Our Attempt for an Ideal Medical School in Nepal: PAHS Rural Rotations

Inaugurating a brand new medical school in the valley of the capital city would have made a little sense if it sheerly added itself to the list of for-profit colleges and hospitals that had been there since long. This was however far from truth as we were creating a medical school most suited for the needs of Nepal without compromising the technical standard already being provided aiming for greater feat of excellence. Though there are innumerable amazing aspects about the medical school especially adult self-directed lifelong learning, I would focus here on clinical and public health postings all around the nation.

Through Community Based Learning and Education (CBLE), we are constantly exposed to rural community to know the ground reality of the country health problems rather than having a cross sectional image of the health issues in the tertiary level hospital inside capital city. In fact during his or her entire course of being a doctor, a student spends around twenty-five percent of his time in those rural communities ranging from urban slum in the capital city to a place where people live their entire life without going to hospital or visiting a doctor. For many of them medicine is synonymous with cetamol (Paracetamol) and visiting healthcare providers may mean distrust to the local traditional healers. Unfortunately, many medical students in our country are not fortunate enough to have this level of experience, let alone foreign graduates returning and working in the motherland. 

Albert Einstein said: “The measure of intelligence is the ability to change.”This remains one of our main objectives of community based education that we learn to adapt to rural settings and be exposed to ground reality of Nepal. It was vital to make sure that the life in Kathmandu is not the perfect reflection of the county, even more so in the healthcare services and its provision. Studying in a medical school in Kathmandu valley and practicing in tertiary level hospital for decades will not give the slightest idea about the health problems present in the country. The experience is so important as it exposes you to the health issues or problems and challenges including acclimatizing to an entirely different scenario that may not be possible within the urban borders. 

Easier said than done and achieving this level of change in medical curriculum was certainly a big feat. Having said that, change is inherently meant to be challenging and rightfully so otherwise no one will be with shoddy habits and character. It is one of the great boon of Almighty to perfectly adapt in any condition where even native creatures may find it extremely hard to survive. 

CBLE is what makes the students of PAHS (Patan Academy of Health Sciences) well oriented with the ground reality of the community, health system of the nation as well as the challenges and opportunities in the health care areas. The exposure of the students to diverse rural communities helps them to identify and address population related health issues effectively. It also helps to develop clear insights about the nature and magnitude of the community health problem as well as foster an attitude of compassion and desire to contribute towards its resolution in the future. 

Having experienced healthcare system of a developing country without nationwide health insurance where patients’ economic background is one of the strong determinants of health care he or she receives, rural setting exposes you to the much exaggerated version of the same. Sometimes the exposure is in its most brutal sense. It’s very usual for doctors in Nepal to consider cost of the treatment before prescribing it to a patient. This may be manifested in many forms like prescribing generic name with the hope that the pharmacy would provide the cheapest one possible to the patient or aborting the investigation options altogether if that doesn’t change the management any further. These stories of patients and health system in Nepal were greeted with eager anticipation, surprise and shock in most settings when I was with foreign students in Australia which was very unusual in their setting. 

During the course of the posting, students can learn with supervision and in many cases get immediate feedback about many aspects of the learning and modify the same as per the feedback thus getting closer and closer to the deliberate practice according to Swedish Professor Dr. K. Anders Ericsson. However if such activities are not done cautiously under supervision or constant feedback and guidance, they have potential to be deviated to the cozier side of the curve far from education. Nothing inherently wrong with easier alternatives or having fun in life but excellence is seldom a product of mere enjoyment.

We were posted in different level at different times from an urban slum, the FCHV’s home, a sub health post, a health post, a primary health care center to a district hospital for variable durations ranging from one week to five months. In a district hospital or primary health care center with a doctor, the doctor is more than just a doctor. A doctor may need to be an administrator. A doctor might act as a counselor. A doctor can be an ultrasonographer. A doctor might act as a forensic expert. A doctor might have to perform duties of a pediatrician or a surgeon. These are just very few examples. A doctor has to fulfill all the roles that might be needed in the course of his or her work in the periphery. There might be many cases in which the doctor has to work outside his or her general field of expertise and that’s indeed would be the best option in most cases. The doctor also recognizes the limitations of his work and would refer the condition as necessary to the higher center but in the periphery that is very conditional.

A physician or a practitioner must know his strength and limitations. He should know when to refer the patient outside his field of expertise. At the same time, it is equally crucial for the physician to recognize when not to refer and apply his expertise, however minimal it may be if that is the best option based on countless factors including context and circumstances. In reality, people expect much more from a doctor. This is much evident in the periphery as many people do not want to or could not go to a higher center. Medicine does not work on “all or none phenomenon”. Even if the patient is not compliant with our advice, we could at least provide a part of healthcare to which the patient grants his consent. 

In many places a doctor might be the highest qualified person to take a decision in a particular situation. He might have learned some of the things in medical school. He may also have undergone few trainings while on the job. There are some other aspects he had learnt from reading or observation. Whatever may be the case, there would certainly be more demand of the minute details of the wholesome medical persona while working in the district or working alone while there is no one in a position to guide you. If you work all your life in a tertiary hospital focusing only on pediatric cases, you will not be habituated to work on other subspecialties even though people trained equally good as you are doing it so well in the periphery. That would not be an issue in a big center where there are specialists for each and every subspecialties. But while being alone then either you use your knowledge to provide the facility or if you don’t, no one else will in that setting. Such scenario would automatically persuade the provider to use his or her limited knowledge and expand his knowledge base, no matter how mundane he or she considered it at the outset to give what he can. In the course of our learning, sometime back we encountered a patient suffering from prolapsed intervertebral disc who was not ready to go to the higher center at any cost. After prescribing the medications, we called her for a follow up after a week. In due course, we also learned about the disease in more detail and physiotherapy techniques required for its betterment. The next time patient was in OPD, we taught her all the exercises which took over half an hour and asked her to continue to follow the exercise pattern to which she was very compliant. This sort of service would never be expected, desired or nurtured in a tertiary care center. 

Initially one of the main reasons why I loved these community postings was that by seeing the unprivileged, I got to know how privileged I am. I remember a Jewish proverb-“I felt sorry for myself because I had no shoes, until I met a man who had no feet.” The irony of life is we often value things which we wish have had and not be thankful for what we do have. People tend to value things in their life before they gain them or after they lose them. Being among the underprivileged would certainly make you feel privileged. Nonetheless, this is not always the best way to be thankful. Gratitude, in its most potent sense should remain unconditional. Roy T. Bennett rightly stated in his amazing book “The Light in the Heart”- “Be grateful for what you already have while you pursue your goals. If you aren’t grateful for what you already have, what makes you think that you would be happy with more?”That’s not even unconditional in its strictest essence. You can breathe, you certainly can be grateful. If you are alive, you definitely have something to be thankful for. By living in rural settings where struggle for basic needs of Maslow’s hierarchy, our problems and complaints to life seems all irrelevant and worthless. Every single day we make a choice either to go to vicious ending cycle of complaining or to be thankful for what we do have and executing things under our control. This should never encourage complacency for what we have in life but to be thankful for Almighty for all the blessings and work tremendously for the betterment of life. Focusing on things that you could control with your actions is truly an art of liberation.

Stoicism explains this splendidly by urging people to focus on those aspects of their life that they can control and learning to accept what they can’t which is also one of the six pillars of self-esteem as stated by Canadian-American psychotherapist Nathaniel Branden in his book ‘The Six Pillars of Self Esteem’ . In regard to stoicism in his books ‘Enchiridion of Epictetus’, the stoic philosopher author states regarding dichotomy of control- “Some things are within our power, while others are not. Within our power are opinion, motivation, desire, aversion, and, in a word, whatever is of our own doing; not within our  power are our body, our property, reputation, office, and, in a word, whatever is not of our own doing.” Not giving a damn about what you cannot control is hard. Much harder because once you have done that, you clearly know things you could control with your actions.

The next thing I learnt repeatedly during the posting was that work is a sacred blessing and we do not necessarily need materialistic things to be happy in life. That’s valid on realism in many settings as much as in idealism. The kids in the village were so happy and contained. Most of us remember our childhood full of video games and gadgets but the children there had their own world of happiness and bliss. Just a few minutes of talk will be enough to bring precious smiles to their faces and obviously ours as well.

To be able to be a part of institute in Nepal with such a noble mission without any constraints of learning and opportunity made my resolution to serve the humanity and making the world a better place to live than it would have been in our absence even more powerful. Steve Jobs said- “Do what you love”. The reverse is just as true- “Love what you do.” I am sure that my experience and understanding will be perfectly reflected in the form of love to my profession, compassion, empathy, kindness and more importantly in relentless pursuit to my work ethic in the future. 

Finally I would like to thank all members of Patan Academy of Health Sciences (PAHS) for designing and implementing such an innovative curriculum which not only produces technically competent doctors but also teaches the medical professionals the art of compassion, tolerance and responsibility. 

Article by

Anish Dhakal (Aryan)
Patan Academy of Health Sciences (PAHS)
MBBS Final Year

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