The training of a doctor is long and challenging. Over a six to seven year period, if you include the premed year at the beginning and internship at the end, there are huge amounts of facts to be absorbed, skills to learn and techniques to master. It is a time during which new knowledge, new contacts, new challenges and fears absorb, mould and change us. It is a time when lifelong learning skills are developed, attitudes to our profession and our colleagues are formed, and most importantly, we learn something of what our patients really want or need from us. We develop a mutual partnership of respect, concern and care.
In this month's edition of MMJ Wendland and Bandawe demonstrate how Malawian medical students enter medical school with preconceived ideas as to what it is be a doctor. They come to medical school with the wish to help people and to improve conditions in Malawi, but during the 5 or 6 years of training their idealism and visions are bruised. Wendland and Bandawe found that despite this the students and young doctors remain committed to the patients they care for, concerned and angry on their behalf for society's failure to respond to their needs, and desirous to ‘uplift Malawi’ and especially her poorest and most needy citizens. Students in the early years of their training gained confidence in themselves as they acquired knowledge, and even thought themselves superior to other clinical trainees. But in the later, clinical years of their training some students and interns became disillusioned with certain aspects of medicine. They became angry with the lack of political support for the health services and overwhelmed by the workload and lack of support in trying to deal with large numbers of very sick people.
It would have been interesting to separate the views of the interns from those of the medical students. The challenges of the intern years, when a young doctor is taking clinical responsibility and making decisions, are very different from those of students. Though the interns' attitudes greatly influence those of students who watch them at the start of their working lives.
Wendland and Bandawe take heart from the fact that unlike many of the medical students from North America - who become cynical, critical of patients and afraid to criticize their profession and senior colleagues -Malawian students remain concerned for their patients, critical of their profession and judge a good doctor to be one who shows ‘heart’ and ‘love’ for his patients.
I too am full of admiration for young doctors who retain the vision of what it is to be a good doctor and want to challenge the system and the profession to improve the lot of the sick and the poor. But these reports are also disturbing. Why do our young doctors feel so unsupported? Why do they have to deal with workloads and decision making that are overwhelming, potentially dangerous and damaging to them? Are they right to say that the health service disregards the poor?
And most importantly what can we do to rectify this and what can we do as a profession to advocate for the sick and poor in the country? Are we all the advocates for health service improvements that our students feel we should be? Are we collectively (perhaps through the Medical Association of Malawi) and individually willing to challenge the system and question the lack of facilities, drugs and overcrowding? Are we as concerned for the welfare of our nursing and clinical officer colleagues as we are for ourselves?
Role models are important. My student days were four decades ago and I remember the people who taught me rather than the facts they fed me. Why did we go into medicine? Was it not for the same reason that our young colleagues are going into medicine? Where do we get most satisfaction in our working lives? We enjoy and get enormous satisfaction from clinical care, and from the teams with whom we work. Wendland and Bandawe state that students have an almost religious approach to their entry into medicine. They are expressing their belief in medicine as a vocation; a belief many of us share.
And on a practical note, can we reduce the workload of interns? It is hoped that the increasingly number of medical students will lead to less onerous ‘on-calls’ as they are shared by more young doctors. Praise for a tired colleague, listening to student's concerns and simply being there when moral support is required can ease the sense of isolation.
Young doctors need to be able to see a career path ahead of them. They need to be assured that they will receive a salary that relieves them of anxieties about such basic necessitoes as housing, travel and schooling for their children. Wendland and Bandawe have shown that our trainee doctors want to serve Malawi and that they are committed to improve the health services. It is vital that their enthusiasm and energy be used in the betterment of Malawi's health services and it is a huge loss to Malawi if they leave to work where they consider the career opportunities and financial rewards to be better.
Medicine is a hard profession - trying to get alongside our patients and help them through sickness, anxiety, loss and grief - and having to admit on many an occasion that the cure we would so like to be able to give is not possible. It is physically demanding and in the intern year frankly exhausting. But if we are honest, none of us wants to do anything else. The deep delight of making a little child better or delivering a mother of a perfect baby; the satisfaction of an operation well done, pain removed or broken bones reset; the quiet contentment in knowing everything you could have done has been done and now nature must take its course.
Let us as a profession look after the future doctors of this country. And young and old alike let us demonstrate to our patients and to each other what the students have called ‘a heart’ for people, which means a heart for our patients and a heart for each other.