Edited by- Dr. Preeyati & Dr. Praneet

About Dr. Sharad

Dr Sharad Philip is clinical and teaching faculty at the All India Institute of Medical Sciences, Guwahati’s Department of Psychiatry, Clinic Neurosciences and Addiction Medicine. He is a qualified psychiatrist from NIMHANS, Bangalore and completed his PGDFM (Post-Graduate Diploma in Family Medicine) from Christian Medical College, Vellore. Furthermore, he has completed his Post graduate diploma in medical law and ethics and a postgraduate diploma in human rights and law,  from the National Law School of India, Bangalore. He is currently pursuing his postgraduate diploma in child rights and law.

As a person with a lived experience of visual disability, he has dedicated himself to working toward the upliftment of disabled persons. He has gone on to equip himself with further training in medical ethics, medical law, child rights, human rights, and disability rights. He works with many international and national organizations with similar visions and goals.      

Q1. As per your LinkedIn profile, you describe yourself as a “PSYCHIATWIST”, we would like to know where did it originate from?

Yes, I refer to myself as someone very different from my peers, colleagues and everyone around me. This has particular relevance in multiple ways. Firstly, I am different from others since I have to do things differently. This reminds me that my greatest foes are complacency, mediocrity, and a lack of meritocracy. It also serves to bolster that I may be just one, but I will also be the first of many.

Secondly, this also tells others that I am doing many of the things that others do just as well, if not better but in an inaccessible and discriminatory  environment that they are party to in its defiant maintenance against the recognition of those like me as part of human diversity.

Thirdly, and this is the dearest of them all. It is so that those who need help enter the process of inquiry and possibly engage in collaborative problem-solving approaches instead of resigning themselves to overblown ideals of fate and destiny.

I have also used other terms such as PsychIartist and most recently PsychiaTRYST – taken together, I would say they represent aspects of how I want to connect with this world. I can also report these are dynamic and very much based on my atmosphere of thoughts and mood.

Professionally, I am different from other psychiatrists in being trained in family medicine and retaining a marked interest in psychotherapy and social determinants of mental health.

Q2 What are your views on the current weightage of Psychiatry as a subject in the MBBS curriculum? As this is one of those subjects which often ends up getting neglected by the students, what should be done about it?

Well, this is a very badly flogged horse here- so much has been done and said about it, albeit to no discernible change.

Personally, I feel the exposure in the MBBS curriculum should in some way reflect what one would encounter as a general practitioner or in routine clinical practice. Here, proportions of those with some mental health morbidity range anywhere between 20-30% of general practice. The proportions are even higher if one includes those with concomitant substance use disorders. Additionally, learning more about the mind and locating it in the brain helps to grow the germinating medical profession. There is abundant scope for personal growth and development; reflections for me are most triggered when I engage with patients and their families. It improves perspective-taking, conflict resolution, problem-solving, coping skills, communication, and negotiation skills – all important differentiators of medical professionals.

It would be prudent to understand that those developing curricula also have their own obligations, compulsions, and maybe even biases, ultimately leading to compromises here and there. After all, their biases are a reflection of what exists in society at large.

A big limitation I see towards a greater emphasis on psychiatry is the relatively shorter duration of the Indian undergraduate medical course compared to the learning objectives. Our medical curriculum has not seen any disruptive changes since its inception and it’s about time readers of this magazine took it upon themselves to find the leverage and advocate for psychiatry and psychology. One not-so-tangible benefit would be the improved quality of care for patients even when consulting with other disciplines. Another positive would be better peer surveillance of mental health and a probable reduction in suicides/suicide attempts.

Q3. In your opinion, how far has our medical curriculum evolved in terms of inclusivity over the years, whether that’s inclusivity towards differently-abled individuals, queer communities or perhaps, any other minority communities that often struggle to be socially accepted? What are your opinions about the degree of inclusivity in the contemporary medical curriculum? What are the possible ways to make our medical curriculum more inclusive?

Continuing from what I said earlier, any training, even medical training seems to reflect only the prevailing social norms and attitudes. Marginalization in any form or practice, even its non-recognition, is an affront to human dignity, almost dehumanizing. It is now well known that certain forms of human health-seeking behavior are actually idioms of distress – maladaptive psychological processes of dissociation, somatization, etc. present along with physical symptoms that require an understanding of the social antecedents and determinants, chief among which is marginalization as a tremendous source of social distress. Those experiencing such distress have multiple intersecting issues.

The current curriculum does look to teach about a lot of these issues but does not adequately train medical professionals in identifying or addressing them. I’m going out on a limb here and stating that the reason medical models and medications are as despised as they are today by the public at large is partly due to this lacuna. Often, many report when it is almost too late or when health conditions are so advanced that only palliative inputs can be given…

What a travesty there!

We train nearly 90K doctors yearly now, all MBBS and yet there is not enough chicken soup to go around the room. For starters, trainees could be exposed to how to examine people with such lived experiences of marginalization. How many of us would be comfortable examining a mute patient? Or completing a neurological exam for a deaf person? They are not represented in the clinical material students are exposed to for training. So it can be overcome by teachers taking up roles as patient actors and trying to impart MCI or skills towards eliciting information empathically rather than rattling off a checklist of questions. Furthermore, headings such as behavioral interventions, psychological support, and breaking bad news should figure in trainees’ long case presentations in practicals.

Q4. As a psychiatrist, what advice would you like to give to all those medical students who might have phobias from medical procedures or perhaps, needles etc.? Do you think that’s something professors at medical college should address, because that’s something we rarely talk about and most of the time, medical students are expected to not have such phobias and even if someone opens up, they are often told that they shouldn’t be a medical practitioner.

Phobias is a very strong word – like everything else in this world, this too represents a pole on the spectrum of fear and avoidance in our behavior. For a psychiatrist, it can only be carefully diagnosed during a detailed clinical interview whereas colloquially most use it to refer to genuine yet not-so-phobic fears. Yes, these issues are not as talked about as they ought to be. One cannot expect medicos to be insulated from an illness that is prevalent in the general population; that would be preposterous.

Whether one wants to work on those phobias is an individual’s decision, but addressing them requires a lot of courage and patience with oneself, as well as a lot of dogged determination. However, that said, it is not an insurmountable peak. With the right help and guidance, one can overcome one’s own phobias. Medicines also help to a great extent.

Remaining oblivious to it is only going to put the patient who consults you at a disadvantage – with regard to being diagnosed and treated for this condition. Awareness of these conditions ensures that one has good mentalization abilities while conducting clinical interviews. These can help in retaining the focus on lived experiences too.

I would not let anxiety determine my practice choices – this may be different for others. One always has a litany of things that are so anxiety provoking that they remain prohibited activities . For me, this might be holding a snake; for another, it might be seeing/handling blood; the latter becomes dysfunctional simply because of its close association with the work of a medical professional. In such a scenario, it would be quite functional to work on this anxiety or – that is working with a professional to change the appraisal of such a stimulus or work towards making the avoidance more relevant while realizing that such efforts might not completely insulate oneself. As an example of the latter strategy, those with a problem handling/seeing blood can take up practice choices that put them as far as comfortable while rearealizingat such a separation may falter in crises sometimes.

 Q5. Being a medico comes with a certain expectation to be able to work and, dare we say, thrive in a high-stress environment. Interns don’t even have proper places to rest and sleep during their night duties! Do you think this should become a norm? If not, what do you think should be done?

This horse is dead and long buried. The solution lies at neither extreme but somewhere in the intervening middle.

High stress is quite subjective, to say the least. The expectation of being able to perform any and every duty task is a humongous responsibility which not for everyone to bear. This need seems to arise from the expectation that doctors need to be prepared for every emergency come what may – it would be prudent to identify those who do well and even thrive under such high-stress environments and perform brilliantly. At the same time, it is important to identify and support those who are exceptional but have special needs or modifications. They can deliver their best under certain supportive circumstances much better than anyone else.

Slogging shits should not be the norm but it should be incentivized for those who undertake such challenges. It should be kept in mind that those choosing to forego such experiences ought to be engaged in a quid pro quo other tasks.

Most importantly, it would be sensible to keep in one’s mind that these kinds of concerns should not govern one’s choice of discipline to practice – that should be exclusively left to one’s interest in said discipline.

It is high time that the medical fraternity insists on treating its junior members better and looks to develop better facilities. We can’t still be fighting for the same basic needs. In my opinion, this pits junior colleagues against the seniors in the administration who are more often than not senior members of the medical fraternity. Something which might be at fault here is the almost universal presumption that experience somehow implies good administration skills. At higher levels, it is just so cluttered that amongst myriad tasks it’s those that can be dismissed that become pain points. Somehow administrative calibres are also inferred in how needs and demands can be shown as unjustified – one must rise above simple compromise and look to merits and long-term gains.

That said the medical fraternity is the most splintered group of professionals – which is quite saddening given that we can only go forward together. However one must acknowledge some progress as regards awareness of such issues in training programs and some action that has made lives in emergency medical settings a tad bit better in some places. Those in power should be encouraged to act favourably in the interest of their fraternity.

Q6. Our undergraduate curriculum doesn’t really encourage research for the undergraduate medical students as much as it should. Although currently, students are certainly getting involved in research projects, particularly for CV purposes, lack of guidance often makes them ignore the importance of following ethics in every aspect of conducting research. For example, a medical student who simply cares about getting a publication for building a CV, often ends up manipulating the data to get the desired result. So, somewhere, the very idea of research, its significance, and the real idea of ethics is getting hampered which can have long-term implications as well. What’s your take on this?

I agree research exposure is quite limited but one can’t expect more to be squeezed into this 4+1/2 years course! Research should never become a burden. It’s an extension of the innate process of inquiry and inquisitiveness. Much has already been said about this topic but no practical solutions have been identified as of yet.

It would be best if the duration of training were to be extended so as to include some aspects of medical training that so far have gotten the short end of the stick – research activities would be one such aspect. Ethical research is the bedrock of actionable knowledge. Manipulation of any kind in research activities becomes extremely abhorrent – it’s akin to fecal contamination of drinking water! But it would be quite a leap to consider all research manipulation to be stemming from inadequate UG exposure too. Some of it can be addressed by re-examining the need for career goals or promotions etc. Research cannot grow as it should unless it is differentiated enough to allow only keenly interested and motivated persons.

Q7. What is that one essential skill apart from clinical skills that every young doctor should be equipped with and what factors should they keep in mind while choosing their subject of specialization?

I would say the most important skill would be communication – hands down – for any medical professional – in practice or training. It is very important to be able to understand your patient. Whether the seeker is helped or not, they would need to be understood – and that is where the differentiation between a layperson and a professional lies. I can’t advise on any set of factors that would guide budding professionals’ choices except their interests and opportunity. More often than not certain practice choices are aspirational while others are relegated to ignorance – this itself becomes a conflict when future specialists are unable to choose their specialty or don’t get their preferences despite repeated attempts.

Q8. As we all know, even if we are talking about bringing a change in the curriculum, that change isn’t just going to happen immediately, so, until then, what’s your advice for all the medical students for being truly good “doctors”, not just clinicians?

I am not the right person to opine on what other students should do. One thing I can reassure, change is inevitable, it’s up to you to be a part of it or just feel content wishing it would happen.

The time is ripe for disruption – along with everyone reading I too hope things change tomorrow itself. In the interim, it is important that students gain the best resources, get opportunities to learn and grow and aspire to become the most competent versions of themselves. For interns and young doctors, the mantle is heavier – one day soon you will be in positions to effect change – let no one forget their journeys, struggles and thoughts on making it better for those after them.

Every opinion and every stakeholder counts – I rephrase from Wodehouse – you can’t be a dictator and design clothes – similarly you can’t fashion the best doctors and design their curriculum without including students and young doctors in the dialogues and processes.

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