Chapter 68-Freedom

Dec 1997

If it possible to be delirious with joy and relief, and numb at the same time, then that is what I am. 3 days ago, at the same time,  as the sun set with a new day 12 hours away, I was in the throes of terror mixed with depression, with some minor bursts of hope and optimism thrown in.
Anup and Condom come back from their respective exams. The others slowly troop back. Some may have failed but no one can tell. Passing and failing is almost an afterthought, what matters is that the scariest, most unpredictable and stressful set of exams a medical student will ever face is now over.

I call my parents and tell them. I can tell that they have been as stressed as I have been, largely because I have been feeding them stories of Final Year and explaining how normal it is to fail, so that if I actually do, the blow will be softened. Failing really is no big deal. One retakes the failed subjects in 6 months-all that is lost is some time. There is no loss of face because it can happen to the best of us.
I close the door of my room and look around at the mess on the floor, on the bed and the table. Over the past few days, life has been a blur. I have hardly eaten a proper meal for the last 15 days. My shorts, once tight, are in danger of slipping unless I wear a belt. My eyes are red.
And I am really tired.
And in major withdrawal.
I am in study withdrawal. For the best part of the last 11 months, I have done hardly anything except study. Classes, tests, Labour Room, Ward Leavings, exams-it has been one non stop ride. My head is still swimming with Medicine, Surgery and OG and as I look at the mess of books, I pick one up and start reading something at random. I can't help it. It's like quitting cold turkey.
It is the pinnacle of intensity and stress followed by absolute nothingness. The swings are extreme.

The suddenness and intensity with which Final Year ends does not give one any time to actually consider that 4 and half years of student life-the ragging, the tests, the exams, attendance issues-all over. That will take some time to sink in.
I have a long, relaxed shower-my first in a long time (the relaxed bit, that is-I had, of course showered regularly), change and go to Snappy. And for the first time in 4 and half years, since that August in 1993, I sit there with nothing to do except just sit there.

I can sit here as long as I like.

If I pass, I will be an Intern from the 1st of January. But that can wait.

I am free.

Chapter 67-The Final Climb

Dec 1997

I've finished 2 days of exams. I think I've done well enough to pass though one can never say. Unfortunately the news is that many people on the 2nd of Surgery seem to have run into trouble and are not expecting to pass. That's the problem with Final Year. Together with the study load and the nature of the exams, the indescribable stress and the narrow margins for error combine to make a heady mix of disasters waiting to happen. Internal Examiners try to smoothen wayward vivas and rampaging Externals but too much attempted smoothening can also backfire. The Internal Examiners often walk a tightrope and it must be a tough job.
It's also a fact that for Undergraduates, most lecturers/Consultants/Professors are known not by how good they are in class but how they behave in exams. Some are out-of -the-way helpful, some are brutally fair, some are too junior to make a difference. Some are downright nasty, though thankfully there aren't too many of those.
Many an exam story is laced with "....And I passed even though So-and-so came for the exams"...Respect for seniors goes up when such an examiner falls in the brutally honest or nasty category.
Some of the time between Send-Ups and Univs is spent praying for a particular set of examiners to arrive.

The morning comes. This is it-my last exam and I hope that for the next few hours, I can keep it together and get through this nightmare. OG is a logical, less demanding subject though again, small slip ups are plentiful and there have been numerous anecdotes from previous years to keep me honest.
There are 2 cases-one from Obstetrics and one from Gynae and we will take them one after the other, presenting each to a different set of examiners.
Our exam is in Ward 12-the Obs ward. We troop in there at 8 and are shunted off to the Procedure Room-one of the small rooms in the corridor leading to the Ward. Rajeev meets us here and takes one last, very quick revision class on basic instruments and some vital Labour Room type questions. This kind of thing can be either deflating or confidence inspiring and thankfully, I'm OK.

We're off. There are 12 Obs and Gynae patients lying opposite each other. Naveen and I are together. He starts with Gynae and me with Obs and half an hour later, we shift cases. One hour later, I'm done.

I start with my Obs viva. I remember to wish the patient, get a screen, drape the patient and warm up my stethoscope. I follow protocol exactly and ask all the proper questions in hsitory. I take an accurate fundal height. I'm asked to demonstrate grips and this goes off well too, making sure to not follow the order of grips described in Dutta, which for the Dept's purposes, are incorrect.
The usual questions on Labour Room management follow-Partograms, Oxytocin drip maintainance, episiotomy suturing etc and apart from a few minor hiccups, it goes off quite smoothly.

Then, it's Gynae time. I get a UV Prolapse and sit in front of Dr GR and an external who looks benign but starts off with all kinds of questions I find myself struggling to answer. The viva continues like this. I'm asked a question-Dr GR gives me a hint and I answer. Then GR asks me a question and the External gives me a hint and I answer. And this goes on for the next half hour, punctuated by expressions of profound exasperations that Madam GR is known for.

Then. It's over.
Except for the afternoon viva. And this time it really is in the afternoon.
We start by 3. There are vivas on Instruments and X-Rays and one on Deliveries with a dummy baby and pelvis. One more on contraception methods.

In my Send-Ups, I had been given a pair of Obstetric forceps. These are long, gently curved blades designed to hold a baby's head if it's got slightly stuck. The blades articulate in the middle but I'm given 2 blades which are not.
I'm told to articulate them. I spend the next 5 minutes desperately trying to get these 2 blades to slot but all I manage is a non stop sound of steel hitting steel. And then suddenly, after 5 minutes of rattling, the blades slot. Just like that. I'm asked a few questions and then told to disarticulate them and leave.
But the blades won't budge. So after 5 very awkward minutes of trying to disengage them, a frustrated GR asks me to leave anyway.

This time I'm ready.

The vivas are fine. Instruments is benign as is Contraception and the dummy delivery. Then the last Viva of my MBBS life. X-Rays.

We have seen the usual X-Rays that can come. There is a stock of these and we have had a revision class so that all of us can identify them at a glance. Of course, one is expected to actually read an X-Ray the proper way with the type of X-Ray, the view etc. My turn comes. The X-Ray is displayed on one of the viewboxes and I look at it for a second and turn to face the examiners.
"Yes?"
"Sir, it's anencephaly"

Now, I had spent a second looking at that X-Ray and I knew what it was. But the external is not happy.
"You looked at that for ONE second! You cheated. You have been told the diagnosis!"

Oh God! This is not what I need, not now. So I deny any cheating. Then I'm told to go and look at the X-Ray properly and come back. So I make this big show of taking 2 minutes and really looking at an obvious anencephaly. And I come back and say all the right things.

Just like that, it's over.

It's all over. All of it.

I get back to the room. It's 4 PM and only our group has finished the exam. The Medicine and Surgery boys are still in the exam.
I'm like a zombie. There are no thoughts, no feelings, no emotion. I stare at empty space while I lean against the ledge. I am still in my white coat with my steth around my shoulders and I stand like that for a long time. Then I get my chair and sit like that for some more time.
 I had imagined so many things for this moment- the moment that pass or fail, all of us had been waiting for many months, dreaming about it, just willing it to come.
I had imagined I'd get beers and go lie on the beach and just sit there all night. I'd imagined I'd be in Ramanathpuram under a starry sky. I'd imagined getting drunk stupid. Shouting. Screaming. Going crazy.
But nothing happens.

More than anything I feel like crying. Maybe this is what it feels like when you finally achieve something that has consumed your existence for so long. Just an emptiness. A vacuum.

Freedom.

Chapter 66-Clinics Part Two

Dec 1997

There is no way I can read anything at 1030 PM after a long, tiring, very stressful day. I have, however, another two equally stressful exams coming up and I hope they won't be as long as Surgery.
I am up by 6. There is no point in doing a night-out for Clinics. The syllabus is too vast and too vague and I need to be on full alert the whole day. Anything can go wrong in a matter of seconds-a missed point in history, a missed clinical sign, an inexplicable diagnosis, a screw up in the management. Medicine is a bit of a weak point with me and if I manage to get through today, I will have gone a long way in passing these exams.
I start with Cardio-heart murmurs and their pathogenesis. OP Ghai to the rescue here. Quick brush up of trivia, like causes of raised JVP and types of pulses-all from PJ Mehta. Then I tackle Neurology. Root values of reflexes, all the dermatomes and muscle examination. Aphasias and GBS. Strokes and Spinal cord anatomy. Muscle tone grading. Moving on to Respiratory and this is where I hope God will come to my rescue. I hate the RS. The breath sounds all sound the same, the signs are very subtle and if the lesions are bilateral, things can get extremely sticky.

All I can do is to make sure I have all my instruments with me. I reach as usual by 745 and we are sent to Ward 46 for our cases. The pattern will be similar to Surgery- a long case, one short case, one Paeds case and 2 spotters.
I start with my Short Case. A 31 year old guy. Lots of edema. Nephrotic syndrome. Not very common in adults but still, there it is. I do a quick examination and my examiners arrive. Dr Dilip Mathai from CMC Vellore and TKD. The Viva is bedside and is going well when suddenly:
"Dr Mathai, he missed a Bitot spot".
Oh damn! I did. A small brown spot on the eye signalling Vitamin A defeciency. Fortunately, there is no immediate adverse consequence and we proceed to discuss the examination findings and some pathology and we are done.
The examiners lead me to my spotters. It's like a walking viva where I see a patient with some skin lesion and am asked to diagnose. And another one.
There isn't much scope for a viva here because both of my spotters are wrong.
2 more cases to go.

Paeds is next. I'm led to another part of the Ward by Somya, (a fantastic PG who had taken some fantastic classes for us) where kids have been brought over from the Paeds Ward for the exam. We walk past a few and stop at my "case". A 10 year old boy who turns out to have RHD with MS. A very standard case. No complications, no hassles.
Phew.

And then it's the long case. Things are happening fairly quickly today with both Short and Long Cases going on simultaneously in the Ward. It's about 12 PM and I'm nearly done. The problem is that even after one has taken the Long Case, the wait for the viva can be very long with each Viva taking 45 minutes or so.
I start. 15 minutes later, with the clock ticking, all I have been able to gather from the patient is that he is a bit breathless at times and has fallen off his bicycle once because he fainted. That's it.
Panic sets in. I still have to figure out if this is a RS Case or a Cardiac Case or whatever. I put my steth on the chest-usually done at the end of a case and hear multiple whooshes and murmurs. It's Cardiac!
From here the history is focussed and I do the usual examination. However, when it comes to actually finding what valves are involved, the situation becomes dicey. Murmurs are everywhere. Systolic, diastolic, pansystolic, mid-diastolic. Everything is a murmur.
I'm done after the allotted 45 minutes and have been waiting bedside for another 20 when AKD walks by and asks if anyone is free for the Viva before they break for lunch. I grab this opportunity and we start. I can't wait for a Viva for the next hour. I'm hungry too.
The Viva starts reasonably. AKD listens to my history, nodding vigorously and muttering "Yesh Yesh", "Very Good, Very Good" at regular intervals. Then he turns to the externals and says
"See Sir, he's a good boy, I know. Very Good"

I have no idea why I'm "very good" or what I'm doing that deserves such commendation. But here we are and I'm not complaining.
I start talking about the murmurs. When I say "Pulmonic Stenosis" there is a frown. I'm asked to check again-a signal for "better get it right this time". So I imagine another murmur and they agree.
This happens three times.

And then the viva is over.
Wow. Did I pass? No idea.

Many of us are still left for the Viva when I finish. I'm told to come back later, by 6 or so for the Evening Viva and I do so.
We're there till about 8 waiting.
The Evening Viva is a series of quick vivas on ECG's, X-Rays, some drugs in vials and questions on them, some haemat slides and a theory viva. All this makes up part of the Theory marks and is mostly a formality.

I'm dead on feet now. I stagger back at 1030 again.

2 down. 1 to go.

Chapter 65-The Clinical Exam Day One

Dec 1997

I get up early. It's still dark when I'm up but with every passing minute I am closer to starting the toughest set of exams I have encountered so far.
I take my Das, switch on my table lamp and read up Hernias and Hydroceles. I am still not very confident of these two topics, not because they are difficult, but because we are expected to know everything about them-from the intricacies of the Anatomy, to the many variations that exist and the operative details for each. Hernias are the bread and butter of any aspiring Surgeon and gaps in knowledge will not be taken well.
Soon I find that I am down to my last cigarette. This is a small miscalculation and instead of getting some the previous night, I had convinced myself that my stock would be enough to get me through the morning. At 630 AM, with 90 minutes to go, this has turned out not to be the case.
It's just about getting light when I get on my bike and go out to the shacks, 2 or 3 of which always have a running 24 hour stock. Or so I thought. I have never seen these shacks shut but this morning, of all mornings, there is a grey tarpaulin sheet covering them and not a soul around. Everything is closed, from the tea shops to the pharmacy to Casino-Johny's tea shop and to my favourite coffee/cigarette shop next to Johny's.
I, of course, am a veteran of shop locations by now, so I gun the bike and head down the road. The closest shop is on the road where Joy lives. This is a right turn off the main road about a kilometer down and I reach there by 645, with the minutes ticking by and a small panicky feeling starting to surface. The shop is also shut. Shutters down.
My next target are the 2-3 shops at the Muruga theatre junction next to a mosque and I turn the bike. If not there, I'll head back.
Then, while still trying to get back on the main road,  my bike runs out of petrol.

I am, however, barely 50 meters away from Joy's house and I push the bike to his house, run up the stairs and ring the bell. It's 650 AM and a startled, barely awake Joy opens the door.
I explain the situation. Joy takes it in his stride and we ride back on his Yamaha, back to a campus now buzzing with activity, with the shacks still shut. I then sit on the steps of Osler House for the next 10-15 minutes, flipping through my Das and avoiding the curious looks of all and sundry. Then Joy brings me some cigarettes from somewhere.
An eventful start to the morning. And I haven't even started the exams.

745 AM: 
I am ready. In any case, there is little more I can do. This is it. White coat, stethoscope, measuring tape, rolled up X-Ray film (scrotoscope), pens. Roll number plate.
All done.
I have read up some of the theory paper questions I had screwed up since they tend be asked in the Viva. The answer sheets would have been corrected over the weekend and sometimes, especially when a viva is not going great, the examiners ask some of the theory questions. The idea is to check if we bothered to go back and read up. On top of a slipping viva, not answering these questions will probably not be good news.
23 of us have Surgery today. We are divided into 2 groups and 12 of us head off to Ward 34 for the Short Cases and Ortho. I am in the other group and we troop off to Ward 36, where our Long Cases await. It is general belief that doing well in the Long Case will go a long way in passing the exam since it carries half of the marks for the Clinics. In a way, it's good that I'll get it over with early. Assuming it goes well.

Every Ward is set at right angles from the main corridor. Smaller corridors lead off to the Wards from here and at the Entrance of Wards 34 and 36, there is a green screen with a chart paper stuck on it. It reads "SILENCE PLEASE. EXAM IN PROGRESS".
These smaller corridors leading to the Wards are lined with various other Rooms-Duty Doctor's rooms, a Store Room, Treatment Room, Bathroom etc and we are escorted to one of these by Shetty, a Final Year PG in Surgery who has been allotted Exam Duty. We spread our books and bags on the two beds and wait.
Some read, some stare at the walls, some chat. Mostly though, there is nervous silence.

At 8, Dr Kate comes in. He is a Prof in Surgery, not an examiner, and he calls for my Roll Number. Just me. Without a hint of why I am being singled out, I follow him to the Ward where I am taken to a large table across which sit Prof AK and the External. The exam has not yet started and no one is taking a case yet. Without preamble, Prof AK asks
" Did you write the Surgery theory paper"?
The obvious conclusion is that this is somehow related to my Urinary Diversion debacle. But they don't go there.
Me: "Yes Sir".
Prof AK: "Did you write Section B in Paper 2"? "Because we can't find it"

I look at the table. Answer sheets lie scattered all over the table. They have been hunting for my Section B Paper 2 for the last ten minutes and can't find it. I join the hunt and 2 minutes later, it's in my hands. It's the Diversion section. So, they ask me
"Why is your paper not in order? Why is not after 4417537 since your roll number is 38"?
..and so, 5 minutes before my Final Year Surgery Long Case I explain to my examiners how I was short of attendance in Pharmacology and wrote 5 papers because I was stopped from that particular exam and how that is the reason my Roll number had been pushed to the back and was not in order.

What a great start. But no mention of getting caught trying to copy.

I get back and 5 minutes later Shetty comes and calls 6 numbers. They will start the Long Cases first while we wait. They will get 45 minutes and then Shetty will come back for more. 45 minutes later, it's my turn.
The Ward has 3 sections divided by large glass partitions and our set of 6 patients lie in the middle. I am taken to one and Shetty leaves me.
I start. The complaints are early satiety, epigastric pain, constipation. I see the patients nails and find that one is broken. This apparently happened when a rice beater or something hit his nail. I take a good history and examine the 13 areas of the abdomen and quickly write it up. It's a case of DU with GOO. Duodenual Ulcer with Gastric Outlet Obstruction-a case I love.

The 6 of us finish and sit in line waiting for our Vivas. This takes some time since each candidate is examined for almost 35-40 minutes and almost 2 hours of waiting later, it's my turn. I hand over my case sheet and proceed to make my most awesome presentation ever. I even explain the reasons for the broken nail at which point I'm told to "Carry On" rather impatiently. My findings are spot on, my history is perfect. It's beautiful. There are no interruptions at all.
I am careful with the diagnosis-Gastric Outlet Obstruction MOST LIKELY due to Duodenal Ulcer, as we have been taught. From there, the Viva is predictable. Upper GI Endoscopy, differences between malignant and benign ulcers. I am asked about the Electrolyte abnormalities and I leave out Paradoxical Aciduria because even though I know it happens, I've forgotten the mechanism, which will be the next obvious question.
Some questions on surgery-Vagotomy types and Drainage procedures and I am dying to talk about Billroth procedures and Gastrojejunostomies but they are happy with TV with GJ. And that's it. My viva is over.

Wow. I think I have not been reported for Diversion after all.
The exam is not over, however. I still have Ortho and Short cases left. The 12 of us are escorted to Ward 34 where the other 12 are still being examined. We are put in a Room again-no food and we stay there for the next 3 hours. The afternoon Sun comes in through the window and it is really, really hot. We stay like this for the next 3 hours, some dozing and happy to have done the Long Case well.
The wait is too long though and after 3 hours, when the first 12 have all finished and have been taken to Ward 36 for their turn at the Long Cases, all of us troop out.
It's now 5 PM and I start with Ortho. I am allotted my case.

My patient's leg is bent in an impossible shape. His leg is bent at right angles and then there is another right angle to the foot. I know this is a case of Pseudoarthrosis of the Tibia because I have seen it once but that won't help me. I proceed to try to measure some distances between some bony points and do some haphazard examination but I'm a bit flustered and things do not go well. The Viva is so-so and I hope that I won't set a record and be the first to fail Ortho. Dr DKP is cool, unflabbable as usual and gives away nothing.

It's dark outside by the time I am led to the Short Cases. There are 6 sets of cases, each consisting of two patients. I have 20 minutes to examine and present, this time without a case sheet to help organize my thoughts. I am standing directly opposite the Examining table and I see Dr J sitting next to an old  huge, bearded man who looks all business. My time starts.
My first case is a Cancer of the Lip who has undergone Radiotherapy. Essentially, an ulcer examination. So I get the gloves and do my thing and shift over to the next one. This is a case of Undescended Testis and it's straightforward too. So far so good.

About half an hour later, it's my turn. I sit and present the first case. Dr Mahendran is the External, from Chennai and is senior to Prof AK also. This might mean that in case of a pass/fail issue, he can override Prof AK. By this time, I am also very tired and hypoglycemic and deprived of nicotine. I am asked
"What will be the fractional dose of Radiation for this patient if divided into fractions over 5 days/week for 6 weeks assuming a total of 6000 rads"?

Maths is the last thing my brain can do right now so I take my time and finally cough up the answer. Some more standard questions on cancers and ulcers and we are on my second case. I present this one well enough and then Dr J asks
"What is the function of the Oblique Muscles of the Abdomen"

I stare at him blank for a few seconds. Then I mutter something. And he asks
"What do you do in the morning"?
I have no idea where this is going and all I can come up with is
"Umm...Sir, I wake up, brush...."
...at which point, Dr J leans over and staring through his thick lenses and black plastic frame with his trademark frown, shouts (and very loudly)
"YOU SHIT"!

...and then it hits me

..."Sir, the action is to help in straining" ....
Dr J: " OK Man, Go".
My Viva is over. I am stunned. But also very dehydrated and hungry. And I have no idea if I passed.

But....the day is not over. It's now 8 PM and I get back to Snappy to find eager juniors asking "How Was It"...I shrug and say "OK" and an hour later I am Back in the Ward for the theory vivas.

I now have to face a set of 4-5 quick vivas on Operative Surgery, Surgical Specimens, Instruments and X-Rays. About 5-10 minutes each in quick succession. The marks for these will be counted against the Theory and so it's not that much of a pressure cooker now.
I do OK in the X-Rays, Operative Surgery and Instruments and have Specimens as my last Viva. These are taken from the Path Museum and are surgical specimens preserved in formalin. They are also labeleld with a strip of white paper across the bottom and we have been told that one can sometimes read the label if done surreptiously enough. In any case, I don't need to resort to any shenanigans and I finish.

I'm done. It's 1030 PM.

I am exhausted. Any thought of reading for Medicine tomorow is a no-go.

2 more days to go.

Chapter 64-In Limbo

Dec 1997

5 days of exhausting, stressful theory papers over and I feel like I'm done with the exams. If only that were true.
I come back from the OG exam and crash out. I'm too spaced out to read anything and I spend the evening goofing around, mingling with the others around the staircase, exchanging notes and getting some gyaan from seniors on their way up or down. It's established fact that in the entire population of MBBS students we are the ones with the most knowledge, courtesy of back breaking reading over the past year but because there is just so much to read, I feel like I'm a jack of all trades, with big holes here and there just waiting to be exposed. Medical reading at this stage is very extensive, spread over many books, notes and manuals with some areas that also require very intensive detailed reading. The trick is to know what those areas are and hope the others are not asked in detail.
Exceptions like Urinary Diversion exist and it's things like this that make Univs such a profound headache. I learn that out of the 70 people writing the exam, only 2 had actually read Diversion before the exam. A few more managed it during the exam. One got caught-me.
A lot of the Clinics boils down to luck and presence of mind. Reading reduces the effects of luck but on the whole, I have to admit, sheer knowledge alone cannot get one through.

The sad truth is that even if one manages to top the class in theory and generally do spectacularly well, a small misstep on any of the 3 Clinics Days can mean a Fail grade.
I will start with Surgery on Monday, sharp at 8. This consists of a Long Case-Breast, Thyroid, Abdominal masses (which can be anywhere and be anything), varicose veins, hernias etc. We get 45 minutes to take a history and examine. This has to be written in a Case Sheet which, in the viva, is handed over to the examiners. The presentation has to be smooth and very accurate. Seemingly small errors-like a missed lymph node in Ca Breast or an inaccurate assessment of a mass will probably mean failure. The spoken history and examination has to tie in completely with what's on the paper otherwise one is asked questions like "Did you do this test" or "Did you ask that question" which is a signal that all is not well.

The diagnosis has to be reasonable. Not necessarily the correct one, but the key is that it should be deducible and defendable from the history and examination.

The ultimate warning signal is when one is asked to "go back and check" whatever examination finding one has blurted out. Chances are good that one is wrong and in the one minute or so that one is given, in that pressure cooker atmosphere, one better find something that the examiners want.

Star students have been reduced to dust in these exams.

If one gets through all of this, the viva moves on to Management. At this stage, disaster can still strike though most of the minefield has been crossed. The exceptions are in the basics like Hernias where Operative Details of Herniorraphy or the intricacies of the Liechtenstein repair are fair game. I have pages and pages of old notes and loose sheets with all the wisdom imparted to us over the past 3 years, stuff that can't be found in any standard surgical text book and will likely be asked in exams. This is why attending Clinics is so vital.
Short cases, 2 in number will be up next. I will get 20 minutes to see both, examine them and present them verbatim, without a case sheet. This calls for rapid mental organization and clarity of thought and knowledge. And the short cases can sometimes be the killer. Anything-any ulcer, mass, anything at all can be a short case.
And then there is Ortho. My nemesis. I have heard no one fails in Ortho but there can always be a first time. A malunion or a nonunion, some joint deformity maybe. Who knows what will come. Here it's examination principles and techniques that are tested and Dr DKP, the Head, with his thin rimmed rounded spectacles and an expression of amused tolerance will be our Examiner.

Examiners are a hot topic. A lot of time is wasted in discussing the pros and cons of which 2 examiners will come for the vivas and what to do and not do with them. Prof AK and Dr J will be our Internals. I don't yet know who the 2 externals will be and because in the exam, the Internals usually keep quiet ad let the Externals do the talking, I hope they will be reasonable. The Internals are supposed to steer an awkward viva to more friendly waters. Some do and some don't.

The weekend is spent reading here and there. There isn't that much that can be done now and I spend the 2 days looking at some manuals, answering mock vivas and mugging up the more vital Must Know things.
Saturday evening arrives and with it, a couple of Residents in Medicine and Surgery pop up with a long tabular list of names and diagnoses. These are supposed to be the cases currently in the Ward and therefore might turn up in the exam. This sounds like a boon but is a very sharp double edged sword. In many an exam, a candidate has failed because he/she knew the diagnosis but could not demonstrate the signs needed to make the diagnosis or back it up with the proper history. In some cases it's not even possible to make that diagnosis purely on clinical grounds.
4 years ago, someone, a potential Gold Medallist in Medicine knew that his case was a Syphilitic Aortic Regurgitation (AR)-a very rare case in these times. He took a great history and did the proper examination and when asked the diagnosis, said "Syphilitic AR". That diagnosis cannot be made without investigations for syphilis and he failed.
One or two major stars will fail in every exam. Such is life.

I take a quick look at the list and then forget it. There is no point.

Sunday evening: 
I'm all set. Clinics are very taxing and can go on pretty late each day, so I make sure to get organized and get some rest. I take some last looks at Das, the Surgical Manual and leave Hernias and Hydroceles for tomorrow morning. I lay out my white coat, washed and pressed after ages, check my stethoscope and scrotoscope, pens and pencils and lay them on the table.
My heart is pounding and sleep will be tough.

My last 3 days of exams are starting.

Chapter 63-Theoretical disasters

Nov-Dec 1997

I am up early. I haven't really slept all that much. They say that "Rest before Test is Best" but that is a luxury I don't have. Today is the first of our five theory papers. Today and tomorrow are the two Medicine papers Paper 1 has a 40 mark section on General Medicine and a 40 mark section on Peadiatrics. Paper 2 has another 40 mark section on Medicine and a 40 mark section covering the Allied Specialties of Dermatology, Psychiatry and the like-topics I've barely seen and now don't have the time to. They were scheduled for Day 7 or something of the study leave and that day came and went while I was still stuck on the topics for Day 2.

Today is D-Day and I need to have breakfast. During exams at least, breakfast has been a constant feature. Normally I never have breakfast. There simply is no time. In exam time, when I have already been awake for hours before 730 AM-breakfast time- it gives me an opportunity to take a break, head down to the mess and eat puris/dosas/grub and just mentally delay the inevitable-more reading. Its a relaxing break where I shut down and just eat and gossip. The end of breakfast signals the last hour of reading and from about 8 to 9, I sit with some tea and read some last minute obscurities. I never cease to be amazed at how much information one can imbibe in the last dying seconds. Pages fly, points and tables stick and I feel more confident with every passing second. Of course, such last minute reading doesn't stay for a long time but I only need to remember it for the next 3 hours.
By 9 AM, I'm done. I relax, shut the door and blast some good Rock on my system. This is a ritual I have followed religiously in every exam. It relaxes me and puts a full stop to reading and tension. A stress buster. (Till I discover my Hall Ticket has disappeared again).

I make the 5 minute bike ride to Banting Hall, ditch the book outside, take a deep breath and walk in. Banting has blue tables and chairs which are foldable and made of iron. Some guys hold on to books till the last possible second and are the last to take their seats. I've never done that. For me usually, the reading ends when I leave for the exam venue, leaving my fate to my own karma, which I can only hope I've generated enough of.
The chairs in Banting Hall have been arranged in neat rows with enough spacing between them to prevent "cooperation".  My roll number is 4417538 so I should be between 537 and 539 but I find that I'm placed at the end, after the entire class and with some of the guys who are rewriting the exam from last year. This has happened as a result of some reshuffling when I had to write the 5 papers of Pharm, Path and Micro last year and so I find myself in the last row to the right. It doesn't really matter where I sit.
Invigilators are sourced from various Departments and answer books are given out-a long 20 page booklet which will be followed by 4 sided smaller booklets whenever someone raises their hands and says "Sir, sheet".
The papers are given and at 930 we are off.

One dictum in an exam is to write SOMETHING. Anything. A blank answer gets no marks. A wrong answer may also get no marks but then something may be right about it. Over the last few years here I have also learnt the fine art of filling up pages with text that borders on correct without actually knowing much. In Jipmer lingo this is known as "farting". Farting is an art essential to passing.
Another dictum is to make sure that for each question, whether a 4 marker or the long 16 marker, one writes enough to get atleast 50% of the marks for that question. If that can be achieved, then by definition one passes the paper.
Time is of the essence. I start, like I always do, by jotting down approximate finish times for each section on the question paper. I should finish 30 marks or so of the paper per hour and I time myself accordingly.
The Medicine paper is unique in that it has 8 fill-in-the-blanks questions and these are must get marks. It's always a race and by the time the clock strikes 1230 my wrist hurts and my writing has become an illegible scrawl. Sheets lie here and there and 5 minutes before time we are told to gather them up and tie them together with the supplied pieces of thread.

Lunch is always a postmortem of the paper. The juniors want to see what questions came, the Interns always proclaim how easy it all is. I ignore all of this and get back up and crash out for the next 3 hours.
The routine is the same. Get up and start reading till the wee hours. Sleep for 3-4 hours, up by 630 and then it's time to Rock and Roll. Paper 2 is also reasonable. Paeds thankfully was pretty general and I get through it. I think.

Surgery is up next-2 papers again. The first has General Surgery and Ortho, each for 40 marks and the next has General Surgery again followed by 40 marks of Related Specialities. This is where things can get tricky. Each section has a 16 mark long question followed by some 4 mark short answers. The 16 marker can be a killer if not known.
My routine now is set. I sleep till 5 PM or so and a quick tea later I'm back reading outside my room, first by the setting sun and gradually, under the tubelight.
Ortho is still something that confuses me. All the fractures seem to be treated the same way and my head is swimming with Internal Fixations and Joint Replacements. The first Surgery paper is fine and is actually my strong suit. This goes off well also.
3 down, 2 to go.
By this time I am half surviving on adrenaline and coffee. I can't afford to sleep off and I read my Bailey well into the night, flipping through GI Bleeds, thyroid lumps, Pancreatitis and Oschner-Scherren regimens. I flip through some Urology notes of the classes I managed to attend, glance at Head injuries and Cardiac valve surgery and that's it. I am pooped.
I pray that we don't get a bomb like one of our senior batches "Describe the Management of a patient who has a cardiac arrest while undergoing surgery under General Anaesthesia". This was a 16 marker and was asked under Anaesthesia, a "Related Speciality". I have managed to read up some drugs and that is it for me and Anaesthesia.

I walk in as usual, dump my Bailey just outside the door and take my place. The clock strikes 930 and papers are given out. Section One has a 16 marker on Upper GI Bleed management. This is a sitter. The other questions are fine.
I flip to Section Two and continue looking in growing horror at the questions unfolding in front of me. I glance around and find that everyone else is glancing around too, expressions of barely concealed panic and bemusement.
We get a 16 marker on "Describe the Indications, Techniques and Complications of Urinary Diversion".
This is followed by 4 markers on "Diathermy", "Cryotherapy", "Digital Subtraction Angiography" and 3 more equally obscure, vague questions. 40 marks down the drain. No one has read "Urinary Diversion". This is the first time in my life I'm hearing of such a thing.

5 minutes into the exam, still reeling from the shock, I see someone get up and get permission to go to the loo outside. 2 minutes later, someone else goes. It doesn't take a genius to figure out what is happening. These 2 students are good students and it is obvious that this time, desperate measures are being resorted to.
I see something peculiar happening on the far side, in the first two rows. Soon after the first guy comes back from the loo, there is some hasty scribbling on a small piece of paper which is then casually thrown on the ground and picked up by someone else. There is more hasty scribbling. The crumpled small paper is tossed again and for the next 2 minutes, I sit and watch a small piece of paper flying around, presumably with Urinary Diversion scribbled all over it. This is unique. I'm impressed but I'm at the wrong end of the action.
It's time to take matters into my own hands. The problem is that even if I manage to get my hands on a Bailey, I won't even know where to look. I've never heard of Urinary Diversion before so I'm panicking like crazy.
I get up, get permission to go and walk out. A few Baileys are scattered on the floor and as soon as I am out, I grab one, run to the loo, frantically open the Urology section and start hunting. I'm standing with the book wide open, having found the answer 30 seconds ago and am doing a massively fast scan through it when I look up and see my invigilator staring at me.

I troop back with him right behind me. I am sunk. I sit down. He says
" Come on, write the rest of the paper. I am going to complain to the Chief Invigilator".

I mutter a sorry and probably very red in the face, I sit sown and turn my attention to Upper GI Bleed, a question I can answer almost by reflex. It takes me 30 minutes to fill up 20 sides of the answer sheet, right from History to Sengstaken tubes to Sclerotherapy and finally to Orthotopic and Heterotopic Liver Transplants. The entire time, my invigilator is standing next to me muttering how he's going to complain and get me debarred. After watching me write reams and reams of stuff, he smirks and walks away.
In the 30 seconds that I got for Diversion, I manage to pick up enough to scribble one page of barely readable rubbish. I draw some uereters and bladders, divert them here and there and create some complications. Something has to written after all.

The 4 markers are equally vague. I draw a rough sketch of a table and a man on it with some wires leading off to a machine with some dials. I label them as "Patient", and "Cautery". I know there is a Monopolar and Bipolar type so I write that. That's it.
Then I draw the exact same figure for Cryo but label the "Cautery" as a "Cryo".
I scribble some stuff for DSA and the others. It's an unmitigated disaster.
I walk out at 1230 not knowing if I have been reported.

It is of little solace that at lunch, everyone agrees that it was a real bastard of a paper.

That is however, already in the past. OG is up next. There isn't anything I can do about what happened today so I continue to crash out till 5 PM and read till 3 AM, brushing up on all of Dutta and Shaw in one massive speed reading session. My eyes are watering and I am very sleep deprived, but this is the last paper and I make a final push.
OG is a relief. Antepartum Haemorraghe is the long question and is very expected. It is really really long though and by the time it's 1225, I am racing to finish, my writing hardly decipherable and I am left with one 4 marker-"Complications of Oral Contraceptives". My fuzzy mind reads this as "Indications of Oral Contraceptives" and as I finish writing, I realize that I've written the wrong thing. I cut it out, write a "Please Omit" across it and the clock strikes 1230.

The theory papers are over. One big blur spread over 5 days where the days blended into the nights and the distinctions have gone unnoticed. One long 120 hour day.

And of course, as we have been told many many times, the theory is "OK man". It's the Clinics that will make or break you."
Clinics are a different ball game altogether. They have to be passed separately. They start on Monday.

For now, I'm going to crash out.

Chapter 62-Study Leave

Nov 1997

12 days. That's what we have. And I am seething. Our senior batches had got nearly 3 weeks of study leave before their Final Univs and here I am, sitting alone in my room, surrounded by books, notes and papers, staring blankly at a calendar and a date 12 days from now that will signal the beginning of the end of my MBBS course. Pass of fail, the course will definitely be over, and right now, all I want is for these 12 days to get over and somehow,magically, read all that I simply have to.

Wise men come and give counsel. 12 days, they say, is "cool". After all, one has, or is supposed to have, studied for this exam over the past three years-in clinics, in classes, over Ward Leavings and even in Snappy sessions. One has made, or is supposed to have made, extensive notes on all the possible cases that can come, cross-referenced the countless books in Medicine, Surgery and OG, spent hours in the library and in the room studying and therefore, in theory, one is well prepared. These 12 days should be about quick revisions, final touches and a rapid integration of all that has been taught over the last 4 years.

But it doesn't work that way. The stress is on a slow burn, not yet the adrenaline fuelled panic that will soon start, but I can feel it. I keep it at bay on the first day by making a plan and organizing the Himalayan climb to come.

Medicine-Davidson, Harrison, PJ Mehta, clinics and class notes.
Surgery-Bailey, Das, notes
OG-Dutta, Shaw, Labour Room notes, class notes

This totals up to about 10000 pages and I am already depressed. This takes up 2 of the precious 12 days I have and the plan has to be revised even as it is finalised.

I feel like I'm back to square one. I have this bad habit of needing to look through everything at least once, even if it means a one second glance at a page or a set of notes. Also, many things had been read months ago and are long forgotten and need to be refreshed. Some things look downright new. There are classifications, signs, symptoms, approaches to diseases, management issues etc, and anything right from Anatomy to Pharmacology to core Medicine and Surgery is fair game. This is the culmination of 4 years of work, not just this past year, and it is now weighing on me. Sometimes, in my darkest times, I wish I had studied a bit more regularly. Not more necessarily, but just steadily. Sigh.

November here is a quiet month. All batches have exams but we, the Final Years have special status. I stick a notice outside the door-" Shut Up. Reading", or words to that effect. The room of a Final Year exam going student is hallowed ground and no one will enter unless it's another Final Year or unless it's something vital. Casual conversations, unless self initiated, are strongly discouraged and not entertained. Gossip sessions on the staircase are sometimes interrupted by loud "Shut up buggers, I'm studying". Snappy sessions are very brief and often just an excuse to get out of the room for a minute or two.

Harry, the sole Sardar in the whole MBBS course and my classmate is a few doors down and pops in, equally spooked. He however, has managed to learn fluent Tamil and although I can now manage conversant Tamil fairly well, there are still large lacunae that I hope won't suddenly pop up in the exam. That's the last thing I need. He is also reading on his board perched on his chair outside his room. Anup is locked up inside his, probably still making notes and underlining endlessly. Condom and Vinod are usually in the Library or Curie, reading with their partners in happy bliss. It's a quiet corridor and there are no distractions.

This is serious business.

Three years ago, when in 2nd year, we had had nearly a month to study for Anatomy and Physiology. At that time, I had changed my entire sleep schedule and was effectively in a Mid-Atlantic Time zone, reading at night and sleeping in the daytime. This was great but nearly got me screwed towards the end when I had to tell my body to start waking up on time as the exams approached. I was effectively very jet-lagged. I can't afford that now, not with just 10 days.

So, I start early. The plan is to read all day till about 12 or 1 at night and then re-start. The problem is knowing where to start. I should be reading a lot of Medicine, a subject I think I'm weakest in but I start with Surgery, my strong point. Human nature. I take my wooden chair outside to the corridor and put the rectangular wooden board on the arm rests. A Bailey sits on the board. A pen and a marker lie on the side. Some notes to cross reference leave little space for my elbows to rest.
The start first involves an alteration of the time table since I have invariably overestimated my reading capacity and underestimated the reading required. This is followed by a half hour thoughtful reflective self-flagellation session, usually accompanied by nicotine and tea while being perched on my chair, elbows on my reading board, and, lying untouched by my side,perched precariously on the board, the book of the moment.
The corridor of my room faces East, and in the early morning a lovely cross-ventilation breeze blows through, especially if I leave the doors open. It feels good to wake up this early without worrying about an 8 AM class. I take my time and savour the cool breeze, the greenery in front of me and the sights and sounds of the morning.
Sitting and thinking with the puff of smoke that accompanies me everywhere these days I see some guys heading for breakfast to the mess, inevitably some inedible glob except on Sundays when we all wait endlessly for the promised Masala Dosa. Some guys wait in the middle of the InterHostel road near the Iron Man who is working his magic. Bikes start up and whizz past, either towards the hospital or out of the gate, perhaps for a tea in the shacks. Lots of young doctors or Interns, in white coats and stethoscopes zooming off for work. The sound of rushing feet, chatter and shouts signalling people getting late for class or perhaps, for an exam. Shouts of "All the best" and equivalents. An hour of noise and activity from 730-830 AM.
And then it's quiet again. And I'm all alone with my books, all day, every day. I sit and mope, wonder if I will pass and generally kill precious ticking minutes before reality kicks in and then every second of the day is squeezed out- reading, getting mentally ready for reading, taking a post reading smoke/tea break, planning and making time tables, altering time tables.....rescheduling the schedule, finding notes, books and long lost papers....Snappy...

Snappy. My saviour from the drudgery, but it does not open till evening and so my source of tea and smokes are the shacks outside. Harry is not much of a tea drinker but even he needs a break, so one afternoon, three days into the study leave, he saunters in and says "LGFT"? This apparently means "Let's go for tea". There are two responses for this:
a. Get up and go
b. Say "NFO", which means NO, F Off

Mostly I get up and go. More than needing tea, it is good for the soul to get away from the books and notes. Even though I study mostly outside in the corridors, I am gripped by fleeting moments of panic where I can feel walls closing in, pulse rates rising, blood pressures spiking and a general feeling of inevitable impending doom spoiling an otherwise lovely day.

Harry and I walk down the four floors of stairs, all books left behind in all forms-physical and mental. Jokes, chatter, gossip-anything except studies and books. As we walk down, some other similarly afflicted figures meet us-Reddy-a study in concentration, nose to the books and wondering what on earth we are up to. Deepak, as usual, pacing up and down the corridor, book in hand and mumbling loudly, Condom, zooming off on his trusted Bajaj Chetak towards Curie or, on occasion, returning from there. But mostly it's just Harry and me out for some fresh air and stale tea, recharging for another assault on the books.
The shacks take 15 minutes and then we are back up, back to the books and waiting for the next break.

Harry is not my only source of welcome interruptions. There is Shom, now a 2nd year PG in ENT who has shifted out of the campus and lives with Sirisha, his wife, in one of those apartments behind the Police Grounds so popular with Jipmerites. I have spent many evenings there, mainly to kill time and chat and also to taste some home food I have been deprived of for so long. Shom has moved on from his bike to a Red Maruti and often honks from below when getting back home after work. That's a signal for tea and I never fail to oblige.
This also happens at all hours of the night when he is on call and provides more welcome breaks from the stagnation that can set in when surrounded by a mountain of Medicine.

Many evenings were spent in his house and with no means to confirm if he would be at home, I often went across only to find the house locked. In the many instances that it wasn't, time was spent in home comfort with some whisky and food and idle chatter. He cribs about the politics of his Department, Sirisha about hers and I listen patiently, just chilling and killing time, precious minutes ticking away.

One particular evening, Shom and I went for a drive in his car and found a newly opened Burger joint on the corner of the road opposite the Pondy Railway station. Burger joints were not common here, so I went and promptly ordered a couple of Chicken burgers. 45 minutes later and with no sign of the burgers, Shom asked me to go and enquire if we should come and get them the next day.
The answer was "Yes Sir, no problem".

Joy has also moved out of the hostel and is now a PG in Ophthal. He lives on the first floor of a house, situated down the road about a kilometer away. He is now married to Anju, a PG in Pharmacology whom he met when she came to write the Jipmer Entrance Exam in March.  In fact, in the same Exam, Manoj also found his future wife, both Anju and she being friends of Sirisha from Delhi.

The days tick by. The pace is increasing as is the tension and stress. Our regular tea breaks in the shacks continue but are faster and quieter. My room is getting messier by the minute and many minutes are wasted in trying to find notes that I MUST read now or books that have mysteriously disappeared. Many of us zoom off to the hospital in the evenings to see cases in the wards but I don't have time. There is so much to cover that I am overwhelmed and at times, terrified at the ordeal to come.
I have been told that this is normal for a Final Year exam but it is of little solace.

Our time table is released. The exams start on a Monday. Two theory papers each in Medicine and Surgery and one in OG. Monday to Friday, from 930-1230 in Banting Hall, that pseudo-auditorium with horrendous acoustics. The clinics are after the weekend. The whole batch, all 70 or so of us have been divided into 3 batches and I am in Batch B. I will get Surgery first, followed by Medicine and then OG. Monday to Wednesday, back to back.
And that will be it. Passing and failing, by this point in time, is a secondary, incidental outcome. All I want is for these exams to finish.

Finally, after 12 days of misery and torture, 12 days of hope alternating with despair, 12 days of optimism and doom and many many teas and smokes, I start my Final set of exams tomorrow.

I have managed to read almost all of Bailey, except for some obsure Urology bits that I am sure won't come and some Ortho bits, that although very well presented, are best read from Maheshwari, the recommended Ortho book. I have gone through past papers and brushed up on the clinical cases. I have even been to the library to look up a book called Rutherford that describes the tourniquet system of examining varicose veins so wonderfully. I had missed that class and have never seen a case so I do detailed research on this topic and finally feel equipped to rock and roll, albeit with instruments that are slightly out of tune.

I have gone through Dutta and Shaw and now am quite confident with OG. Owing to the nature of the Department and it's inhabitants, I had also paid particular attention in OG Clinics and Labour Room and so a lot of OG is familiar and easy to deal with. There are the usual painful topics like DUB and the like but it's largely an OK subject.
Medicine and Paeds are a different ball game. I have made serious efforts at reading Davidson, the core book, but with less than 24 hours to go before the opening whistle, I feel like I know and remember nothing. I spend most of the Sunday before the start staring at a Davidson, my mind getting increasingly numb, nothing seeming to stay in my head and I'm feeling increasingly helpless. I am looking at Hypertension-a pretty important topic by all accounts, but now even the basics are looking like Greek and Latin. I flip pages, sometimes to Endocrine-some Adrenals perhaps?, then quickly over to Sarcoidosis-a minute there and over to arrythmias, bouncing across nephrology, strokes, epilepsy, infections......There is just too much. Nothing stays in, it's like I'm reading everything for the first time.

It's around 8 PM when the first visitors come in. Well wishers- juniors and seniors, coming to wish the gladiator before the lions come marching in. Mishra comes in and finds me in disarray-books all over the place, the sole table lamp casting depressing shadows , me hunched over with a blank expressionless  face and very happy to see him, simply because it's an excuse for me to get up and chat for a while.
Mishra however, says a quick "Best of Luck Golu" and leaves. I was hoping for an extended break-anything to get away from my claustrophobic room, even an inane pointless chat about anything, anything to go in the corridor, smoke a smoke and forget about exams for ten minutes. But they won't let me. I get a constant stream of people for the next half hour and then I take matters in my own hands, thank everyone, then tell them to buzz off while I get back to my table with the lamp throwing depressing shadows around a room that feels like a refugee camp offering no refuge from the terrors in my head.

I have dinner and spend some time trying to find my Hall Ticket, well buried under some books. I locate my bike keys and hope it has enough petrol to get me to Banting Hall tomorrow. I check for some pens and keep all of this stuff on the table, ready for me to take the next morning. I go out for tea to the shacks. I have made peace with my exams and now it's all fate, or whatever one calls it when matters are out of one's hands.
I climb the 18 or steps to Osler Rooftop and spend some quiet minutes alone in the cool night breeze, staring at the night sky but at nothing in particular.
I have a headache from trying too hard, a feeling of doom that is normal under the circumstances but won't go away but at the same time a feeling of immense relief that exams are finally here.
For the doomed man, the torture is in the waiting. My wait is over.

Exams at 930 AM tomorrow.

Chapter 61-The Final Postings of my Student Life

Sep-Oct 1997

August is a month of mixed emotions. I want to see Interclass, see Spandan in all it's glory, bask in my filthy room and get awarded for it again, and like the rest of the campus, just take a break from the drudgery.
Instead, the spectre of exams is haunting me in my dreams and it's a race to the finish line, with no real guarantee that the race will be over.

Paeds drags on-kids with chests to be auscultated, abdomens to be palpated and developmental milestones to be mugged. OP Ghai, my standard issue Paeds book is completely unmarked and unread except for the section on heart murmurs which I read in Medicine, not here. My classmates discuss what's good in the book and what's better in Nelson (a huge Post Graduate book) making me feel decidedly incompetent and inadequate since I can't contribute to the discussion at all. At this level, a lot of Paeds is like Medicine for kids and I figure that by reading some Medicine, I can get by with Paeds in the exam.
The ward leaving comes and goes and we move to Medicine.

The Medical wards are on the top floor of the hospital. I've climbed the steps to this floor countless times, at times stopping briefly at each landing to admire the painting on the walls, all signed by a "PK Patra", all done in the '60's. The stairs open in front of Ward 41 across which is the Dialysis Room. Leading left is a long corridor with all the other wards-43 being the subject of much debate in particular. This ward, which is now a CCU, started life as a RICU (Respiratory Intensive Care Unit) which promptly got the Chest Diseases Dept to stake a claim on it. The RICU was a brainchild of the Anaesthesia Dept however, and so they renamed it and now it's their sole baby.
I've been here once and it looks pretty state of the art. Last year, while reading for my marathon 5 paper exam, Vij, a PG on Obs/Gyn had asked me to donate some blood for one of his patients admitted there. It was 3 AM, I was bored stiff and I willingly obliged. I went to see the patient here that time and there she was, lying alone in the quiet pale blue light with tubes and wires, monitors beeping, sedated, or probably, unconscious. She had DIC and her chances were slim.
She died a day or two later and it affected me a for a while before life, and I, moved on.

The rest of the wards, like all in the hospital are numbered in sequence and on this floor, the Ward at the end and to the left  is occupied by the Plastic Surgery Dept. Manned by Dr KA (whose wife is a Consultant in Medicine and specializes in long, silent, uncomfortable stares after asking a question) and Dr P, this Dept is almost like a hospital in itself. It has it's own Record filing system, meticulously kept and religiously maintained complete with pre-op and post-op photographs. Dr KA has a reputation of being an excellent surgeon, specializing in cleft lips and palates. I've often seen the couple walk around the campus at night and I'll be dealing with Dr AA, his wife in the coming weeks.
Dr AKD is a gem. He is the Head and is a short, sweet guy although I hear that he can be hard on his Residents when needed. By all accounts, he is a boon in exams and we all start praying he comes as examiner.

The posting is like any other. We start in the OPD, move on to the Ward where a case or two are allotted and we take turns to present these to the designated Consultant/Resident. This varies from day to day depending on the Unit that is in charge of the case. Like Surgery and OG, Medicine has 4 Units and each Unit takes turns to allot and take class for us.
This drags on-heart lesions, lots of TB and pleural effusions, ascites and fluid thrills, pulsating abdominal masses, enlarged livers and spleens, strokes and facial palsies. It's a very long list and we are told that really, there is no defined case list at all. Anything can come, it's just vital to examine systematically and arrive at a working diagnosis. As long as that can be justified based on history and findings (which must be accurate of course), the odds of passing improve dramatically.

This sounds simple in concept but there are many, many roadblocks. I hear of a someone, a topper, who found a lymph node and made a diagnosis that could have only been made with prior knowledge of the case. His history and examination were top notch, but he failed. My hearing has become selective. Instead of hearing success stories, all I can think about is who failed in previous exams, why they failed, how they got unlucky, which examiners were "lousy" (or "bastards"), how tough the exam is and how exotic some of the questions can be.
Pondicherry is an alcohol haven and once, while driving to the bus stand at 7AM to book tickets, I saw an open booze shop and a lone cyclist, probably a worker in one of the many factories, cycle along to the shop, order a peg, gulp it down and speed off, all while still on the bike. It is no surprise, therefore to find so many cases of cirrhotic livers and distended abdomens, enlarged livers and bleeding varices.
I have thought about my own liver occassionally but the standing joke is that one must get the liver enzymes to work regularly by imbibing enough lest they fall into disuse atrophy. And I have kept them busy.

It's an uneventful posting. Nothing has changed from the last time. Dr RP with his "Diagnosis Doctor!!", preceded by a long diatribe in incomprehensible Tamil, his shotgun approach to Medicine, Dr KRS with his stern, professorial looks and fantastic diagnostic acumen, Dr TKD with his reputation of being fair and impartial in exams and Dr AA with her silent, uncomfortable pauses between questions. Classmates reading fervently, me looking a little lost, patients being examined multiple times and probably suffering in silence, the usual feeling of doom and gloom and the odd panic attack.
The subject is so vast that I really don't know where to start. Some have called Medicine "Intellectual Masturbation" but I don't feel particularly intellectual right now. Reading has to be done however, so I read Davidson, mug up the thousands of signs and symptoms in PJ Mehta, read all the notes I can and listen to all the classes in earnest. These are the last few classes of my MBBS days and each one can make a difference.

The days pass by. Interclass and Spandan whizz past. I hardly see anything and in the few events that I do manage to see, I feel guilty after half an hour and go back to read. Spandan will be back next year, when I will hopefully be an Intern and I can devote all my attention to it then.

For now it will have to wait.

October 1997

It's all come down to this. My last 4 weeks as a Medical student. Surgery is my last posting and will finish 2 days before my Send-Ups, the full scale dress rehearsal Exam before the Univs. By this time, all I am doing is reading. The reading, of course, is punctuated by lunch, dinner, classes and the odd Snappy excursion but it's all about reading now. I feel comfortable with OG and most of Surgery but Medicine and Paeds remains a problem,especially the theory simply because of the size of the subject. I have to focus now on Surgery however, in these last 4 weeks of my student life.

Surgery has logic. There are visible things to examine-ulcers, swellings, breast and thyroid lumps, abdominal masses, varicose veins, hernias and hydroceles. There are well defined points in the examination of each of these and at the Undergraduate level, fairly structured treatment plans and options that we need to know. I like Surgery even though the smell of infected ulcers and cancers of the penis can drive one straight to the loo. Surgery, however, does not like me. About a week into our posting, some of us are called into Prof AK's Office. There are about 6 of us and we are called in separately. When the first guy goes in and comes out with a worried look, some rapid, urgent questioning reveals the problem. It's attendance.
Sigh.

I'll never come to terms with attendance. The college requires 75% and this can be condoned to 65% with a fine. Except for Pharmacology where I landed up with 64.6% and therefore 1 class short, getting stopped from writing the exam in the process, I have managed to make it through each attendance related potential disaster. I have even done well in exams so far aggregating about 69% in the Univs. I hate attendance as a criteria for writing an exam but rules are rules and I am probably short again in Surgery.
I walk in. It's a fairly bland office with the usual cupboard of books and journals, some furniture, a tubelight and an examination bed and green screen.
Prof AK, with his ultra-dignified looks and horn rimmed glasses perched on the bridge of his nose, peers down at me, standing nervously 6 feet away.

I have imagined this scenario happening to me. In previous years, it has happened to a few of my seniors and they gave me this wonderful piece of advice:
If told that you are short of attendance, tell Prof AK that you will make it up by attending Casualty posting during your study break.
This worked for them and they were allowed to write the exams.

Prof AK is serious. He has a paper open in front of him and quotes exact figures of my theory and Clinics attendances over the past 3 years. They are not flattering but not that bad either. I am both a bit amazed that I attended so much and a bit upset at myself for not attending enough.
So I quote Shom's gospel.
"Sir, I am truly sorry but I promise to make it up by attending Casualty posting in my study leave. I 'll go every day for however long you want me to go"
Prof AK gives me long look, no smile and in a firm, even, almost fatherly tone, says
"Look man. If you attend classes in the 14 days of study leave you have, both your numerator and denominator will increase. Your attendance percentage will hardly increase. So there's no point doing that. I can't allow you to write the exam".

I come out. I've given up now. I don't care about the exam itself. What I'm worried about is how I'll convey this news to my parents. They took it well the last time and I wiped that memory off with my best performance in the subsequent 5 paper exam. That was then and I am now in the same situation. It's frustrating and depressing. Of course, I have only myself to blame.
5 months earlier, a notice had been put up stating that all of us needed to pay the 400 Rs or so of tuition fees for the year by a certain date. I read it, saw that the date was a month or two away and forgot about it. The deadline passed, another reminder, complete with warnings about "Name removal from the Register"  came and went and my fees remained unpaid because I forgot to tell my parents.
In class a few days after the second deadline, my name is not called in Attendance. Thinking this has to be an oversight, I walk up and find that my name has been witheld owing to unpaid fees. To make matters worse, the College has sent a letter stating exactly this to my parents who, I imagine, would have been less than amused to read about their son, in a far away land, not paying the token fees simply because he forgot and has got his name removed from the Register.
The matter is remedied quickly after an awkward phone call home. Now another much more awkward call may be required.

There is still hope. Historically, no one has been stopped from exams in Surgery because of attendance. The fall-out of my one-on-one meeting with Prof AK is that he now knows me quite well and is well aware that I have attendance issues. This has put extra pressure on me to do well in the upcoming Send-Ups and I HAVE to pass this. I get the feeling that if I fail, I won't be writing the exams.

The posting drags on. I haven't yet seen a Varicose veins case and I'm worried. Varicose Veins involves tying tourniquets at defined points on the leg to see which veins fill and which don't. The idea is to locate the perforators and see which are patent. It sounds simple enough but I know that unless I see it, or better still, actually do it myself, it will be very difficult to suddenly do an accurate examination in the pressure cooker atmosphere of the exam.
There is a Cancer of the male breast somewhere in the Wards and we make a beeline to see it since it is rare and so will definitely be kept in the exams. The problem with Breast Cancer is that the treatment for each stage is unclear. We have been told many different things for each stage and it's very confusing. We approach Prof AK for a class, having been told that he often takes lecture classes right at the end to clear up really tricky issues.

The class is wonderful. Breast Cancer has never been clearer. He even explains Estrogen Receptor measurements (in fmoles/L), takes time to answer all our questions and just demystifies it completely.
Then, this happens...

Normally after a class, the teacher calls out attendance by name which is entered into the register as either an "A" or a "P". Some of them choose to pass this register around and we mark ourselves. This is rare however.
Prof AK passes the register. This has happened with senior batches and Prof has a reason. The register starts from the bottom row where the front benchers sit. The register has the entire attendance from the start of 1st Clinics. In theory, all the "A's can be overwritten to "P" and for the first two rows, the register passes quickly, first because Prof AK is 2 feet away and second, because this group of people probably do not have attendance issues anyway.
The drama starts after that. The register is passed very slowly, each guy taking time to overwrite as much as possible while desperately trying to hide this from Prof, standing and waiting for the return of the register. There is much tension because we know that at any time he can call for the register and some of us might get left behind. The register is almost snatched from one another and by the time it reaches me, I barely have time to overwrite as much as I can, and to anyone it will be quite obvious what has happened. After a while, bored of waiting Prof AK calls for the register and walks off.
There is an audible sigh of relief.
We later learn that he does this for every batch for whom he takes a last effort class. We had been warned
"Bugger, he will circulate the register. Make sure you get your hands on it"

A few days later, with the posting nearly over, the Dept posts the Attendance list. I am at 82%. I know that not of all this increase is because of me and the register.
He didn't have to do this, but he did, knowing that exams are round the corner and that's the best place to expose knowledge lacunae.


Send-Ups: 
2 days. 2 days in which to revise nearly the whole of the last 4 years. There will be a theory paper in Medicine, Surgery and OG. This will be followed by Clinics in those subjects with a short case in Paeds and Ortho as part of the Medicine and Surgery exams respectively.
The structure is thus:

Medicine: 
1 Long case-45 minutes to examine and write a case sheet
1 Short Case-15 minutes for examination
1 Paeds case-20 minutes for examination
A bedside viva in each
This is followed by 2 spotter diagnosis and viva on them, a viva on microscope slides, instruments and ECG and a drug viva.

Surgery: 
1 Long Case-again 45 minutes
2 Short Cases-20 minutes total
1 Ortho case-20 minutes
A bedside viva in each
This is followed by vivas on Operative surgery, surgical specimens, instruments and X-Rays and  general theory viva.

OG: 
1 Obs Case-30 minutes
1 Gyn Case-30 minutes
A viva for each case.
This is followed by vivas on Insruments, X-Rays and a Normal Delivery demonstration with a dummy baby and pelvis.

The real killer is the Long Case. It carries 75 marks out of 150 and in 45 minutes, we have to take a detailed history, examine completely, get a diagnosis and then write all of it down. In the case presentation, whatever we say is matched with whatever is written. If something is not written, it is assumed it has not been done. It's vital to write a good case sheet.
The short cases do not need a case sheet. But that makes it trickier because one must then present logically from memory. Examination findings are key here.
In general, if one does well in the cases, the later vivas do not really decide the Pass/Fail result. However, one has to pass separately in Theory and Clinics to pass overall.

My Send-Ups do not start well. The Medicine paper, as expected is not good. The rest I manage well. I am particularly nervous about Surgery Clinics. I need to pass this because even after all the attendance register shenanigans, I'm not sure I'm out of the woods yet. The Long Case has a hard mass in the umbilical area and I don't know what it is. Dr Benjy, my examiner kind of half nods, half shakes when I venture "Ca Stomach" and I walk out not knowing what just happened.
Prof A, the head of OG comes for my OG Viva. This can be make or break time especially if she decides to come for our University exams as well. She is sweet, the vivas are great and I walk out feeling much better about life.

The results are announced. I fail Medicine. I get 75/150 in Surgery. I pass!
OG is a breeze.

Surgery puts up the final atendance list on the notice board. I am at 82%. No one in the class is short.

I'm nearly there. My study leave starts now. Univs are in 12 days.

Chapter 60-Sastri, Interrupted

July-Aug 1997

For a fresh batch, the Jipmer academic session usually starts on the last Monday of July. I had joined on the 11th of August 4 years ago, which meant that I had missed 2 whole weeks of Anatomy, Physio and Biochem-at the time seemingly insurmountable gaps in knowledge, remedied eventually by hard core last minute cramming, helpful seniors and BD Chaurasia, that saviour of all Medical students in Anatomy. Over time, as one moves through the course and becomes more senior in the process, the terrors of getting ragged and reading that joining as a Baby Junior bring are replaced by the joys of doing the ragging, with reading now having being reduced to a necessary evil in the scheme of things. While it is not true that a medical student has to study ALL the time, it is probably true that they need to study more than anyone else, in more ways than anyone else and with more pressures and lesser rewards than anyone else.
The reading has become a part of life. The ragging and the anticipation of meeting fresh baby juniors, however, straight out of school and into the big bad world, is very real and comes around only once in a year.
August is the "Silly Season" here. It is the month before Spandan, the month of InterClass, Hostel Days and the month where, within the unwritten code of Jipmer ragging, the raggers can have a field day (or month). It is also the month where the Jipmer Students Association (JSA) screen the Jipmer Film Festival.

The Festival lasts for 3 days and consists of non stop movie screenings in Hunter or Bernard Theatre starting from about 5 PM till whenever the last movie finishes, sometimes by 3 AM. It's back to back, tickets are at 5 or 10 bucks, movies are projected onto a big screen and it's a time to catch up on lost movies and sometimes-hard-to-get juniors.
So we shall sit in AirConditioned comfort sans the accompanying booze and nicotine. The theatres are located on the Ground and first floors, at the end of a corridor which starts off at right angles from the Main Hospital entrance. The corridor leading straight on is the OG corridor on the ground floor and the Paeds/ENT/Ophthal corridor on the first floor, with a ward at the end reserved for Surgery.
The ground floor corridor of OG is a long one, starting near the Main entrance and ending at a T Junction with the Psych Ward on the Right and Private Rooms on the Left. However, it's actually more like a crossroads with the Hospital effectively ending here and the corridor, now continuing on, leading to the Hospital kitchen area, complete with the smells of freshly cooked Sambhar. There is a way to Aschoff House from the kitchen, although to get here, one has to leap across a wall and walk through some bushes and trees. Aschoff, of course, is where all the juniors now stay, safe from the terrors of meeting seniors in Lister and Osler, an exercise in isolation from which I was thankfully spared.

These days are small welcome breaks from all the academic tedium, especially for us Final Years, who do not benefit from the respite that Spandan confers to the campus. Everyone will be off except for us and we will have to go to Clinics from 9AM-1PM while the rest of the campus entertains and plays host to the 4000 odd Spandan delegates. This is actually fine and for 2 reasons:
1. Clinic attendance is vital to passing exams. One missed Clinic may mean a missed exam case.
2. The Final Years have organized Spandan etc the previous year.With that, their role in Spandan reaches a zenith and when it's over, they hand over the reigns to the next batch and move on.
The party is over, so to say.

I have seen some of the new juniors and there has been no real time to rag anyone. I have heard of a particularly cocky behaving guy called "Sastri" whom I haven't really met but has been pointed out to me from a distance. He walks with a slight swagger, and thinks he walks the walk and talks the talk. This kind of attitude is fairly common among uninitiated juniors and one of the aims of ragging is to get them back to Mother Earth.
It is therefore, inevitable that I say "Hey bugger" when I see Sastri in Hunter Theatre just before Batman and Robin is due to start.
He saunters up the step to me and says "Yeah, what".

I should have caught him by the collar, dragged him down the stairs and into Lister House, tortured him all night and dumped him back in Aschoff. But I am beyond all this, too tired, too senior and too bored. Sastri, from what I hear, is already a marked man and I suppose the rest of the lions will feed on him at some point.

The movie starts. It's one of the worst I have ever seen. Sheer stupid torture. It's dark but I can make out Sastri sitting on the front benches with some other babies. I'm getting the impression that the movie, horrendous as it is, is just an excuse for people to get closer together in the dark. In any case, around 3 AM, with the movie drawing to a close, I see Sastri suddenly leave, quietly and quickly.
This can mean only one thing. Our man has decided to cut and run, bypassing the hordes of frustrated and bored seniors in the theatre who will undoubtedly make him their entertainment for the rest of the night.
I am bored too. And I know exactly where he's going. I rush out into the corridor and see Sastri walking fast and turning into the OG corridor. This means that he will take the short cut to get to his room in Aschoff, again not risking getting caught by anyone. I won't be able to catch him, what with me being fatter, older and with less able lungs but I have a bike. I jog to my bike, gun it and get to Aschoff House. 5 minutes later, Sastri emerges from the trees in front of Aschoff and stands in shock. His escape to freedom has just been short-circuited.

"Hi bugger, where do you think you're going"
...Silence

Hoping to run away and go to sleep, Sastri is instead met by me, a Final Year student fed up with books, vivas, classes, attendance issues and longing for some entertainment. Sastri and I, however, end up just chatting. He is a bit in awe of how I saw him escape and cut him short and how his jaw dropped when he saw me, standing between him and sleep. It turns out that he's from Bangalore and interested in Neuroscience  He wants to do Neurosurgery apparently, preferably in NIMHANS. (My eyes roll here. This guy is about a week old in MBBS). He seems smart which may not be the wisest thing to be in ragging season and I tell him so. Talk veers around to books and he tells me he reads a book called "Stryer" for Biochemistry.
I know this is rubbish since Stryer is unreadable, massive and not even recommended. Maybe he hasn't discovered this yet.
He has made the fatal mistake of expressing an interest in basketball and will be recruited for the team. His classmate, Muneer, has also done the same. Both will spend the first year running laps around the field, doing German drills on the court, fetching water for the big boys and despite being treated like dust, will develop an attitude and swagger that everyone on this team manages to do.

It's now 430 AM. Sastri and I go out for tea in the shacks. I think he's a bit relieved that nothing more came out of his aborted attempt to escape. I feel good too-in Jipmer lingo, a typically "jobless" thing to do. Chasing juniors at 4 in the morning.

The joys of College, Final Year or not.