Dr Kruthika S had known exhaustion, but this was a different kind of fatigue. She started Covid duty at All India Institute of Medical Sciences, Delhi, in April 2020, and continued till May 2021, devoting as many as three weeks every month to it at the peak of the pandemic. Each shift was six hours long, but including the time it took to wear and take off her personal protective equipment – a suit that covered her from head to toe – it would usually stretch to seven or eight hours. She would work with a team of four or five others, tending to wards of usually between 10 and 15 patients.
Any time she caught a break, she would scan the ward for a chair, trudge towards it and sit. Then she would count her laboured breaths, one, two, three. Sweat would trickle down her body inside her PPE suit. Within minutes, she would be summoned by a colleague to place a central line or intubate a patient, rush someone to surgery or admit a new patient.
She couldn’t eat or drink during her shifts, because she couldn’t take off the PPE suit. If she was menstruating, she would pop a painkiller before her shift started, but she had no way of visiting the restroom. It was only at the end of the shift that she would remove her suit, and, drained of energy, gulp down some water or eat something. She would then take the shuttle bus to her hostel, whose starkness brought back flashes of the ward, and of the painful experience of watching people of her own age dying. She would worry about her family too, scared that the phone would ring and that it would be bad news.
But it wasn’t just the shifts that left her distressed. Another anxiety loomed over her in the hours that she spent outside the Covid ward. “It was the same worry I woke up with every morning,” she said. “When I graduate from here, will I be the doctor I came here to be? Will I be competent?”
Kruthika is pursuing a Masters in Surgery at AIIMS. The 25-year-old from Chitradurga, Karnataka, joined the program in January 2020. “The mind, hands and eyes working together in a symphony, the challenge of having to think fast and smart, and the beauty of several minds working together inside the operation theatre. That is what attracted me to surgery,” she said.
She came fully mentally prepared to tackle all the challenges that the demanding three-year course would throw at her. It was normal for postgraduate medical students, known as resident doctors, to spend endless hours in the hospital, overworked and sleepless.
What she wasn’t prepared for was the complete disruption of her education by the Covid pandemic. Postgraduate students typically undergo most of their training within hospitals, save a few lectures and classes. Under the supervision and guidance of senior doctors, they treat patients, execute basic medical procedures and even do minor surgeries. But during the first and second wave, several hospitals, including teaching hospitals, were turned into Covid-only centres. Most postgraduate students were immediately thrown to the frontlines. They were allocated Covid duty, irrespective of the year they were in or their chosen specialisation.
Under normal circumstances, Kruthika would have been either assisting on or observing between 30 and 35 surgeries a week. Now in a span of 18 months, between January 2020 and June 2021, she had attended just a little more than 30. The number also dropped because fewer students could gather round and observe each surgery – a crucial mode of learning. “Pre-Covid, students would crowd around and watch. Now only a limited number of us can be together in a room due to social distancing norms,” she said.
At the end of each day, Kruthika’s time in her hostel room always left her feeling distressed because she had no surgeries to prepare for. “I did not have anything to do after my shift,” she said. “I didn’t have an agenda or a plan. If things had been normal, I would have gone back home and read up on the surgery I assisted on that day, or I would have prepared for the surgery I would have the next day.” With the threat of the third wave looming ahead, Kruthika is petrified that she will lose two years of her three-year course to the virus.
The lack of opportunities to treat non-Covid patients has drastically affected students’ learning and training across different levels of medical education. “Academics ki waat lag gayi”– academics got screwed, as Dr Sanjay Sasane from Grant Government Medical College and JJ Group of Hospitals, Mumbai, who just completed his second year, put it. “The first wave started in my first year, now the second wave is ending, and if there is a third wave, my third year will be ruined too,” he said.
A survey of 1,000 students in undergraduate medical colleges across the country found that almost two-thirds felt anxious and uncertain about their careers and futures because of the pandemic. These students were also twice as likely to exhibit anxiety, social dysfunction and depression. When asked in the questionnaire if the pandemic made them feel uneasy or uncertain about their medical school careers, 338 out of the 1,000 students answered “yes” and 264 answered “somewhat”.
Some postgraduate students have protested and boycotted work because of the disruption that Covid has caused to their studies. In December 2020, students in Karnataka staged a symbolic sit-in to draw attention to the fact that their surgical training was being neglected because of the pandemic. In March 2021, 700 postgraduate students boycotted work at Bangalore Medical College and Research Institute, demanding that non-Covid beds be retained and not be converted to Covid beds. The students were angry that although a year had passed since the beginning of the pandemic, the government had not made alternate arrangements for non-Covid patients, and was insisting on shutting the door to them.
“Even if you keep Virat Kohli away for a year or two from a cricket field, and then ask him to face West Indies fast bowlers, he’s not going to be able to do it,” said Dr SP Kalantri, Director Professor of Medicine at the Mahatma Gandhi Institute of Medical Sciences in Maharashtra’s Wardha district. “The process of both teaching and learning is a joyous experience. At the end of the day students feel happy that they learnt how to treat pneumonia, figure out heart failure or a stroke, or fix an ailing kidney or help to deliver a baby. Now all those cases are on the back burner.”
Sri Venkateshwara Ramnarain Ruia Government General Hospital, a tertiary care centre in Tirupati, Andhra Pradesh that was converted to a Covid centre, offers an instructive example of the impact of Covid on surgical training. A study released in May 2021 compared a four-month period in the hospital between April and July 2019, and a six-month period between April and September 2020. It found that in the 2019 period, the outpatient department had treated 19,983 patients, while in the 2020 period, it treated only 4,481 patients. Similarly, 4,274 patients were admitted in the same period in 2019, but only 506 in the the same period in 2020. Elective and emergency surgeries took a huge hit – while 1,102 elective surgeries were conducted in the 2019 months, there was a complete cessation of elective surgeries in the 2020 months.
“The decrease in emergency surgeries from 694 in 2019 to 220 in 2020 signified how the pandemic had led human life to a standstill,” the study noted. Another survey, conducted in 2020 among neurosurgical residents from across India, to assess the impact of the pandemic on their training, revealed that the number of surgeries that residents performed or assisted in each month dropped from an average of 39.86 before the pandemic to 12.31, a decrease of 69.1%.
Kruthika’s senior at AIIMS, Dr Ratan Naskar, joined the institute in January 2021, exactly a year after Kruthika, to train for a Master of Chirurgiae, an advanced postgraduate degree in surgery. He had prepared for six months to secure admission to the course, and was to specialise in minimal access surgery – specifically, laparoscopic and robotic surgery. “It’s an emerging field with so much promise and I was excited about learning something that is so new in medicine,” he said. “There is less risk, less blood, less pain, post-operative care is shorter and smoother, and there are fewer chances of mistakes because of the 3D view. More lives can be saved.”
Naskar did not qualify for the course in his first attempt. He was working as a senior resident at Nil Ratan Sircar Medical College in Kolkata when he started preparing for his second attempt. After spending between 12 and 14 hours each day studying, the 32-year-old was overjoyed when he qualified. When he joined, he knew that since the pandemic had not passed completely he would have fewer cases to work on. Sure enough, where ordinarily he would have observed at least 30 cases a week, he could only observe around 12 a week during the second wave.
When Naskar was given Covid duty earlier this year, he was overcome with stress and frustration. “The thing was that I wasn’t learning anything,” he said. “It wasn’t what I came here for. I was supposed to be spending that time learning laparoscopy, not sitting in a ward where I was feeling helpless. It became mentally very overwhelming for me.”
Dr Yogesh Jain, a public health physician with Sangwari, a not-for-profit healthcare organisation that works in Surguja, Chattisgarh, described postgraduate students like Naskar as “the biggest casualty” in terms of their training. “For almost all postgraduate courses, the training is mostly hands-on. I cannot imagine a surgeon who is in training, who hasn’t been to an operation theatre in two of their three years of training. Or a surgeon who hasn’t looked after preoperative and postoperative patients.”
After Covid cases dipped in July, Naskar saw a marginal increase in the number of cases he observed – but not to more than 15 a week, still inadequate for his training. For Naskar, wearing a PPE suit was also an obstacle when it came to performing or learning a surgery properly. “The heat inside the equipment and the limited movement makes it difficult to concentrate properly and learn,” he said. Surgery can only be learnt with practice, he explained. “The more surgeries we experience, the more confident we become of our skills. Learning and improving these skills bring so much joy. Not being able to do that left me extremely frustrated and depressed.”
For Kruthika too, anxiety about her academics took a toll on her mental health. “It was worse for me because it was also a new city,” she said. “There were cultural and language barriers.” She couldn’t easily meet new people, and missed her family back home in Karnataka. “My family wouldn’t tell me everything that was going on in Karnataka and I didn’t know exactly how bad things were,” she said. “All this would make me feel very negative.”
Kruthika has visited Chitradurga only once since she moved to Delhi and only stayed for three days. “I was scared that I would carry Covid home and infect my parents,” she said. Kruthika herself caught the virus during the second wave but because her parents were deeply worried about her, she chose not to tell them about it. “Only a couple of days before I got discharged, I informed them. Before that, I had only mentioned it to my brother,” she said.
Postgraduate students in fields other than surgery were also severely affected by the pandemic.
A 2020 study on the impact of Covid-19 on postgraduate orthopaedic training in Delhi-NCR found that before the pandemic, around 57% of students would attend classes twice or thrice a week. During the pandemic, this plummeted to 9.4%. Meanwhile, nearly two-thirds of students said they had zero classes, and almost a quarter said they had classes once a week.
The study also found that nine out of ten students felt that overall the pandemic had decreased their clinical and surgical training, with eight out of ten pointing out that even basic skills in various common orthopaedic procedures, such as cast application, skin and skeletal traction application, local and intra articular injections, wound care and dressings, had been severely affected. The dissertation work of 72% of students had remained incomplete for various reasons, including that patients in their studies had not returned to the hospital.
Similar results were found in another 2020 study on the impact of the pandemic on the teaching and training of postgraduate anesthesiology students in India. About 72.6% of students were of the opinion that the learning of technical skills like airway management, vascular access, and regional techniques had been affected due to the pandemic. Of the participants in the survey, more than half complained of a steep depreciation in the quality and quantity of academic activities, and nearly three-fourths said there had been major changes in or cessation of clinical rotations.
Kalantri feels that the pandemic will result in doctors graduating with “half-baked” knowledge, but added that there might be other, equally serious problems to consider. “We’re going to have a batch of graduating doctors who are very frustrated,” he said. “They are going to be wondering what is going to become of them, if they are becoming competent doctors and how this is going to shape them professionally. When they are spending all their time drawing blood, monitoring Covid patients and ordering tests, their life gets monotonous.”
Though the MBBS course doesn’t involve as much clinical work as postgraduate courses, undergraduate students, too, suffered major disruptions to their training, much of which moved online. Postgraduate students themselves told me that they sympathised with their juniors for this.
Before Covid, Lakhan Prakash Gupta, part of the 2017 MBBS batch from Jawaharlal Nehru Medical College, Aligarh Muslim University, would start his days at 8 am sharp. He would have his first lecture at 8 am, and then three more hours of class in the latter part of the day. But from 9 am to 12 pm, Lakhan would have clinical duty – the best part of the day. His class of 150 students would be divided into batches of 30 or 35 and allotted different medical departments. Each batch was expected to get clinical experience in their respective department for two or three months. At the end of this period, the batch would have a clinical test based on their work in the department and then be rotated to another department.
Each day, the students would do rounds, during which they would be allotted a bed and asked to do patient work-ups. They would have to ask the patient’s history, learn about their symptoms, and watch as their teacher interacted with the patient and explained the diagnosis. Then, in the evenings, the postgraduate students would meet up with the MBBS class. “We would clarify any doubts we may have had during the clinical rounds and our seniors would take the time to explain everything to us,” he said.
Even after the lockdown, Lakhan would get to his classes at 8 am, just via his phone or laptop screen – making for a far inferior learning experience. “If someone came in with a tumour, we would study the size, colour, shape and feel,” he said. “Now the teachers explain the symptoms to us but without seeing it with our own eyes, learning becomes very challenging.” This is besides the internet troubles and other technical difficulties that the students face during online classes. Learning online also meant that Lakhan couldn’t go to the campus library, where he normally accessed books that would otherwise be too expensive and not easy to find online.
A survey conducted among undergraduate medical students from 30 medical colleges in Kerala and Tamil Nadu in 2020 showed that 78.4% of the participants disliked online classes. The students cited several reasons for their dislike: 85.8% of students cited network problems, while 61.1% cited the lack of interaction during the classes, and 48.3% said they experienced visual fatigue after attending online classes. Only about 9.5% said that they did not face any issues while attending online classes.
Dr Anuradha Ananthamurthy, Vice Dean of MBBS and Professor of Pathology at St John’s Medical College, Bengaluru, said that online teaching was suitable for pre-clinical and para-clinical subjects, since concepts can be taught online, but that clinical training had to be imparted with patients for it to be most effective. “The final year students really found it difficult during the final exam this time because they missed out on their training last year,” she said. “We had an intense marathon clinical training for three months.”
MBBS students gained some clinical experience after Prime Minister Narendra Modi announced that fourth-year students and interns, who are in their fifth year, could be roped in for Covid duties – the former could provide teleconsultations and monitor mild cases, while the latter were allowed to work in Covid management. “Covid experience for students has been good,” Ananthamurthy said. “They have been witness to a lifetime occurrence of a pandemic, being in the thick of things, and contributing to patient care.” But, she added, they “may have lost out on other clinical skills.”
The prime minister also announced that those who had completed 100 days of Covid duty would be given priority when they applied for government posts. Some states like Karnataka followed up by promising final year nursing and medical students who had done Covid duty grace marks in exams and financial incentives if they had rendered service during the pandemic. But the former measure was criticised both by those who felt that students were being underpaid, and the latter by those who felt that they hadn’t gained the range of experience they should have as part of their qualification.
In other states too, medical students boycotted work or sat in protest to demand hikes in stipends. In May 2021, 850 MBBS interns in Bihar threatened to strike if their demands over their stipend weren’t met. In July 2021, 134 MBBS interns from Doon Medical College, Uttarakhand, organised a rally to protest low stipends of Rs 7,500 per month, or barely Rs 250 a day.
States have recently resumed offline classes for medical students. Despite the turbulence of the past two years, Ananthamurthy believes that the break in regular classes for MBBS students will not have any long term impacts. “With medicine, learning is life-long and so even if students don’t feel so confident right now, it will change in the future,” she said. “As they gain more experience, they will develop confidence and figure out by themselves how to do the job better.”
Dr Jacob John, professor at CMC Vellore’s Department of Community Health, concurred with this view. “Will the cohort of medical graduates be under-equipped?” he said. “Definitely. However, we don’t learn everything in medical school, we learn on the job. So eventually everything will fall into place.”
He suggested that students would benefit if the training period was now extended by a few months but pointed out that this would only be possible if the entire healthcare system came together to invest in such a plan. “Both the government and the administration should have the appetite to prolong the training time,” he said. “Very often the system does not work that way, it is geared towards ‘getting the job done’, not towards training students. When the pandemic dies down, there will still be dengue, typhoid, tuberculosis and diabetes. Question is, are we willing to train the students?”
Dr V Seenu, Head of Surgery at AIIMS Delhi said that though the derogatory term “Covid batch” had begun to be used for students who trained during the pandemic, and though they would need to make up for their disrupted training, their professional prospects were unlikely to be affected. He suggested that simulations could be an alternative to clinical training for the time being, though he cautioned that extending the course for an already exhausted batch of students might not be a good idea.
Seenu predicted that there was a bigger problem looming ahead than incomplete training – specifically, he suggested that the volume of death that medical students have witnessed, especially in the second wave, will have a life-long impact on them.
India recorded 6,148 deaths in a single day in June, the highest in the second wave. What particularly affected Rahul Kumar, an MBBS student from AIIMS Delhi, who is interning at the National Cancer Institute in Jhajjar, Haryana, was how quickly patients would deteriorate. “I would be speaking to their family via video call, giving them the prognosis, the next step of treatment, and suddenly the following day I would be calling them with bad news,” he said. Doctors are encouraged to stay empathetic yet detached from their patients, but it is a difficult balance to strike, he explained. “You still end up overhearing their conversations with their relatives, engaging with them and getting involved with their lives,” he said.
Interns are trained on how to break bad news to the relatives of patients, but the frequency with which the students had to undergo the process exhausted them. Rithika Induloshini, an MBBS student and intern from Mahatma Gandhi Government Hospital, Trichy, Tamil Nadu, said that she would dread the moment when, after she confirmed the death of a patient with senior doctors, she would have to walk towards the family to inform them. But what distressed her even more was when patients without beds would beg her for help, saying, “Yedhuna pannunga” – do something.
The distress affected even those who tele-consulted with patients. Sathish M, a final year MBBS student from Thiruvarur Government Medical College, who volunteered to participate in teleconsultations in the war rooms in Chennai, said that both he and his roommates had nightmares that phones were ringing around them and that they had to get help for the patients.
When cases began to emerge of a rare fungal disease called mucormycosis, commonly known as black fungus, Induloshini’s hospital would get about 20 vials of Amphotericin-B a day for treating patients – but each patient needed four vials. “All the patients would be eagerly looking, hoping that it would go to them but we had to choose the patient in the worst condition,” she said. “The disappointment in their faces was heartbreaking.”
It wasn’t only the deaths they witnessed in the hospitals – many young doctors also lost family members, and many others lost their seniors, mentors and teachers. According to the Indian Medical Association, as of June 2021, over 700 doctors had died in the second wave of Covid-19 in India.
Two of them were teachers of Hazique Jameel, an MBBS student from Jawaharlal Nehru Medical College, AMU. Just seven days before they were admitted to the hospital, Jameel’s head of department and another senior professor had face-to-face vivas with his class for their final semester. Fifteen days after they were admitted, both the professors died. “Our entire batch was completely shocked,” Jameel said. “Everything was absolutely normal, we did our vivas with them and then suddenly, just in a few days, they were no more.”
Dealing with loss at this scale has had an unavoidable impact on students. Several studies have shown that depression, anxiety and stress are widespread among the medical student communities in India. A study conducted in Kerala among MBBS students found more than half felt depressed, a third experienced anxiety, and more than a quarter were stressed. The prevalence of depression was highest, at 58.4%, among first-year medical students.
Jameel credits his seniors and colleagues for giving him the advice he needed to cope with the deaths he was dealing with. Kruthika also repeatedly mentioned that she was thankful to her seniors for giving her support and steering her away from “negative” thoughts. “But I know many seniors are on antidepressants and anxiety medication,” Jameel said.
Dr Seenu of AIIMS Delhi said that at his hospital, teachers were constantly on the lookout for students who seemed to be slipping into depression. “As a teacher and Head of Surgery, I can’t tell students I’m helpless,” he said. “Whatever we have we should make do with. But continuing to maintain the morale of the residents is a lot more important right now. They’ve been exposed to a situation that is beyond anyone’s control.”
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