When Kallur Sureshs viewpoint was originally published in the BMJ, it sparked off a virtual debate between doctors all over the world via the website (bmj.com). Here is a selection.

Editor—When I trained, the detailed neuroanatomy we studied seemed largely irrelevant to any but neurosurgeons. Now we have computed tomography scans in most hospitals—and those of us in the front line are expected to be able to see at least important abnormalities.

Budding surgeons who struggled with biochemistry and immunology may have wondered about their necessity, but now they work in concert with molecular oncologists and manage their own transplant patients.

How can a psychiatrist refer patients for ECT needing an anaesthetic if they dont know if they are fit for that procedure? And how can they safely prescribe if they have no understanding of drug interactions and physiology?

Possibly the move towards holistic care has gone too far, but I expect any clinician to be able to manage his own complications, and to assess sensibly, and if necessary refer appropriately, serious incidental conditions in his patients.

Editor—There is a lot of merit in this suggestion, and it was recognised many years ago by practitioners working on teeth. Now we have dentistry, and I think we are all the better for dentists not having to spend endless hours studying material outside their field.

There are many other fields in medicine that could benefit from selecting a similar path. This doesnt mean that these specialist courses have to cripple knowledge in associated fields. It does mean that as the burden of knowledge continues to expand we will have a way of dealing with it by producing men and women who have the time to become better trained and trained more quickly.

In every other field, except medicine, we are increasing productivity and working conditions. Why is medicine the one field that resists the modern world?

Editor—Letting students decide what they want to study based on what they want to do in the future is unrealistic. There are students who have a career in mind when they entered medical school but how many of them actually stick to those choices?

In two separate studies Babbott et al reported that 79.5% and 79% of students changed their specialty choices.^{1 2} Similarly most of the postgraduate training programmes worldwide take 5-7 years and the dropout rate is also an area of concern. Therefore it is advisable to have some core knowledge and skills about each specialty included in the undergraduate curriculum rather than teaching about rare syndromes.

Im one of those who decided even before entering medical school that psychiatry was to be my ultimate destination. This made life easier for me because I could sort out what I needed to learn. The clinical postings in anaesthesia, surgery, obstetrics and gynaecology, and ear, nose, and throat medicine were all taken very lightly because they seemed rather irrelevant. The assessment system failed to identify shortcomings in my training, and today Im a practising psychiatrist as well as a medical educationalist in one of the leading universities in Pakistan.

However, often relatives or friends ask me for an opinion, and I have to admit that I cannot answer them. Or a patient coming for a psychiatric consultation may want to discuss contraception or another medical complaint. That is when I long for the things I missed in my training.

Then, I fear when flying that there may be a medical emergency and if Im asked to help I can only say, “Sorry Im a half cooked potato—I can help only if a psychiatric opinion is required ”

Editor—“No one can become really educated without having pursued some study in which he took no interest. For it is part of education to interest ourselves in subjects for which we have no aptitude.” (T S Eliot)

The primary objective of medical training in India is certainly not the production of superspecialists. But it is the creation of a group of clinicians whose chief duties lie in identifying and treating common medical illnesses and in promoting or preventing health issues. Basic preclinical and paraclinical study should strengthen the understanding of human health and disorder.

As suggested by other respondents, it would be wiser to add components of communication skills, breaking bad news, and possibly the study of literature into medical courses—the intention after all is to make the students more holistic in their approach to humans and not diagnostic robots.

Editor—I read with interest the article by Suresh advocating that doctors should start specialisation at medical school. In particular I was struck by the sentiment that generalists are a thing of the past. A number of rural communities exist in the United Kingdom and abroad that do not have ready access to specialist treatment centres. Such communities often rely on local hospitals to meet their need for medical care.

Between June 1997 and May 1998 Sir David Carter, then chief medical officer for Scotland, chaired a group charged with reviewing the role of acute hospital services in Scotland.³ The review noted that the practice of consultants based in rural hospitals encompassed a wide range of disciplines. Citing evidence from Scotland and Canada, they drew attention to the fact that surgeons working in remote areas may have need to “undertake orthopaedic, gynaecological, obstetric, urological and endoscopic procedures in addition to general surgery.” It was recognised that hospitals in remote areas require individuals who have been trained to work as “generalists.”

Medical training, however, does not currently produce such doctors. Consequently, there have been difficulties identifying professionals with the breadth of experience necessary for consultant practice in remote areas. This poses a threat to the viability of remote hospitals, which may ultimately lead to their closure and reduced access to health care for the populations they serve.

Although proposals for earlier specialisation in training may seem attractive, the repercussions may exacerbate the problems facing providers of health services for remote communities.