Chapter 29-The first few weeks in Clinics

Jan-Feb  1995

This year, I learn fast, is supposed to be an 'easy' year. At least, that's the impression I get from the lunch time conversation around me but I really should know better, since it's a given that when one passes a semester, that suddenly becomes the 'easy' one and your current semester is a 'tough one man'.
1st year was such trauma that anything will be easy compared to that.

Post lunch is practical time. Today, it's Pharmacology. Other days will be Pathology and Microbiology.
We've already had an introduction to the subject by Prof S, who is the Head. Apart from the usual lectures, there are now two different sets of practicals....Pharmacodynamics which involves a lot of animal experimentation and Pharmacy (which is exactly what it sounds like). So we will either be chasing animals around the lab or mixing up powders and liquids.

This first afternoon, we are split up into two. 30 of us enter the powder room and the rest go to the animal farm. I'm in the latter group. I meet Dr G, the better half of Prof B, who fortunately missed us in our Anatomy Univs. exams. She is in charge of this lab and tells us that an upcoming Sleep lab is a pet project of hers. I suppose now is not the time to tell her that most of us have done PhD's in Sleep already and so we just continue on a guided tour of the Pharm Dyn lab. She seems a bit sarcastic and we are warned about attendance, record keeping, discipline in the labs and such typical routine academia related threats. And we discover that, in trying to be unique, the Dept has also mandated that attendance (!) in Practicals in Pharmacology carries marks (!!). Talk about juvenile rules, but rules that I shall have to obey.
With worktables on the sides and 2 big tables in the middle, the Lab also has some frogs and rabbits and guinea pigs. These will be our unwilling victims through the year and we shall be ably assisted in all of this animal experimentation by the Lab Assistants (henceforth called Lab Asses).
Our first class ends soon enough, mostly a mix of orientation to the Lab and the odd sarcasm laden threat.   And as usual, we troop back to Snappy where we spend the rest of the evening planning where to go for dinner and liquid appetizers.

This year, time will not be planned according to months. So, rather than saying that such -and such will happen in April for example, we start saying that it will happen when we are in our Medicine Posting or Family Planning posting etc. Just saying stuff like this makes me feel like a doctor and far removed from the disaster that First Year almost was. This is also the year where some classes are being taken by doctors actually practising medicine. In the early days, I'm fascinated by the concept of real doctors taking class and I listen with rapt attention, which unfortunately dwindles exponentially as normality and routine takes over.

Our time is variously spent taking patient histories, feeling babies yet unborn, getting worked over by Consultants at our poor history taking skills and getting used to the smells in the hospitals.
Some of our time is spent in the Wards (No 12 for Obs and No 16 for Gynae) where I sometimes see a bunch of very haggered, unshaven seniors huddled in a class. Someone tells me they are in Labour Room posting. Sometimes, we go to the Operation Theatre where I witness my first Caesarian which I suppose must be a landmark in every student's life.
There are 4 Units in OG and a couple of weeks into the posting, we meet some of the other big bosses in the Department. Dr GR is sarcastically magnificent. I wish I had her command of English. Prof H is reputed to be tough but fair. Dr RR, a gentle looking lady brings up the rear and there are many others who either take class for us or give us the "cases" to clerk and present.

It's just a few days into this year and the effort of waking up at 7 AM to attend class is already taking it's toll. Ashley and I still use the back of our cupboard to mark attendance and stay one step ahead, but sometimes we are just plain lazy to do even that, and so I'm losing track of where my attendance is. Attendance in the Final Year subjects like Medicine, Surgery and Ob/Gyn is computed from this year till the end of Final Year and so there is huge scope there to make up for lost attendance. In practical terms, this means that I can hardly be bothered to attend those classes, especially when they start the day.

Our Clinics are now following a predictable routine. Get there by 10, make yourself seen by the highs and mighties, clerk a few cases, present them, hang around seeing expectant mothers and their problems and note down every uttered word diligently. I hear terms like "quickening", "abdominal grips", "Dutta is a great book", "Dutta is a screwed-up book", "P/V exam" and I'm quite enjoying it.
My Tamil continues to be woeful and I spend some time mugging up the Tamil version of the questions I'm supposed to be asking patients while the rest of the class actually does the asking. When I do manage to ask a question a patient actually understands, the answer is completely unintelligible to me. Still, I suppose it's a start.

Pharmacology has started with an introduction to what the subject is about and some terms we will hear throughout the year. This Department, I learn specializes in extended torture and conducts class tests spread over 3 weeks. Week 1 is a theory paper followed by a viva in week 2 and a practical exam in week 3. Our first test on the Autonomic nervous System is scheduled in a about a month.

Pathology this year consists of the 1st 9 or 10 chapters of Robbins and also Haematology for which we need to read another book called DeGruchy. I think this will definitely be my favourite subject, slides notwithstanding.
And there is a "museum". Entry is free. All kinds of human diseased specimens are kept in formalin jars for close up viewing. There are appendices, hearts, lungs, kidneys and everything you can imagine. At least it's a bit better than the foetuses in the Anatomy Museum.
 Pathology lectures start off in a flood of doom, gloom and boredom. The initial lectures are full of how wounds heal and what inflammation is and so on. It could have been fun stuff to listen to but a quick glance at the Robbins-the recommended book,  tells me that I will be much better off just reading it.

There are actually 3 versions of this book. One is the encyclopedic version, thick and hardbound and this is the version I possess and am reading. Inspite of it's size, it flows very well and is brilliantly written. 

There is also a slightly condensed version of this written by the same authors and a pocket edition, apparently designed for people who can't move without their constant Robbin fix. 

They are referred to as "Papa Robbins, Mama Robbins and Baby Robbins" respectively. 

Pathology also has practicals, which at first consist largely of staring down microscopes looking at slides which have blue and red splotches on them. They are supposed to be something, I know, like tissue cells and ulcers and kidneys and lungs, but I was hopeless in Normal tissue slides (Histology, part of Anatomy) and this is worse. We are supposed to identify the normal parent tissue and THEN say what is wrong and I can't get past the first bit.
And we have to draw this stuff in our records.
I'm beginning to understand why record drawing is dumped on a few juniors during ragging.

In the meantime, I bump into Mishra coming down the stairs from his abode on the top floor of Lister House. He warns me "Golu, attend classes man". . Maybe he's heard something. I'm not too bothered , though and with an arm around his shoulders, we head off to Snappy to spend the rest of the evening. Shomeshwar and Vikrant are in the Community Medicine posting and are having a ball before the real Internship kicks in. 

Bong is in Final Year and I hardly see him these days, even though there is a year to go. That year is just one hard struggle it seems. 

Vinay and I continue to haunt Urvasi, MASS, Rendezvous, Seagulls and a few other bars at regular intervals.

It's just that getting there in autos is a pain so we try our best to catch people with bikes to come with us. 

We are also introduced to Microbiology, the subject that deals with which bugs can bugger humans and how to diagnose them and generally everything about them. We start off with some general stuff on antigens and sterilization and autoclaves and bacterial cultures. There is a "Cooked Meat Medium" , a "Blood Agar", a "Chocolate Agar" and some other very weird stuff. I am told that the diarrhea in cholera is called "Rice Water stools". 

In Pathology, I learn that when amoebae get inside the liver, the pus they produce is called "Anchovy Sauce Pus". There is "Bread and Butter Pericarditis", "Nutmeg Liver"....The list is endless. 

Why did they have to target food? 

In Pharmacology, everyone reads a book called Tripathi, which is fondly referred to as KDT (for KD Tripathi). This is a highly condensed version of some foreign books and has very little by way of concepts but more than enough material to pass an exam. The American equivalent is a book called Katzung (or Goodman Gilman for the nerdy brigade) and I start my reading with this book. It's lucid and clear and no-nonsense as American books generally are. 

The Micro book is called AnanthNarayan and is a good, if very fact based reading. That's the subject's fault I guess. Of course, there are other books for Parasites also but we won't get to those till next year so that's not a worry for me yet....

But Our first Pharm test is looming. So is my Ward Leaving in OG.

And those are worries indeed.

In MBBS, the fun never stops. 

Chapter 28-First Morning in the OPD

Jan 1995

On entering the main entrance of Jipmer, one can either turn left and walk to the College with all the Lecture Theatres or go straight right into the crowded corridors of the Obs/Gyn Dept. This is the first day of our Clinical Postings-Obs/Gyn and sharp at 10, after our first 2 lectures, we head here to Madam A's office.

Madam A is a small, petite lady. She may be small in height perhaps but she is every bit the personality we have all heard about. She says something and giggles, and we all giggle, totally humorlessly and totally nervously. As with many people, her reputation precedes her and we have been told that first impressions go a long way. How those impressions are made is beyond me so I just stand at semi-attention, nod and smile aimlessly when she does and look very serious. I hope that counts.
She is also supposed to have a massively good memory hence the need for a good first impression. I try to sort of hide and blend in with the others.Our steths hang around our necks and our aprons are spotless. Our standard OG book, called "Dutta" is NOT by our side, since apparently this is a no-no with Madam A-another benefit of advance warning by seniors and apparently a way to make a good impression, or atleast not create a bad one.

We enter the OPD. This is my first experience of a Govt. Hospital OPD, and boy, is it crowded. And hot. And there is a smell whose origin appears uncertain. It is a slightly sweetish smell, not unpleasant, but not too pleasant either. After a while, like the smell of formalin, I don't even notice it.
The OPD has a couple of big rooms with scattered tables around which the real doctors sit. All manner of forms and papers are littered about. I make out one or two fresh Interns who are also nervy, not because of Madam A, but out of sheer cluelessness. Some Residents sit around looking massively competent and unnecessarily authoritative and the Consultants are in a chamber next door.
There is an examination room consiiting of cubicles separated by green hospital curtains and occupied by hassled doctors and more than hassled patients. All the patients seem to answer to "Amma".

Then there are us. 13 or 14 of us, trying to look confident but failing miserably in the process and looking more like the lost bunch we really are.We keep small note pads by our sides hoping to write whatever pearls of wisdom fall our way. These notebooks are worth more than gold since in the Final Exam, 3 years away, viva questions can be asked from what we hear now. Much of that is not in the books.
The first half hour or so is spent looking lost and trying not to feel overwhelmed. Classmates I've hardly spoke to in the past few months have become brothers in arms. I'm almost the only one with NO knowledge of Tamil so the "lost" feeling is more acute for me.

We are soon spotted by a Resident whose reluctant responsibility is to teach us in the middle of a massive OPD.  We are led to one of the examination rooms where someone with a seriously sexy smile/pout introduces us to the joys of a Per Vaginal examination. She seems to have a "Come Hither" look which totally distracts me from what she is saying. Then, it's time for a class on how to take an Obstetric History. The Gynae part of the subject is reserved for later it seems. For some time we will focus on pregnant women and all the problems they can have.
Pregnancy is divided into 3 trimesters and we need to ask some specific questions for each trimester. That's the easy part. The tough part is the asking, since I can't actually do that. So, I resort to nodding cluelessly when someone takes a case and starts our first history-taking class. It's very systematic and I dutifully note everything down.

We listen to a foetal heart sound and it's magical. I feel a foetal head and that's amazing too, especially when I move my hands and feel a kick. I learn that we will need to figure out in what position a foetus lies in the abdomen, what the expected dates of delivery are, what "booking" means with regards to vaccination, and the various idiosyncracies of various potential examiners.
For most, Dutta is a good book. For Madam A, it's not. The technique used to feel a foetus, called "grips" is apparently described in the wrong order in Dutta, among other things.  She should see us with Llewelyn Jones, a British book, well written, but quite useless for exams.
If we do not warm our hands and the steth before examining, we fail. (This part is just for show. There are no winters in Pondicherry).
 Ditto for not explaining what's going to be happening when we examine a patient and not covering the patient with a sheet or asking for a privacy screen.
It's possible to fail even before touching a patient.

The first clinical morning ends with attendance. It's a nice feeling to marked present.

My first morning as a "Real" Medical student is over but the adventure is just beginning.

Chapter 27 -The start of Clinical Years

Dec 1994
I am at home, not doing anything much. One morning, someone in College calls me and tells me that I have somehow passed. This is not entirely unexpected, but this kind of news is always welcome. With exams, one is never quite sure and so, after 18 months or so in Jipmer, I have managed to navigate the 1st MBBS, and by all accounts, should be entering easier territory. Or so it seems. I wasn't to know it of course, but this year was going to be affect my life very deeply.

Jan 1995
I feel like I've entered a new class in school. The subjects are different, the books seem bigger and stranger. The teachers are new. For the past 18 months, we've been taught in Lecture Theatres on the 1st 2 floors of the College (Hunter and Bernard Theatres), and now we will move up, quite literally to the 2nd and 3rd floors. Pasteur Theatre and Lister Theatre will be our new homes now. Just moving up a flight of stairs makes me feel senior already.
Classes have not started yet and I'm already excited. For the next 3 years, we will be going to clinics, OT etc-doing the "real" doctor stuff. I have bought a new stethoscope, a Littman, quite expensive and at present, quite useless.

Advice has been trickling in:
"Golu bugger, make sure you attend classes"
"Just attend clinics yaar, lectures are just fart"
"Everyone fails Pharmacology"
"Make the most of this year-drink every day"
.....
Not all of it is solicited. In turn , I make it a point to act all senior and dispense my own advice to my juniors (the only junior batch I have), temporarily forgetting what drama it took for me just to get through Anatomy.
There are failures of course. About 15 from my batch. They will form the Additional batch and will repeat the failed subjects in 6 months time, and will continue throughout the course 6 months behind the rest of us. It seems cruel but I'm quickly learning that this course is not always fair and a far cry from the hey days of school.

After the relative paucity of subjects in the past 18 months, I am hit with the full load of stuff that will continue throughout the next 3 years. This is the real deal. For starters, there is the trio of Pharmacology, Pathology and Microbiology. These are the subjects we will be examined on later in the year.
Then, there is Medicine, Surgery and Obs/Gyn. There will be clinical postings as well as lecture classes on these which will continue till the end of the course.
And then, there is Preventive and Social Medicine. Known usually by its acronym- PSM, this one is a bit of a mystery. It is neither core clinical medicine nor a basic science and a quick glance at the book, written by "Park" shows that it covers things like Health Programmes, Statistics and a chapter on various types of toilets. I am told by seniors that PSM organizes fun field trips but the reading is very drab. Our introductory Lecture is taken by Prof Dana, who is affectionately known as Danny Boy. Unfortunately, in the same class he also tells us he is retiring soon.
On the first day itself, the entire class has been divided into 4 batches in alphabetical order for the clinical postings. I am in Batch C, and there I shall stay for the next 36 months. There is no question change of batches or any such thing. If you don't get along, its your problem.
Batch C starts their clinical life with Obs/Gyn. I start my clinical life with a mega crash course in Tamil.
For someone from North India, this is about as alien a language as they come. The script means nothing to me, the words sound as unfamiliar as they can and the first hour of my posting is spent in abject despair. Apparently, we will not get interpreters in our exams if the patient can speak Tamil. My MBBS course just went up several notches in difficulty but I take heart from the fact that no one has had language issues by the time Final Year arrives. One just learns eventually and I know I'll have to as well.

Rahul has also scraped through and has entered the Golden Year of MBBS-his batch will organize Spandan and the rest and it is perhaps the most relaxed year of MBBS, although "relaxed" just means a little less tension, a little less stress and a little more extra-curricular fun.
Bong has arrived in Final Year and I can see a change in attitude already. Casual gossip sessions are minimized, reading has started in earnest and he seems to exude this air of seniority. Final Year batches are an exalted bunch, a batch that has "been there and done that" and now has to "go there and do that" (pass the bloody Finals). He's reading the same books that I have just bought, except that they are all marked with highlighters and accompanied by reams of notes and scribbles. I guess my lovely new books will meet that same fate also.
Shom, Vikrant, Plaha, Mishra and all have passed Final Year and are now Interns. Their MBBS ordeal is over and will be replaced by the tragi-comedy that Internship can be. From the seniormost Med School students they are now the Junior most Hospital staff. Still, they get paid and don't have to study.
Vikrant and Shom are in Batch D of their batch and have started their Internship life with the PSM posting, also known as the "honeymoon" period of Internship. This is spent in either the Rural Health Centre a few kms away in a village called Ramanathpuram or in the Urban Centre near the sea called Kurchikupam. The RHC posting promises to be fun, with a casual OPD, and many hours spent drinking toddy and playing cricket.

It's a new year, a new day and a new chapter in my nascent MBBS life has begun. In my dirtyish shirt, covered up with my new, clean, white coat and adorned with my useless, expensive steth over my neck, I join my other Batch C mates outside Prof A's room. Prof A-she of the scary Maruti car, a legend in College and Head of the Obs Dept.

My Clinical Years have started. A milestone has been crossed.