Wednesday, January 22, 2020

189. Do Not Doctors Need To Learn Continuously? P S Remesh Chandran


Do Not Doctors Need To Learn Continuously?  

P. S. Remesh Chandran

Editor, Sahyadri Books & Bloom Books, Trivandrum

00. Article Title Image By . Graphics: Adobe SP.

Public service careers are the forefront of social life. People with good analytical, social and communication skills and ability to take good decisions of wise judgment under pressure are much sought-after in any society and would make good administrators, leaders and doctors. Among these careers in public services, doctors’ have the distinction of being lifelong. But once a person puts the title of ‘Dr’ in front of his name, he becomes committed to lifelong learning too.


In every profession, those who do not update continuously are out.

02. Instruments Autoclave Nurse By Otis Historical Archives.
Doctor’s is a high paying and rewarding career of saving human lives, using the latest technology available, with a job surety guaranteed by the increase in population and longevity of human life and also by a steady flow of patients resulting from diseases originating from man’s permanent farewell to nature. But can a doctor choose to remain not continuing his studies and updating his knowledge? Of course he can, but he will have to pay the price and the penalty for it someday. Science of today was yesterday’s philosophy, day before yesterday’s hypothesis and the ancient past’s speculation. Unless a man of science updates himself as his own attempt at self improvement or with university help, he cannot carry on the torch of truth for long. In every profession this is the case, let alone in the field of medicine.

Pre-Historic, Middle Age, Renaissance and Industrial Age doctors learned continuously; so too will Space Age ones.

03. Instruments Lithotriptor, Anesthesia And Fluoroscopic Machines In OR By Diver Dave.
Since when man appeared on this planet, and since when magician priests in the pre-historic world began to function as medicine men also, physician learning has been going on in this world. Perhaps these magi have been the first professional group to embark on a mission of lifelong learning, the second of course being astronomers. Or, these magi even might have been learning astronomy too, as suggested by those famous Three Magi who following a star traveled the Asian-European route with herbs and camphor and went in search of a newborn babe in a Bethlehem cattle shed. Even during the Dark Ages in the Middle Centuries, they had been learning continuously and advancing medicine. In the Sixteenth Century in Italy during Renaissance, their efforts culminated in Leonardo Da Vinci’s dissecting a number of human bodies, (we do not know if he had opened even living bodies or if he had a license to open them or how he got hold of a steady stream of human bodies), to study internal configuration, especially of nerves and muscles, in order to learn where wings could be fixed when man learns to fly naturally like birds. Though man did not fly naturally, his sketch books paved the way for modern anatomy and surgery. Industrial Revolution changed medical field a thousand fold. Space Travel and Space Age brought new metals, new technology and new processes, and medical science was the first to benefit directly from these discoveries and developments. Many of the discoveries and developments by NASA were soon made available to the medical field too. The last was NASA’s staff confidential medical data accessed to a Professor of Medicine in the University Of North Carolina School Of Medicine to treat an astronaut in the International Space Station for an asymptomatic blood clot (Deep Vein Thrombosis- DVT) in the jugular vein of the neck for three months, using the limited stock of blood thinners like Enoxaparin available at the Station, by way of e-mails, phone calls and ultrasound self scans of his neck by the astronaut, all routed through satellites, as reported by press in January 2020.

Why are doctors’ families there?

04. Instruments Operating Room Store By Haitham Alfalah.

It is ironical that background is important in medicine. Even though skills are distributed far and wide among population, genes do manifest. Children coming from Physician Families are more at home with medical culture, medical techniques, and medical jargon: they undoubtedly adapt more easily to the problems and hurdles in the field. They also have the drive to secure admissions as well as sustain studies: they have to. Otherwise it would be a disgrace to the Paas and Maas. In Europe, most of their dads would be heads of departments in prestigious medical institutions. Whether they get admitted through excellence or preferences, medical field is saturated with descendants and heirs. It has not yet been studied whether they are driven by genes or necessity. Professions of parents of medical students have been one of the least studied subjects. Many must be sons and daughters of doctors, nurses, technicians and subordinate medical services staff and would be coming from a background with patient care and with an air of attending to other people’s needs. This would place them above everyone else in withstanding pressures and sustaining studies. There indeed is a great difference between fresh greens from non-medical families coming out of medical school and their counterparts with a background of patient-care doing the same. In developing a flair for medicine, securing admissions, learning techniques for studying, withstanding the rigors of studying and sustaining oneself to the end, and keeping up the zeal for learning and continuing their education, this difference is great. Actually that is why there are doctor families.


Dramatic changes in blood-letting, transfusion, patient-carrying stretchers and ambulances.

05. Instruments Roman Age Surgicals By Zde. 

Medicine is an ocean into which the rivers of all new developments in physical and biological sciences and space technology flow themselves. Cures, treatments and procedures which were once considered great in text books become obsolete and outdated and are replaced by newer medicines, treatments and procedures everyday. Equipments also change. Knowledge in medicine multiplies in every decade. Blood-letting was once done using live leeches and leech houses were maintained in the countryside for this purpose. Today there are sophisticated equipments to let blood that spill not a drop of blood. Blood transfusion which was once done from donor-to-patient by direct transfer also has undergone dramatic changes, in hygiene as well as in technology. There are blood banks everywhere today and the donor and the recipient needn’t see each other; they may even be living in different countries. Look at the development in even stretchers to carry patients from simple shoulder-carrying bamboo poles to complicated metal creations, elegant and running multiple gadgets. Evolution of ambulances also was wonderful from canopied and wheeled stretchers to driving marvels of Benz and Toyota, doubling as high-tech moving operation theatres also. Doctors do have to keep up with this development in everything connected with health care, not only not to be pushed back into neglect and disuse but to provide to the patient the latest in health care also. An ever-learning student, who keeps up with the advancement in physician practice, and through him upkeeps the excellence in the state’s entire health system, is expected to be living in each doctor.

Good doctors have to keep pace with new medical knowledge generated in research.

06. Iron Lung Machine Old Germany By Anagoria. 

Research is where the bulk of new knowledge in medicine is generated. Knowledge accumulated through research will take a long time to be put into medical practice. This accumulated knowledge has meanwhile to be translated into practical use through assessment, review and utilization. Unless and until proven trustworthy in clinical use, this new knowledge will remain in the research lab unused. Without authentication and validation from clinical use, it will remain just hypotheses. So it is reviewed by peers in the field and then repacked in a suitable form for doctors to understand and use. A part of this new knowledge will come out as articles published in medical journals, and the most relevant and applicable among this would then be assimilated into text books for medical schools and materials for doctors’ reorientation courses. Even then only a small part of this new knowledge would have come out into the general stream. A large part of it will be proprietary, i.e., knowledge developed by pharmaceutical companies in research, to be used for developing their new products. In time, it would also be released to doctors by piece meal, in the form of literature accompanying products. Good doctors have to keep pace with all these new developments in the field.

New treatments replace old ones everyday and old learning becomes obsolete.

07. Iron Lung Machine Old USA By Michael Barera. 

Once, a medical student coming out of college was confident of his knowledge in successfully treating a patient. But now he is not. He lives in constant fear of how much of his knowledge would become outdated the next day. New treatment replaces old ones and old learning becomes obsolete everyday. A clinical procedure which did not exist at the time of his passing out may be the most trusted and widely followed one now. One which was trusted and was prevalent in his time may have become questionable now and lead to judicial prosecution, compensation and disbarment. What a doctor learns in anatomy, physiology, biochemistry, microbiology, pathology, pharmacology and psychology in medical school become part obsolete every five years. Only basic principles remain unchanged. Medical ethics and medical laws change everyday and new chapters are added to medical history. Specialties sub divide and branch out, filling hospital corridors with name boards of new departments too often to be followed. Selecting a specialty for study is too strenuous a decision for a post graduate resident to take. Once a selected specialty is proven illusionary, he and she will have to retrain themselves in another specialty. A brilliant anesthetist may later have to retrain himself as a psychiatrist. One who fears patients coming to him in near-death conditions may want to retrain as ophthalmologist. But more precious years would have been lost during all this retraining.

Evolution of disease-causing vectors makes physician-knowledge-update invaluable.

08. Iron Lung Machine Old England By Stefan Kuhn. 

When a virus evolves into a new strain and jumps into a new species, the tests for finding it and the treatment for controlling it also would undergo an evolution. New diseases are identified each day, new medicines formulated, new treatments devised. Patients may ask about these new diseases, medicines and treatments. Only doctors with more than sufficient knowledge can manage these patients and such doctors would always be in high demand. In the competitive field of medicine, doctors without new knowledge will be pushed back fast. 40,000 research papers are published each month in medical research and development and a doctor, how much leisure he gets, cannot even think about identifying and accessing even the new, let alone all, papers in his specific subject. Even a 5,000 hour-long course-time a year would be absurdly insufficient to process this new knowledge in his specific field for him. Unless he keeps the spirit of learning alive, he would be of no use in this world of knowledge explosion. So, he has to continuously gain knowledge, process it and make use of it. He has to do this in advance too as preparation, for he cannot look up this knowledge as and when a patient arrives, or in the patient’s presence.

Today’s World Chain Hospitals maintain patient support systems online.

09. Stethoscope Modern PD By Andrea Booher US FEMA. 

Computer savvy and internet savvy doctors can make use of e-learning technology to expand the horizons of their knowledge. Some will even have to be taught the basics of computer operation, from punching a keyboard to making use of electronic decision-support systems in a hospital. Today world chains of hospitals have all built their own patient support systems online in which every patient data is fed the instant they are generated, and the system analyzes this data and predicts what is to be done next, according to pre-ordained parameters, devised through collective experience in each field and sub field. The doctor cannot heed not the system’s advice and decide to take an alternate course even if he thinks it would be wise. But to be guided by and make use of this system, the doctor has to become computer and internet savvy.

Patients expect their doctors to be experts in cutting-edge technology.

10. Stethoscope Old Monaural France 1870 By Wellcome Trust. 

When a patient sees a doctor, he expects his doctor to be familiar with cutting-edge technologies and up-to-date knowledge in the medical field. He expects the young doctors also to be as experienced as the older ones and the older ones to be as energetic and updated as the younger ones. Remember that old rule: ‘Find an old doctor; he will know many tricks, and look for a young lawyer; the older ones will have lost steam.

Becoming a certified and licensed physician does not guarantee one that he can practice indefinitely. Certified proof of his having been attended orientation courses on modern medical technology and treatment methods at least such and such hours per year is now mandatory in many countries to continue his license unless it is invalidated. In many countries their recertification every four or five years is now compulsory as it is for airline pilots and ship stewards.


Learning to learn for the first time without the aid of a teacher!
 11. Stethoscope Old Wood And Brass 1820 By London Science Museum. 

Think about a student sitting in a medical school. He will have a teacher to guide him, to tell him what to learn and to advise him what not to do. Once he comes out of this medical school as a certified doctor and begins his practice, he needs to continuously update himself but there is now no teacher there to guide him. The fact is, now, he has to teach himself how to learn, and retrain himself in what faculties he essentially needs, selecting what he actually needs and avoiding what he never may need. The knowledge is there, stored in retrievable digital form and print book form but he has to select what to select and what to discard in his limited time from this vast store of knowledge. Knowledge which once looked great would have become redundant and irrelevant now and the presence of someone like a teacher would have been a blessing to guide him but now there is no teacher is there. So, what a medical student has to learn first about learning is how to select and learn without the guidance of a teacher, and to develop one’s own system for learning which would carry him on through to the end of his life. What information he disregards now may someday become relevant and useful. Therefore he has to have his own system for scanning all knowledge with a bird’s eye view and study deeply what he has immediate use of with a worm’s eye view. Reading is the one and the greatest substitute for face-to-face oral teaching and without developing readings skills and a flair for reading, he won’t survive in the future world as a doctor. Medical school in truth is not an end but just a beginning.

Books, magazines, bulletins, pharmaceutical pamphlets, seminars, get-togethers, alumni meetings, orientation courses, Twitter and Linked In- dozens of ways for doctors to update themselves.

  12. Medical Examination Gamma Camera Modern By Brenda ICM. 

The conventional and most followed method for a doctor to update himself is to read books on medicine. Then come magazines, bulletins, newsletters and pharmaceutical pamphlets conveying new ready-to-use knowledge from the medical field. Most doctors gain the most knowledge from these brochures and newsletters. Then there are the specialty seminars, conferences and doctors’ get-togethers and also alumni meetings. The next in the ladder are up-gradation courses and orientation courses offered by medical universities directly and online. For those who are ready to learn through internet, there are hundreds of good online sites which offer knowledge on old and new methods of diagnosis to treatment, curing and rehabilitation. There is not one good medical university or school today that does not have digital presence. Only that a doctor has to have time and the skill to wade through the thick surrounding forest of brushwood and reach the good and useful. Many modern day doctors use digital tools like Twitter and Linked In to follow popular medical journals and noted physicians respectively to continue their education. These platforms offer a vast variety of medical knowledge. Some doctors collect important articles in Ever Note and some write their thoughts as Blogs in Blogger or Word Press.

Today’s medicine man or medicine woman has to be an engineer too, that too a medical electronics engineer!

  13. Medical Examination Neck 1816 By Wellcome Trust. 

Medical schools, teaching hospitals and professional organizations conduct programs and courses for doctors to continue their education. Many institutions have included long-distance programmes also now. Good medical universities tie up with partner institutions and pool knowledge and regularly conduct educational programmes and orientation and re-orientation programmes for associate doctors to disseminate this new knowledge. Text books are being replaced by internet web pages and the number of tech savvy doctors is increasing. The enormous volume of electronic medical information generated and stored each day this way can only be accessed, classified, interpreted and made available to the time-short doctors only by such institutions and organizations. Only they can identify and reroute the most useful in this vast ocean of information. No individual can keep up with the tremendous rate of research and development in medical science, let alone doctors. Even coping with advanced software for patient care and new medical data management systems like e-health is hard for them because horizons of knowledge and technology are always expanding. Most major chains of hospitals in the world are now functioning based on their own world-wide electronic patient treatment systems in which the doctor has not much to do, for every reading, assessment and evaluation goes into the system and the system decides what to be administered to a patient and when to be administered, without risk to the attending doctor. Even if the doctor thinks it wise, he cannot interfere. But even understanding the intricacies of these systems is hard. So, today, our medicine man or medicine woman has to be an engineer also, that too a medical electronics engineer! This is where medical universities come into their role in the reorientation and continuing education of doctors, through seminars and courses where other doctors share their experiences and new discoveries are explained. Remember that, as healing artists, rarely do physicians succeed in mastering technical skills. It’s like the true artist failing in mastering worldly skills as it has been always. So to make them tech savvy there are other courses also. Thus they are helped to adapt themselves not only to changes in the medical field but to changes in the technical field also.

Most institutions now design courses in modules which can be completed as and when one gets time, completed within a reasonable period of time.

  14. Blood Letting Surgery In 1672 By Wellcome Trust.

As doctors cannot interrupt their busy schedules to find time to catch up with new knowledge and skills, institutions engaged in facilitating their continuing education have begun to design their courses in such a way that they will suit serving doctors’ schedules. Remember that a doctor cannot abandon his patients for a single day or even for a few continuous hours. That is where the new education technology comprising of virtual classrooms and internet and video conferencing comes of use. Most institutions now have begun to design their courses in modules which can be completed as and when one gets time, provided the course would be completed within a reasonable period of time without providing too much time to lead to rusting of intellect or information through disuse. Those who have no time to participate in person can watch videos of presentations and round table discussions later.

Finding the right time for learning, and if possible, for teaching and writing too.

Of the twenty four hours in a day not all are helpful for learning new things and updating old things. Finding out which times in a day when one’s mind and body are better equipped for reading and learning new things is pivotal in the successful reeducation of a doctor. Teaching someone what we know and interacting with students on what we teach is one sure way to make our knowledge concrete. Bolder doctors write and publish articles online on what they know where still bolder counterparts and general readers correct them if they need correction. These are all modern day processes to continue one’s medical education.

Doctors’ duty room discussions are universities for doctors’ continued education.

 15. Blood Letting Surgery In 1664 By Egbert van Heemskerck-Wellcome Trust. 

Doctors resting in duty rooms and discussing with other doctors their experiences in ward rooms and imparting their insights into these experiences is the most primary, common and invaluable type of continuing education for doctors. The more time they rest in these rooms, the more elaborate and deep these discussions would go, leaving them with less time in their wards, but ironically the more time they get to spend in their wards only would make these discussions more realistic through direct patient contact experience. Some will point out what physicians in the past would have done with a patient under the same circumstances and some will point out what doctors in future would do. Insufficiency of equipments, implements, procedures, drugs and subordinate staff and their own lack of insight or courage would all come to discussions and young doctors would learn a lot, especially what to avoid and what to make maximum use of in future, and other doctors would come to recognize their follies.

All remind doctors how human they are and their patients. There is nothing in medical texts and seminar papers to substitute healthy discussions in hospitals.

16. The Blood Letting: Painting 1660 By Quirijn van Brekelenkam. 

Some doctors in duty rooms will tell stories of how glad the husband was when told he was going to have twin babies, how shocked the son was when told his father would live only for two more days, how shocked that girl was to know her mother was to have a hysterectomy, how aggrieved the poor woman looked when asked to purchase medicine from the outside for her son, and how he performed an operation without sedation by pacifying the patient by asking her all the while how well her toddler was doing in the world and how fine her elder son was foraying into the world of music. All counts, and reminds doctors of how human they are- they and their patients. There is nothing in medical texts and seminar papers to substitute such healthy discussions in hospitals which serve as their continuing education. What knowledge you enjoyed learning remains a lifetime. That is why discussions in hospital duty rooms are invaluable to doctors. Some bold acts by some old doctors are lessons for others. Following protocols and checklists is not all, though it is safer. Of course a doctor cannot be an adventurer but have not it been adventurers in the medical field who contributed much to medicine and made significant discoveries in this field?

Doctors’ rooms are news rooms too and grapevine presses.

  17. Blood Transfusion Modern PD By Mike Leporati US Navy. 

Some doctors who do not even have time for reading news papers even get news from doctors’ duty rooms. Of course the grapevine of the medical field too would be functioning from these duty rooms. There will also be stories told of how two Directors of Health Services were imprisoned for corruption, a Director removed from post for irregular appointment, a District Medical Officer removed for fraud, how two young brats justified posting patient’s delivery scenes on What’s app, how rural hospital pharmacies are doubling as liquor shops by selling diluted carminative mixture at reasonable prices to villagers and thus depleting essential fever medicine stock rapidly, and how pethidine injections and diazepam tablets are peddled out of emergency store vaults to underground markets in exchange for cocaine.


Internationally accepted indices for gauging the current levels of doctors’ continuing education.

 18. Blood Transfusion In 1800s By Wellcome Trust. 

To assess how much do doctors continue their education, there are internationally accepted questionnaires like the Jeffersonian Indices, which generally covers information such as educational levels, years of employment in rural and urban services, professional titles, individual career satisfaction and training experience, and are used throughout the world with suitable country-specific adaptations. It is to look into the current level of continuing education of doctors that these indices are devised; then only can a country look into the ‘how much and how to’ of their doctors’ continuing education. The usual 14 items, translatable and adaptable by any country, can be answered on a 4-point scale, each item scoring from 1(strongly disagree) to 4 (strongly agree), the sum of all giving the total score which may range from 14 to 56, with higher scores indicating greater orientation toward continued learning. A number of components can go into these studies depending on how large and extensive these studies can be, to explore, analyze, compare and determine factor structure, factor analysis, data explaining, comparison and internal consistency of questionnaire. These components generally are: Exploratory Factor Analysis to explore factor structure of data, The Kaiser–Meyer-Olkin Analysis and Bartlett’s Test of Sphericity for factor analysis, Eigen Values, Relative Magnitude and Direction of Factor Loadings to explain variance and communality, T-Test and One-Way ANOVA for comparing lifelong learning scores, Student-Newman-Keuls Test for multiple comparisons between different groups, and Cronbach’s α Coefficient for estimating the internal consistency of questionnaire.

Socio-demographic surveys to assess level of doctors’ continuing education.

 19. Suction Modern Procedure PD By Kaye Richey U S Army. 

Some points are taken care of while conducting such socio-demographic study surveys based on Jeffersonian Indices. They are 1. Was doctor participation voluntary? 2. Were written informed consents obtained from participants? 3. Did questions have selectivity? 4. Did data collected maintain anonymity? 5. Were participants assigned numerical codes to maintain anonymity? And 6, Were personal details kept confidential and not made publicly available? If not, it would be unethical. The adaptation of the Jefferson Scale of Physician Lifelong Learning (JSPLL) by several countries, and the findings from studies they conduct on doctors at regular intervals, assesses and adds to the validity and reliability of these indices.

To assess the true facts, or nearly true facts, such studies include the most number of doctors possible, selected from all states and regions of the country, rural and urban regions given due importance, and most advanced parameters and sampling methods used to select doctors qualified from the just graduated level to the post-doctoral and teaching levels. In government service there are the Yearly Self Appraisal Forms to be filled in by every doctor in which they may note their achievements and further qualifications gained during the year though, at least in India, no one in headquarters reads them.


Pre-assured economic security and social security has become a determinant in the success of a medical student’s life, not his perseverance and intelligence.
20. Suction Old Leech Suction Therapy By Bob J Galindo.
When his career starts, a doctor will think it would be smooth and trouble free in the years to come, but no sooner he puts his stethoscope to the first patient’s throat or chest than he learns that there are far numerous obstacles in his career. Security in a doctor’s life and the fact that there is no retirement in this field are what attract a youngster to the medical profession. But soon she and he learns that there are the problems of misdiagnosis and patient death, cut-throat student loans the burden of which will have to be borne through years, the exhaustive rigors of post graduation without which one cannot remain competitive in this field, how and where to start and establish a practice exactly like Dr. A. J. Cronin described the green in his novel The Citadel does, and how to run a family while practicing medicine.

Once in practice or in service another set of problems begins, like target achievement, performance grade reporting, work place discrimination, etc, etc, in addition to the usual set of family problems like children not seeing much of their mummy or dad, the wife coming late from work or the husband drinking too much after work. It is in the midst of all these problems that doctors have to continue their education. Youngsters from Doctor Families and Rich Daddy Families may withstand this pressure but it is hard for those doctors coming from poor families and middle class families to endure these ardors. Anxiety and tension eat into their studies and soon they drop out or even take their own lives rather than taking patients’ as surveys like those conducted by The New York Times pointed out. It is sad to note that pre-assured economic security and social security has become a determinant in the success of a medical student’s life, not his perseverance and intelligence.

Need for glasses, depletion of sodium, tending to children and general tiredness, are all obstacles to continued learning as doctors age.

As doctors age, more and more things will emerge in their life to distract them from continued education. The need for using glasses tends to reduce their time for reading books. Depletion of sodium in their body would cause blurred images and rainbow colours and sparkling particles in peripheral vision to be formed and they will have to keep back from computer monitors for longer and longer periods. Tending to children, sending them to school, sending them away in marriages and tending to grandchildren in time will steal their time for learning altogether. And even if they get time, they will not always find themselves in the right set of mind to become a learner again. Going through the research papers of others which tell about new treatments, new processes and individual clinical experiences, and reading those review notes by yet others which refine them for daily use in the medical field, become boring and tedious in old age, unless they are diligent readers and born learners without health problems. Even if they overcome and manage these obstacles, they may still find it hard to make clinical decisions while applying this new knowledge on patients, especially in the sunset years of their life.

Isn’t it inhuman to ask someone to learn, after he has learned 22 years?

 21. Ambulance Modern Interior By Stiopa. 

Medical training is a long and expensive process. If there is an ever-learning human being in this world, we can call him a doctor. A doctor means a learnèd man anyway. 10 years of schooling, 5 years of university, 5 years of medical university, 2 years of specialization and his education has only begins! It takes 22 years of long and expensive study from school to residency to become a post graduate doctor. In countries like India, this period is cut short by three years as one can go to medical school without the three year basic graduation course if he or she is proficient. To remain competitive in the modern age, a medical student must also have a considerable knowledge in Mathematics, Physics and Computer Science also. Proficiency in English also is a must to remain updated in this profession. In some countries the state bears all this expense and in some other countries the student lands in 20-year debts.

Because there is a particular topic in a re-certification course, someone thinking everyone should study it, is irrational.

Everyone values his life and trusts this valuable life with doctors as he is the god player! So unless he learns till the end of his days, he cannot be answerable to god in taking care of the well being of His subjects. Or he shall not go for this divine profession. Being lazy is taboo in the medical field. The only question applicable here shall be if he continues to learn, not if he has got his new knowledge certified. Any attempt at coercing him to certification in the new knowledge he gains will only be hampering his progress in career and dampening his spirits in life. After spending a quarter of a century going through certifications, forcing further re-certification is inhuman. Many new re-certification programmes do not either focus on the specialty of the doctor. Because there is a particular topic in a re-certification course, someone thinking everyone should study it, is irrational. Forcing doctors to study what they do not need in their practice is wasting their precious time.

Why should doctors bear the expenses of retraining? Isn’t it in society’s interests that they update themselves?

  22. Ambulance Modern Interior By Radim Holis. 

Do doctors have to pay for this additional learning of theirs? It is after spending 60 plus hours per week on work that doctors find time for learning. It is in society’s interest that they learn lifelong and update themselves. But from brochures on doctors’ seminars and orientation courses we learn that exorbitant fees are levied from them for attending these seminars and courses. Doctors’ continuing educational programmes are becoming an industry. How many doctors are there in the world? In the United States alone there are 800,000 doctors and in India there are 940,000 doctors. So how many million doctors would be there in the world? (No one including the World Health Organization has been able to give an exact figure). How will not their training and reeducation become an industry? If it is attending a seminar or course, they have to travel a lot to and fro and would not be compensated for their time. If it is learning online, internet speed in their villages would be too low to manage their limitedly available time profitably.

With split duty time, how will rural doctors learn?

In cities, especially in countries like India, the duty time of doctors is from 8 am to 2 pm, 2 pm to 8 pm or 8 pm to 8 am, with rotational double duty. But in villages, we know, the Out Patient Time is split up from 8 am to 12 am and 2 pm to 4 pm so that workers too can get treatment in the afternoon. Thus, in cities doctors can go home after work and they needn’t return to hospital, liberating a continuous time for learning at home, in library or by attending seminars. But rural doctors who worked from 8 am to 12 am must return to hospital and work from 2 pm to 4 pm. Because of this morning-noon-split in duty time, rural doctors cannot get such continuous leisure time as city doctors to learn which must account for their backwardness in lifelong learning- a fact specifically stated in almost all studies but without mention of this split duty time of course.

Acute shortage of doctors is a hindrance to continuing education.

  23. Ambulance Modern Interior PD By 副局長.

Acute shortage of doctors in hospitals is a problem depriving doctors of opportunities to continue their education. To address their shortage of doctors serving in rural areas, countries like China created 3-year college level medical schools which passed out doctors on an assembly line basis which institutions were gradually replaced by or raised to full fledged 5-year medical colleges. Other countries may follow this example of the Chinese who were also the first in the world to bridge indigenous systems like acupuncture and modern medicine, following the communist ideal of bare-foot doctors. In India when the same concept was tried to be adopted by bridging modern surgery with the indigenous system of Ayurveda, i.e. by opening modern surgery training to Ayurveda doctors, there was earthquake in the medical field.

The shortage of modern medical equipments also prevents doctors from putting into practice what they learn subsequently.

Likewise, the shortage of modern medical equipments also prevents doctors from putting into practice what they learn from continuing education. To augment this shortage of modern equipments in rural institutions, most countries in Asia including China introduced the primary, secondary and tertiary three-tier referral grading system by which they equip hospitals according to their grade so that every modern equipment and facility would be available to all by limiting their availability to graded institutions only, provided patients are willing to travel a little and doctors too. All facilities in all hospitals won’t be needed by all, and providing all equipments to every hospital is a waste of money and loss of man power anyway. The only question remaining is how to train all doctors in using all equipment needed in their specialty.

What countries like China lack in the rural in equipments they have begun to have in training.

  24. Ambulance Old By Carmen Bigliardo, Caterina Pizzi. 

Lifelong learning of rural physicians when compared to urban doctors is an entirely different matter in almost all countries. 5 million health workers look after the health matters of 630 million rural people in China, i.e., nearly half of China’s total population. Like the principles of Acupuncture and Barefoot Doctors they had devised earlier to cater to a large population without resorting to Allopathic Medicine- a model to the world, they have also devised methods for retraining rural health workers in modern medical technology. What China lacks in the rural in equipments they have begun to have in training. Countries in Brazil, Africa, Arabia and Asia also face this backwardness of rural doctors not being able to update themselves in medical technology.


If one sees not light at the end of the tunnel, no one will move forward.

Incentives for doctors’ continued education are good name and promotion only. But unless they continue their education, in the modern world, they will not be able to continue their profession. Ranking and promotions are a stimulant for doctors to continue their education. If there is no light at the end of the tunnel, no one will move forward. Doctors are not adventurers, as a rule. But once they are promoted and posted to better positions they do begin intense learning and begin to master more skills. So, higher posts and career satisfaction are incentives to continued learning in medical profession.

What happens in the health sector in Kerala is noteworthy for other countries in watching out for what to follow and what not to follow in future.

 25. Ambulance Old Stretcher Engraved By P Naumann By Wellcome Trust.

In the craze for ranking there can be absurd rankings too. Take for example the health in Kerala which is acclaimed as the finest in India and comparatively better and cheaper in the world. Naturally, what happens in the health sector in Kerala is therefore noteworthy for other countries in watching out for what to follow and what to avoid in the future. In Kerala Health Services, doctors were once ranked as Assistant Surgeons, Civil Surgeons Grade I, Civil Surgeons Grade II, Deputy Directors, Additional Directors and Directors of Health Services. When they were posted in charge of institutions, they became the Medical Officers-in-Charge of institutions. District Medical Officers and Deputy District Medical Officers were selected from the ranks of Civil Surgeons Grade I. It was a time when private hospitals were very rare in the state. Then there was a boom in the private hospital industry. Retired government doctors and those who quit government service for better employment or better terms began to have great demand in this private sector. There in the private sector the grading was different- for legal as well as billing purposes. There, there were not doctors but only consultants. So ranking of retired government doctors who join private hospitals became a problem. Ambitious doctors in the Kerala Health Services and their supporting partners in the political and bureaucratic structure found a solution to this by renaming government posts as Junior Consultants, Senior Consultants and Chief Consultants in specialties! So now there are no surgeons or physicians or medical officers in Kerala Health Services Department but only consultants, such that they could be absorbed into the private hospital industry with equal ranks when they retire.

If you are disinterested in continuing education and are not a specialist, you can opt for administrative cadre and control all specialists!

The good move in India to liberate doctors from the tedious job of office administration at least in major and district-level hospitals and liberate more time for them to continue their studies culminated in jeopardy. Not only was there utter confusion but the danger from non-specialists who know nothing about the specialty heading specialty institutions also. The ministerial administration of hospitals in Kerala was once run by Office Superintendents. But the Medical Officers-in-Charge then also wanted to be named Superintendents and they thus became Superintendents. So the Office Superintendents were renamed as Lay Secretaries & Treasurers. What ugly minds running health services! Administering hospitals is comfortable while functioning as consulting doctors and learning and upgrading all the while is leaving all this comfort. So, under compulsion from doctors’ organizations and politicians, Kerala introduced a Specialty Cadre which was a joke. If you are not a specialist and do not want to become one, and do not want to look after patients, you can ‘opt’ administrative cadre by simply signing a paper and look after the hospital without looking after the patients, without even gaining any higher qualifications in hospital management and administration. Remember that in the past these administrators were holding charge of their specialty wards and looking after patients also. So now the Superintendents of Mental Hospitals, Maternity Hospitals and Heart Hospitals are not Psychiatrists, Gynecologists or Cardiologists anymore, creating total bedlam, incompetence and misunderstanding in hospitals. As a result the once-famous hospitals are failing. After a specialist doctor has come into the office, made a speech of problems in his specialty in unknown jargon, and left, the Superintendent bends down into the lower drawers of his table, takes out a book of medical glossary, and looks up words the doctor spoke!

Note: The images in this article are only meant to denote how medical equipments and treatments were in the past and how they are now, prompting doctors to keep pace.

(Written during 31 December 2017- 07 January 2018 and first published with edits on 22 January 2020)

Image Courtesy:Wikimedia Commons

Thanks to:

01. Article Title Image By . Graphics: Adobe SP.
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24. Ambulance Old By Carmen Bigliardo, Caterina Pizzi
25. Ambulance Old Stretcher Engraved By P Naumann By Wellcome Trust
26. Author Profile Of P S Remesh Chandran By Sahyadri Archives


Doctors Continuing Education, Lifelong Learning Retraining, Medical Research Seminars Conferences, Space Age Doc, Physician Families, Medical Education Technology, World Chain Hospitals, Student Notes,

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26. Author Profile Of P S Remesh Chandran By Sahyadri Archives.

Editor of Sahyadri Books & Bloom Books, Trivandrum. Author of several books in English and in Malayalam. And also author of Swan: The Intelligent Picture Book. Born and brought up in the beautiful village of Nanniyode in the Sahya Mountain Valley in Trivandrum, in Kerala. Father British Council trained English teacher and Mother University educated. Matriculation with distinction and Pre Degree Studies in Science with National Merit Scholarship. Discontinued Diploma studies in Electronics and entered politics. Unmarried and single.

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Post: P. S. Remesh Chandran, Editor, Sahyadri Books, Trivandrum, Padmalayam, Nanniyode, Pacha Post, Trivandrum- 695562, Kerala State, South India.