P. Ravi Shankar
Oranjestad, Aruba (Winter 2016)
The Medical College sprawls across a rocky hillside at Mulangunnathukavu (a real mouthful of a name) in a village some twelve kilometers from the town of Thrissur in central Kerala. It is a converted tuberculosis sanatorium, its various departments and administrative buildings housed in modified buildings. The kingdom of Cochin in Central Kerala was known for its enlightened rulers who emphasized public health and education. The State of Kerala was formed after Indian independence by joining the kingdoms of Travancore and Cochin and the Malabar region of the Madras presidency. With newly-found zeal, independent India went ahead and demarcated states on the basis of language. Kerala is the land of Malayalam speakers (widely regarded as the only palindromic language in the world), though speakers of other languages also peacefully coexist there.
In the eighties and nineties medical education was traditional, with no computers, mobile phones, smart phones, or webinars. Cable TV was still in the future, and we had only the government television broadcaster. The first eighteen months of MBBS (the undergraduate medical course) were devoted to preclinical sciences. Time-honored traditions were meticulously followed and, as students, we were at the bottom of the pecking order. Our teachers were dedicated and interested in teaching. Anatomy dominated the preclinical curriculum and was taught using didactic lectures, dissections, histology slides, and a few models. Learning about joint and other body movements was challenging and there were no videos or animations to help us understand the different processes taking place in the body. We had a reasonably good anatomy museum but the specimens were static and not of much help in understanding motion. The library was good (for a new medical school), but only had traditional books and some journals. Searching for information was challenging and time-consuming, often requiring one to write down the journal articles on index cards and look them up not online but physically in the library by year, volume, and issue number. Some of our textbooks were easy to read but others were a pain in the neck, especially for us non-native English speakers. I was reminded of George Bernard Shaw’s comment that school textbooks are often written by people who did not know how to write.
We spent much time worrying about examinations, how difficult it was to pass them, and how capricious examiners could be. Dissecting the cadaver during examinations, conducting animal experiments in physiology and pharmacology, and learning proper staining technics in physiology and microbiology were emphasized. They were a source of stress in that doing badly in these activities could lead to failure and having to repeat the course. In pathology the major challenge was to obtain access to microscope slides from that department, and we depended greatly on local resources—our professors, books, the library, and our hospital patients. Today beautiful slides are easily available on the internet. Search engines can take one directly to a large selection of images, library and museum resources available online. Internet speed, band width, and the ability to pay may be the only factors restricting students from access to information.
Watching online videos and participating in online courses enables one to learn from experts from renowned universities and participate in discussion forums with people from all over the world. Students may study at a pace best suited to them, watch videos repeatedly, slowed down or sped up. During most of my education we only had mounted slide transparencies and preparing them was a challenge. Using early versions of PowerPoint we photographed them one at a time using transparency film, mounted them on cardboard or plastic mounts then on cartridges, and then projected them. In my medical college slide projectors were rarely used for routine teaching; their use was restricted to medical conferences. The major teaching aid was the good old blackboard. Diagrams were drawn by hand on the board and overhead transparencies were sometimes used. Today educators realize that constructing a diagram step-by-step in front of students has important advantages as students can visualize the process of creation and the linkages between different structures. The ability to project PowerPoint slides directly without first converting them to transparencies and mounting them has been a powerful advance. LCD projectors have steadily decreased in size and improved in performance during the last fifteen years.
At the beginning of the nineties we had little inkling of how teaching and learning would change during the coming years. Computers were uncommon, laptops rare, smart phones and tablets not yet developed. There were no discussions about the internet or about an information superhighway, and viruses infected humans, not computers. Most of us never imagined that we would be able to capture audio, video, and photos on small hand-held devices and that there would be software available on which we could play recordings and display photographs. The concept of an open university, already common in the west, was still new in India, and students could watch educational television programs at scheduled times but accessing lectures on demand was not yet available. Most recorded lectures were traditional lectures given in front of a camera using traditional teaching-learning resources and modern teaching aids were not used.
My students now approach learning in a different manner. Instead of textbooks or even lectures they use their laptops and tablets to access search engines, online encyclopedias, and PowerPoint slides. Books are increasingly read in their online or e-book version and bedside teaching is often supplanted by standardized patients or simulations. Of even more potential is three-dimensional immersion in a particular scene using special eyewear. This eyewear will get smaller and may eventually disappear according to pundits. Experiments and procedures can be learned in virtual space and traditional laboratories may be reduced. Today we do many experiments and simulations on the computer. In the future these may be done using virtual reality.
In our medical humanities module at Aruba, one of the activities is thinking about the patient-doctor relationship in the future. We make educated guesses based on our present day experience, but as with technology, there are many aspects of medicine and of medical education that we cannot really predict!
P. RAVI SHANKAR, MD, FAIMER Fellow in Health Professions Education, is Professor of Pharmacology and Therapeutics at the Xavier University School of Medicine in Aruba. He is Chair of the Curriculum Committee, Research Committee, and Institutional Review Board, and faculty editor of Xavier Times, the school newsletter. He facilitates a medical humanities module at the institution.