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Journal of College of Medical Sciences-Nepal, 2010, Vol. 6, No. 1, 67-69 Medical Education

Correspondences: Dr. P.R. Shankar

E-mail: ravi.dr.shankar@gmail.com

  The word ‘trek’ originated from a Dutch word for

travel and with the Dutch migration to South Africa

came to be an Afrikaans word meaning migration by

oxcart. The term has been modified over the years to

mean travel by foot for many days. Nepal is one of the

hotspots on the global trekking scene due to various

factors. The wide range of landscapes ranging from

the ‘terai’ the flat plains bordering India to the frigid

heights of Mt. Everest and the friendly open nature of

the people could be important reasons.

Treks and trekking styles:

In this article the author plans to explore how

trekking could be a metaphor for medical education

and the practice of medicine. Most treks in Nepal start

at relatively low elevations climb steadily up, cross a

pass and then descend on the other side to a river

valley. There are a variety of trekking styles which

people choose according to their purse and inclinations.

In the simplest style one or more trekkers usually set

out carrying their own gear and organizing their own

logistics. They spend the night at tea houses (lodges)

which are common in the popular trekking areas. The

trekker/s could walk with one or more porters who

will carry the majority of the gear. If there are no tea

houses the trekker/s camps out and the porter may

cook for you. The last and the most expensive method

is to trek with a retinue of porters, kitchen staff, guides

and a head Sherpa or sirdar.

Trekking as a metaphor for medicine and medical education

P.R. Shankar1, V. Malhotra2

1Department of Medical Education, KIST Medical College, Imadol, Lalitpur, Nepal, 2Department of Physiology, K Variyar

Medical College, Salem, India

Abstract

Nepal is a favored trekking destination. Over the years a number of trekking styles have emerged

and the author sees similarities between trekking styles and methods of medical education. Problem-

based learning strategies make students more involved in their own learning and teachers act as facilitators.

Trekkers and medical students mostly concentrate on the immediate trail or different subjects and are

able to obtain an integrated and holistic view only occasionally. The nature of the doctor-patient

relationship is changing with patients wanting to play a more active role in their treatment. Workers in

the trekking industry and doctors slowly rise through the ranks. Often people take up jobs with more

responsibilities and challenges which pay better. Technology has invaded both trekking and healthcare

and most of the money is made by middlemen. In addition to other areas medicine is focusing on preparing

patients for the final exist

Key Words: Problem-based learning, doctor-patient relationship, medicine.

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Journal of College of Medical Sciences-Nepal, 2010, Vol. 6, No. 1

‘Styles’ of medical education:

Looking at the medical education scene in South

Asia I see similarities with trekking styles. Previously

most medical schools used to be supported by the

government. Students were selected through a tough

entrance exam and came from ‘ordinary’ families. Fees

were low. These students can be likened to the single

trekkers who carry their own backpacks. Trekkers

carry guidebooks and maps while students use

textbooks to guide them through the difficult terrain of

medicine. Teachers could be likened to ‘guides’ guiding

the students (neophyte trekkers) over the difficult

terrain ensuring they take the proper trail and eventually

reach their destination. Recently a number of medical

schools have been opened in the private sector in

South Asia. These colleges admit self-financing

students who have to pay high tuition and other fees.

The self-financing students share many similarities with

the group of trekkers who trek with a full retinue. Both

depend on others to smooth out and cushion their path

over the rough terrain. Also as they have invested a

large amount of money both expect a smooth and easy

journey to their destination. They expect their ‘guides’

to read and interpret the maps and other material and

chalk out the easiest path to their destination.

In the more traditional learning system, the

teachers (guides) usually led the way across the terrain

of medicine and students followed the path shown by

the guide. With the increasing use of problem-based

learning strategies the teacher no longer leads the

expedition. He/she acts as a facilitator of the process

and keeps watch from a respectable distance. The

student is trained in leadership and other requisite skills

and a group of students chart their own way across

the difficult terrain. The guide (teacher) intervenes only

in cases of difficulties.

Guiding patients:

The landscape of medicine has dark alleys and

cul de sacs bristling with death, suffering and despair.

Patients often get entangled in these fearful landscapes

and the doctor guides the patient away from danger

and disease to the balmy and sunny valleys of health

and happiness. The doctor-patient relationship is

steadily changing. Previously patients expected their

doctors to lead them out using their knowledge and

experience and they used to blindly follow their

doctor’s orders. Today with increasing levels of literacy

and economic well being patients expect to chart their

own path out of the dark and dangerous valleys with

the doctor providing help and knowledge and

supporting the patients’ efforts.

Rising up the professional ladder:

In Nepal many guides start their career in low

paying jobs with the trekking industry. They slowly rise

up the ladder eventually rising to the post of head Sherpa

or trek leader. The same is true of doctors who start

off as medical students, then work as interns, house

officers, postgraduate trainees and finally become

eligible to be consultants or faculty members. Sherpas

with trekking groups in Nepal sometimes switch over

to mountaineering expeditions. The greater risks and

challenges are offset by the higher pay. Doctors

specialize and super specialize tackling more

challenging and difficult cases for greater financial

rewards. Many guides developing close relationships

with their clients. Many are sponsored to do their higher

education in the west. Others migrate to developed

nations taking better paying jobs in either the tourism

or other sectors. Many doctors from Nepal migrate to

developing countries.

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Inroads of technology:

Technology has made steady inroads into

trekking and mountaineering. Better trails, improved

quality of lodges, better maps, global positioning

systems, improved food and better shoes and trekking

gear are a few examples. Medicine is becoming

dominated by technology and big healing teams. The

individual family physician is becoming rarer in the west

and even in cities of South Asia. Luckily the individual

trekker is still commonplace despite big trekking

companies and outfitters. Advanced technology does

not come cheap. With increasing investments

businessmen and corporate houses are becoming

common. Doctors work for a fixed salary or a

percentage of the profits. Foreign trekkers pay a large

amount to agencies in their countries for planning and

organizing their treks. The foreign agency often

subcontracts the logistics to an agency in Nepal. This

agency then hires sirdars, guides and porters. Only a

small percentage of the original fee paid goes into the

pockets of the guides and porters. Middlemen gain

the most in the transactions. The guides and porters

are paid well when compared to the low local Nepalese

wage standards.  The same is true of the doctors who

work in hospitals.

Life is a trek with ups and downs, happiness

and sorrows. Death is inevitable. What happens after

death? Do we continue our trek on a different plane?

Medicine along with religion has an important role in

preparing people for the final exit which should be as

far as possible without pain and suffering. Medicine

these days is increasingly focusing on dying with dignity

and preparing patients for the unknown frontier.

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P.R. Shankar et al. Trekking as a metaphor for medicine and medical education