The Junior Physician

Akash thought, he did marginally well in his final MBBS Medicine theory papers. However, on-campus everyone including seniors discussed that these written papers were valueless for the final result. It is the clinical and oral that decided the fate of a student. Usually, there was no discussion of grades. Almost all students, including those presumed as good, wanted only to pass the examination. And again in the clinical and oral examination it was the long case that decided the result. No one was going to be failed if he or she did well in the long case.

So, all the students focused on the usual long cases from diseases of cardiovascular system or respiratory system or central nervous system. Other diseases came as short cases. Students made a rush to the wards in the evening to know all the cases in the examination week. It hardly mattered if one had prior knowledge about a case or not. The number of cases was so high that one couldn't cover all. Many new patients were added over the night. And the examiners always wanted to know the real clinical ability of the student. And they fixed new cases.

Akash now remembered his chief examiner P1 Professor Ajaya panda, popularly known as AAP. The extra A had a reason, there were two more Ajaya Pandas as professors in other departments. One of them was habituated to beetle and was popular as BAP. The Other one was a Cinema artist and was known as CAP. Why then AAP? Yes, he was very strict and usually became angry seeing indiscipline. So he was Angry Ajaya Panda, in short AAP.

Students feared to come to his wards for clinical duties. Many skipped but some did not. Akash belonged to the latter group. He was very casual to teachers' strictness. He had tiger-like teachers in his childhood days who caned him to bruises. In the past three years, to his good or bad luck, he worked five out of his assigned six months in AAP's ward. He never thought this would be a boon in coming days.

There was a practical or spotting examination too. Students had to comment on specimens, X-ray plates, ECG strips. On those days there was not much sonography. Computerized axial tomography (CAT/CT) had arrived in the city, camped in a hotel rather than in a diagnostic center or clinical establishment. Magnetic Resonance Imaging was not heard of. So they did not complicate the spotting examination. Like the village deities come out of the temple during the Holi festival week once in a year, these specimens came out just before examination. Students saw them in the previous week and fetched full scores on them. Akash could not remember the reason for which he did not attend that important class. There was no cellphone to be called by a friend. His friend Surajit usually called him for these sundry events but he did not on this occasion. He only did one out of five spottings correct losing forty valuable marks. He was lucky that practical and oral marks were added and he narrowly escaped. 

But on that day nothing bothered him and his friends except the long case.

He got an unconscious middle-aged fatty patient. He collected the history from the attendant, made the record fine to the best of his ability. That bed was at the most extreme corner.

His friends and a few earlier failed seniors were assigned their cases on either side of the ward. After some time Prof AAP came into the ward with the external examiner Prof Kapil Das. He was a student of Prof AAP. He came from a central government famous institution. In the center of the ward, they started with an oral examination. Akaash had finished his long case and could observe the proceeding.

AAP started. - You handsome hero Debababu, our campus Debananda, tell us, what is your problem, why should a guy like you appear for the sixth time to pass? I see you several times in the Yamaha canteen in a happy mood. What is your problem? Be sure whatever you answer you will pass this time.

Debavai, looked relaxed and answered. - Sir, I wanted to be a model, my parents wanted me to be a doctor. I went to Bombay several times. I am the only student here who had done a golden handshake with none other than Hemamalini. 

But I couldn't succeed. Like one's study required family support, any other option requires family support. My father is supporting a repeatedly failed son with his whole heart but he never allowed me to succeed in my chosen field. I am depressed. I am under anti-depressants. I am also prescribed psychotropic drugs.

- OK, then tell us what drugs you are taking?

- A, B, and C.

- Tell us the beneficial effects, efficacy, and side effects of each of these ABC.

Akash never heard the name of these drugs but Debavai answered in detail. He had probably done research on these drugs. He went on until the examiners happily changed the topic. He identified the instruments he was shown correctly. He also could answer their utilities. He was not the same Debavai. An assurance has worked effectively. But AAP also taunted him at the end of the examination.

- See Deba, I am allowing you to exit this campus with a request. Never treat serious patients. Refer them or else it would be a sin of the examiners who made you pass. 

Debavai's face lost its glow so did the face of Akash.

Like Akash, most of the students finished the assessment of their respective long cases. AAP sir and Prof Kapil now came to the bedside of the patients. The first student was Miss Sabnam Haldar the elder sister of Akash' friend Rafiq Haldar.  Rafiq too was in the ward with his case just by the side of Akash.

Sabnam's case was one from the respiratory system, a middle-aged lady. Sabnam was appearing for the second time. She looked confident. AAP sir immediately attacked her, - You young lady, how it will feel if I examine you in a male ward in this manner without a screen? Will you like it? Wanna was trembling so did her answers to sir.

Female cases were brought to the male ward for the purpose of examination. Those who were in charge of this arrangement did not arrange the screen. They did not feel the discomfort of a woman to be examined with a bare chest. An undergraduate student focused on her examination, sadly, had nothing to do with the issue. Any student including Akash would have done the same mistake in that situation just thinking it to be the convention on final examination day. Rafiq and Akash looked at each other with alarmingly saddened faces. They could not look at the face of Sabnam didi.

Next to Sabnam stood Nalini Hota. She had a case of the cerebrovascular system. She was supposed to examine not only the heart but also the respiratory system. She must have done that. She wrote NAD against the respiratory system meaning No Abnormality Detected. She was not supposed to abbreviate. Rather she should have described the normal findings. - You got NAD madam? Give me your stethoscope, let me listen. My stethoscope being of better quality may give different results.

Nalini obliged. 

- Listen here at this place. 

  Keeping the chest piece attached to the chest, sir gave the ear piece to Nalini.

- What do you hear?

- Crepitations sir.

- What do you hear at this place?

- Crepitations sir.

- Here?

- Crepitations sir.

- So these are not corporations but NADs madam. There are a lot of NADs. 

No other question was asked to her and she just was in tears.

Now came Rafiq's turn. He had a case of Gulen berry syndrome. His adrenaline brought back him to examination mode. Brilliant Rafiq answered brilliantly. Prof Kapil asked him many questions. AAP just enjoyed the answer of his student.

Now it was the turn of Akash. AAP sir passed an encouraging remark. - He is sincere to the clinical duties. His confidence increased.

The external examiner asked.

- What is your case?

- Sir, a case of a Cerebrovascular accident with left side hemiplegia with hypertension, in a coma.

- Suppose he is not unconscious then what do you think about his speech?

- Sir, left hemiplegia means, the lesion is on right side. The speech area or the Broca's area is on the left side. So speech should be intact.

- The lesion is on one side of the brain and the paralysis is on the other side, what is this?

- Crossed hemiplegia. 

- What are the causes of the accident?

- Three types sir, maybe due to thrombosis or rupture of the vessel or due to embolism.

- Which vessel?

- Sir, mostly lenticulostriate branch of the middle cerebral artery.

- What is your case?

- Maybe hemorrhagic sir.

- Why?

- Hemorrhage usually occurs in hypertensive patient. He is hypertensive. In hemorrhage, the patient is mostly unconscious. He is unconscious.

- Why you are excluding embolism.

- Sir in case of embolism we usually should have a source of embolism. Usually, the source is the heart. But his heart has no abnormality except his hypertension.

- OK, then how we can confirm hemorrhage?

- By CAT scan sir.

- Is it done. No sir. The facility is not available now.

- If you do a Cerebrospinal tap can you not confirm.

- Sir yes the CSF will be hemorrhagic but we do not do this? 

- Why?

Akash preferred not to give a direct answer but momentarily thought how can he make the patient sit for the procedure. He knew that is not indicated but did not venture to travel further.

- OK, then say what is your treatment.

- Antihypertensive, Manitol, fluid, catheterization, supportive cares to avoid bedsores.

- What is your prognosis?

- Not good.

- You mean he will not survive?

- He may survive by God's grace sir. 

Akash could not be harsh. But he thought, yes, probably this patient's purpose in the medical college was to be his long case and his days are numbered. His saying that the prognosis is good is not going to help the patient. He may fail in the exam for the wrong answer.

Somehow, Akash thought he must pass.

The result came out. Some of his friends all of whom were brilliant couldn't go through. Sabnam couldn't pass the examination for the second time but her younger brother passed in his first attempt. Nalini too became a victim of the silly NADs. Debavai passed.

Students reacted but only in whispers. AAP was a tiger.

Later on Akash, the young junior physician got an opportunity to know the philosophical angle of patient care.

He and his friend Santosh were traveling from Balasore to Ayodha in the bus named Swarnachud. The bus travelled through Mitrapur, Nilagiri and Sajanagarh. This was roughly after three months of his examination. He shared a three-seater with two gentlemen. One was very talkative but his voice had a tinge of difficulty. He was saying about his illness. How he escaped death after remaining unconscious for thirteen days. 

Smash looked at his face. How can he forget his long case only after three months? 

-Sir are you an advocate at Udala, in Mayurbhanj?

- Yes.

- I think you are Gokulananda Pattanaik.

- Right.

- You were treated at Raman Medical college from the fifth of September onwards.

- Yes. But how could you know?

- I was a student there and in fact, I passed the subject of Medicine by examining you.

His face glowed, his eyes turned moist, his voice got choked. He wanted to touch the feet of the young physician who was of his son's age. An advocate, he knew that there was no credit of Akash in his survival. But he just was emotional to show his gratitude to the doctor's community.

- Doctors are second Gods.

Akash felt guilty. The man for whom he passed the examination by saying that most probably he was not going to survive is sitting next to him and unduly praising him and of course duly to his community. 

He could read his road ahead. He thought why should not a doctor lose his hope. For him, the concept of euthanasia traveled far away. He became more thoughtful than his wrong answer fetched him a pass mark where as Sabnam didi failed without her fault and probably the brilliant Nalini should have been asked more. She should have been given the chance. He thought this pass and fail should not be there. He thought it was the mistake of the system that takes the best but is unable to being good mentor. He remembered his Biochemistry teachers. In one teachers class the attendance remained hundred percent all through but in another teacher's class the attendance remained fifty percent. Those fifty percent also remained inattentive. So whose fault was that. Had the Biochemistry department any right to work at fifty percent efficiency. 

Again Akash remembered his mother's words. Where there is no fear there is no victory. 

In later days, he just accepted the system as it was. Within that system he groomed himself to be a teacher, to be a cardiothoracic surgeon. Roles reversed. However, the young physician is still alive in him. And he now at his late age understood that pass and fail were meaningless in long runs. It was the attitude that carried everyone forward.