increase your consultations and build an omnivorous practice. Nothing can be more disastrous for a patient than an endocrinologist treating a myocardial infarction, an interstitial lung disease or a cerebral palsy on a long-term basis, or for that matter, a cardiologist trying to treat hypothyroidism or diabetes over a long period of time or a gynecologist treating Sheehan's syndrome or adrenal insufficiency. Unfortunately, most patients labor under the misapprehension that a pediatric or gynec endocrinologist is more specialized and qualified than “only a general endocrinologist” (if such a thing exists and I have been asked this question!) and nothing can be farther from the truth. It is the 3 full years of training that is the decisive factor and people with degrees in internal medicine have taught the best of what I have learnt in pediatric endocrinology to me.
As I prepare to leave for the day, my mind wanders back to my diary, and as I reflect on my 3 years in endocrinology training, I am left not with nostalgia or with pride, but only a deep feeling of melancholy at the wasted opportunities, the endless red tape, procedural delays, sheer lack of resources, and ritualistic protocols that have become the bane of Indian endocrinology, at least in a few centers. In spite of having good students, eminent faculty and a very supportive body in the ESI, Indian endocrinology has still not touched the rarified heights it ought to have reached. Even today, the average person on the street is very unlikely to comprehend the meaning of endocrinology, most primary, secondary and tertiary care specialists steadfastly refuse to acknowledge the importance of endocrinology and in research, we still look up to the West, when we should have been the regional or world leaders in endocrine research, given our large patient load and the academic brilliance we have, amidst our ranks. An abject resource crunch is perhaps the single most important reason why cutting edge research is still not sustainable in most Endocrine teaching centres in India. It is time the endocrinologists take up this gauntlet of turning the spotlight back on a subject that is arguably “the most elite of the major super-specialties.”
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