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Covid-19: the medical students responding to the pandemic

BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m2160 (Published 15 June 2020) Cite this as: BMJ 2020;369:m2160

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Rapid Response:

The COVID-19 pandemic in India: Perspective of an Intern

Dear Editor,

Kinder and Harvey have explained very well the impact of COVID-19 pandemic on medical students in the UK (1). These experiences are similar across the world and students have found different ways to cope with it. In this response, we offer some perspectives of an Intern from the Indian landscape. A medical degree in India is awarded after completion of four and a half years of medical education followed by one year of compulsory rotatory internship, similar to the UK. The intern is usually the first contact for the patient or family in a teaching institution.

It was at the end of March 2020, only 3 months into my internship, that India announced its first lockdown and the pandemic began to feel real to me. Shortly thereafter, in our medical college which is attached to a 1254 bedded government hospital (2), the outpatient clinics were shut and the inpatient wards were cleared to receive COVID-19 patients. The number of cases in India crossed the 6 million mark in September (3). This has affected the lives of all healthcare workers (HCWs), including the interns who just embarked on this journey and work on the front lines, alongside the residents.

Since March, the HCWs have focused their attention towards the pandemic. The duty rosters have been modified to reduce disruption in case a team member was quarantined. Interns were redirected to clerical work and writing of discharge summaries to relieve the overburdened residents. Elective admissions and procedures were postponed, similar to the experience in the UK, resulting in some missed opportunities in training.

The apprehensions faced by interns are the fear of contracting the disease and the risk of transmitting it. It was difficult to cope emotionally when some of my co-interns tested positive. There is a feeling of vulnerability among trainees that competes internally with a desire to serve the sick.

Additionally, in India we face the problem of violence against doctors. It is disheartening to read reports about assaults on front line HCWs. This is compounded by the attitude of the society and eviction of HCWs from their homes by landlords in the wake of the pandemic(4).

Adaptations:
An adaptation to enhance clinical learning to avoid exposure is a switch towards tele-simulation and telehealth based learning. Tele-simulation is a concept that uses the internet to link an instructor and a trainee in different locations (5). Some of these resources are widely available and are open access like Tele Sim-Box (6).

Telehealth, which is a delivery of health-related services via tele-communications, can improve interns’ learning experience (7). Early into the lockdown, telehealth services were used to replace most of the outpatient visits at the hospital where I work.

We were encouraged to attend online courses, such as the one on Prescribing Skills created by the Indian Council of Medical research to help enhance our prescription writing for common medical conditions. Virtual conferences provide a platform to develop skills required for career growth. I have presented a poster virtually and found the experience of interacting with the judges very fulfilling.

Coping emotionally:
The lacunae in training and its implications on the post graduate entrance examination remain unanswered. It is stressful to hear about our fellow HCWs who get infected. However, it is gratifying to see how healthcare professionals are sharing their concerns and expertise with each other. Interacting virtually with colleagues, friends and family is a stress buster. A recent article writes about how the ancient text of the Bhagavad Gita is still relevant in the lives of HCWs fighting the pandemic. It teaches us not to let fear hold us back and to perform our duties to the best of our abilities (8).

The silver lining:
The pandemic has brought much needed national attention to the shortcomings in our health-care system. We have learnt infectious disease control measures, personal protective equipment, importance of contact tracing and other principles of epidemiology. HCWs are incorporating tele-health practices and medical educators are utilizing best practices for remote learning. It has been a time to witness collaboration across industries. Fashion companies like Louis Vuitton and Chanel responded to the shortage of facemasks by using their supply chain expertise and production lines to manufacture masks and gowns (9). Engineers and doctors from top institutes in India have collaborated to develop ventilators (10). Recently, when an engineering institute in Delhi faced shortage of hand sanitisers, their Chemistry department lab stepped in to produce low cost sanitisers (11).

Conclusions:
In this pandemic, all trainees are adopting newer learning opportunities, such as telemedicine and tele-simulation. Strategies to promote mental and physical health must be incorporated. As young doctors, interns can provide fresh and useful insights into problem solving.

References
1. Kinder F, Harvey A. Covid-19: the medical students responding to the pandemic. BMJ. 2020 Jun 15;369:m2160.
2. Lady Hardinge Medical College & Associated Hospitals. “Index1: Lady Hardinge Medical College & Associated SSK & KSC Hospitals COVID-19”
www.lhmc-hosp.gov.in/index1.php?lang=1
3. Pal A, Khanna S. Virus sows dread in India's festival season as infections cross six million. Reuters, September 28, 2020
https://www.reuters.com/news/picture/virus-sows-dread-in-indias-festival...
4. Withnall A. Coronavirus: Why India has had to pass new law against attacks on healthcare workers. The Independent, April 23, 2020
https://www.independent.co.uk/news/world/asia/coronavirus-india-doctor-n...
5. Mikrogianakis A, Kam A, Silver S, et al. Telesimulation: an innovative and effective tool for teaching novel intraosseous insertion techniques in developing countries. Acad Emerg Med. 2011;18(4):420-7.
6. American College of Emergency Physicians Tele Sim-Box www.acepsim.com
7. Tuckson RV, Edmunds M, Hodgkins ML. Telehealth. N Engl J Med 2017;377:1585-92.
8. Kalra A, Michos ED, Chinnaiyan KM. COVID-19 and the healthcare workers. Eur Heart J. 2020;41(31):2936-7.
9. "Louis Vuitton, Burberry and Chanel put their fashion muscle behind face masks." CNN Business, 14 April. 2020 https://edition.cnn.com/2020/04/14/business/louis-vuitton-face-masks/ind...
10. Basu S. "IIT Roorkee develops low-cost portable ventilator to tackle COVID-19." The Economic Times, 02 April. 2020. https://economictimes.indiatimes.com/news/politics-and-nation/iit-roorke...
11. Kohli, A. “IIT Delhi Makes Hand Sanitiser after Facing Shortage amid Coronavirus Outbreak.” Hindustan Times, 22 Mar. 2020. https://www.hindustantimes.com/it-s-viral/iit-delhi-makes-hand-sanitiser...

Competing interests: No competing interests

29 October 2020
Saumya Nanda
Intern
Dr Manu Madhok
Lady Hardinge Medical College
New Delhi, India