Initially appeared on doktorko.com 3/12/2005.
Some people, despite being brilliant, are still incredibly stupid.
Case in point: back in Medical School, i did a presentation on DYSTOCIA (abnormal labor). I lifted the history off a delivery that i had handled, whipped up some slides, cooked up a spiel, and dished it out to a room full of clerks, one OB consultant, and one first-year OB Resident.
After presenting the H&P;, i was getting into my groove; warming up to the topic, i started my discussion by asking the room, "So what do we know about this ANIMAL called DYSTOCIA?"
The consultant's face darkened. "What did you say?"
Grinning widely at my use of creative metaphor, i repeated what i said.
Consultant, in a gravelly voice: "What ANIMAL?"
I was mystified. "This... animal... DYSTOCIA. Never mind." I then proceeded with the brief discussion that i had outlined the night before. Not a brilliant presentation, but in my opinion, at least halfway adequate.
All this time however, the consultant's face contorted with rage. He opened his mouth and began bombarding me with questions; each query i answered would be confronted with a new one, on and on, at times going off-topic and beyond the scope of my presentation until i had nothing else to say. Then he would let me proceed to my next bullet point - and REPEAT the process. I countered gamely, never losing my grin with each answer i gave (which seemed to infuriate him even more), but of course my meager knowledge was a booger compared to his mental cyclopedia and in the end i was spent and defeated.
At the end of my presentation, he stood up in a huff, and with the righteous indignation of an elephant who has just squashed a gnat, stormed out of the room. The OB Resident shot me a nasty glance and, sniveling, trotted off after her master. I, however, had no idea what just happened.
Light was shed on the matter few days later, when i noticed that i was getting shoddier-than-usual treatment from the OB Residents, who told me in no uncertain terms that i should APOLOGIZE. For what, pray tell? For demeaning a patient and calling her an animal.
Wha-a-a-a-a-t?! WHO called WHO a WHAT?
Clerk chong (that's me) called the patient an animal.
Shortly thereafter, the Clerks' monitor called a meeting to drop not-so-subtle hints about how a certain clerk had made unethical remarks recently and offended the sensibilities of a MORALLY-UPRIGHT consultant. Well, during the meeting i owned up to saying what i said. To which she concluded that i SHOULD go and apologize. To which i replied that the consultant heard wrong and was probably deaf. The room full of clerks agreed and confirmed what i had actually said.
The Resident looked confused. But... you should STILL go and apologize.
Which made absolutely no sense. Not being a subscriber to nonsensical theories, i left the issue for dead and never did become contrite and apologize for something i didn't do. In retrospect, that was probably the reason why they treated me shoddily for the rest of the year, LOL.
It's just incredible that someone who has reached a professional level so lofty as to actually become a GYNECOLOGIC ONCOLOGIST could misunderstand such a basic metaphor. I have the greatest respect for the man's MEDICAL talents (he's a great surgeon with an EXCELLENT knowledge base), but as far as his LITERACY is concerned, he doesn't know beans. In other words, he's just a dumb $h!thead who ab/used his stature to knock down a lowly subordinate because he couldn't understand what he said.
Riddle me this: how could any half-brained person construe what i said to mean that the patient was an animal?
Hayop talaga.
Showing posts with label medical miseducation. Show all posts
Showing posts with label medical miseducation. Show all posts
Medical Miseducation, Part 1
Initially appeared on doktorko.com 11/16/2005.
When i was a Clinical Clerk, i used to do mind-numbing scut work. For hours on end i would take Vital Signs with a frequency of Q4, Q2, and the dreaded Q1 - which would be especially essential in the ICU. I would take the blood pressure, monitor the heart rate, count the breaths per minute, quantitate the urine, and do other esoteric maneuvers like checking Neuro Vitals (SPERM - Sensorium, Pupils, EOMs, Respiration, Movement), and measuring the CVP. Move on to the next patient. Repeat. Monitoring anywhere between eight to twelve patients in the ICU (on a regular ward the number could be more than twenty), i would work my way through all the patients over the span of one hour, then turn around and do it again. And again. And again. For twenty-four hours straight. Somewhere in there an admission or two would be written up, some blood would be drawn, some NGTs and foley catheters inserted.
Dr. Despot (name changed, more for my protection than his) put in his two cents' worth on the matter: that us Clinical Clerks were not monitoring machines, that we were doctors-in-training , and that we should learn the significance of what we were doing, instead of just doing it like robots. Hypotension - think of shock. Fever - think of infection. Tachycardia - think of SIRS. And so on.
A sensible thought, but in practice this was impossible. I guess the not-monitoring-like-robots concept did hold some merit - if we were actually allowed to apply it. Consider: any time we missed monitoring by a few minutes, the supervising Resident would be all over us like a fly on a piece of dung. Demerits would be handed out like gift certificates on Christmas - except that these gift certificates could be redeemed only for more hours of mind-numbing work. We lived in abject fear of being caught having not monitored in the wee hours of the night.
Did we ever sit down to sleep? Of course, when the exhaustion overtook us. Did we ever study? Sure, when we had 5 minutes left before monitoring the next patient and we weren't ready to just lay down and die. Did we absorb anything? Uh, let me put it this way: when you're bone and brain-weary like that, your mind loses all capacity to learn and becomes a solid brick.
Many years later, a little older and (hopefully) wiser, i look back and my miseducation with seething anger and more than a little bit of sorrow. These days, i regularly work with medical students who are expected to do three things: 1. do a night call/duty six times in two weeks 2. learn by reading and asking their Residents questions the whole night through, and 3. not do any manual labor. Their minds, not disillusioned and jaded like mine, are free to roam, to ask questions, and expand their horizons. I've met third year students who know how to manage MIs and decompensated CHFs, which is more than i can say for some Residents that i worked with when i was still in medical school.
Consider: If during those interminable nights during our Clerkships we had been allowed to sit down and study, instead of doing slave labor passed off as a learning activity - how much smarter would we be now?
This is, of course, a rhetorical question.
When i was a Clinical Clerk, i used to do mind-numbing scut work. For hours on end i would take Vital Signs with a frequency of Q4, Q2, and the dreaded Q1 - which would be especially essential in the ICU. I would take the blood pressure, monitor the heart rate, count the breaths per minute, quantitate the urine, and do other esoteric maneuvers like checking Neuro Vitals (SPERM - Sensorium, Pupils, EOMs, Respiration, Movement), and measuring the CVP. Move on to the next patient. Repeat. Monitoring anywhere between eight to twelve patients in the ICU (on a regular ward the number could be more than twenty), i would work my way through all the patients over the span of one hour, then turn around and do it again. And again. And again. For twenty-four hours straight. Somewhere in there an admission or two would be written up, some blood would be drawn, some NGTs and foley catheters inserted.
Dr. Despot (name changed, more for my protection than his) put in his two cents' worth on the matter: that us Clinical Clerks were not monitoring machines, that we were doctors-in-training , and that we should learn the significance of what we were doing, instead of just doing it like robots. Hypotension - think of shock. Fever - think of infection. Tachycardia - think of SIRS. And so on.
A sensible thought, but in practice this was impossible. I guess the not-monitoring-like-robots concept did hold some merit - if we were actually allowed to apply it. Consider: any time we missed monitoring by a few minutes, the supervising Resident would be all over us like a fly on a piece of dung. Demerits would be handed out like gift certificates on Christmas - except that these gift certificates could be redeemed only for more hours of mind-numbing work. We lived in abject fear of being caught having not monitored in the wee hours of the night.
Did we ever sit down to sleep? Of course, when the exhaustion overtook us. Did we ever study? Sure, when we had 5 minutes left before monitoring the next patient and we weren't ready to just lay down and die. Did we absorb anything? Uh, let me put it this way: when you're bone and brain-weary like that, your mind loses all capacity to learn and becomes a solid brick.
Many years later, a little older and (hopefully) wiser, i look back and my miseducation with seething anger and more than a little bit of sorrow. These days, i regularly work with medical students who are expected to do three things: 1. do a night call/duty six times in two weeks 2. learn by reading and asking their Residents questions the whole night through, and 3. not do any manual labor. Their minds, not disillusioned and jaded like mine, are free to roam, to ask questions, and expand their horizons. I've met third year students who know how to manage MIs and decompensated CHFs, which is more than i can say for some Residents that i worked with when i was still in medical school.
Consider: If during those interminable nights during our Clerkships we had been allowed to sit down and study, instead of doing slave labor passed off as a learning activity - how much smarter would we be now?
This is, of course, a rhetorical question.
Medical Miseducation, Part 2
Initially appeared on doktorko.com 11/20/2005.
Dr. Despot said something INCREDIBLE (as in, not credible) at the beginning of Clerkship: that the student, because he (and his parents) payed ludicrous amounts of tuition, was the "customer" of the school and hospital. As "the customer is always right," that meant that we could complain about what we didn't like and the system would conform to us.
We quickly learned that he was lying.
From the beginning, we were told that Clerks are the lowest form of life. We would be expected to work hard and receive nothing in return. We would (literally) slave through the 365 days in the year (good thing it wasn't a leap year) and not have any vacation time. We would be berated and humiliated at every turn. We would receive absolutely no respect.
Naturally, being students, we were inquisitive at heart. On the first day, we asked about how to monitor, how to endorse patients properly, how to do prescribe, etc. Imagine our shock when every question would be answered with either " Dapat alam mo na yan," or "Basahin mo at sabihin mo sa akin ang sagot." We learned to keep our traps shut and not ask anything, lest we ourselves be asked.
The medical miseducational system is set up to penalize the learner for not knowing enough. The morning endorsement was exquisite torture. The history and physical examination being presented would be picked apart at every turn. The assessments and plans were criticized harshly without any redeeming or educational value. Students who "acted smart" were humbled under the onslaught of the almighty seniors.
And then there was the other kind of "endorsement," the more sinister kind. A Clerk who was not liked by his seniors would be marked and passed on for shabby treatment to other departments. It was not uncommon to hear " Endorsed ka na sa amin," before being given an exceptionally hard assignment or receiving a verbal beating. Interestingly, the smartest students with "bad attitudes" (i.e. threatening to the Residents) would receive these endorsements and the heaviest workloads while the mediocre ones with "good attitudes" ( i.e. sipsip, mahilig sa gimik) or sexy bodies (especially in Surgery) would breeze through the rotation with flying colors and more than a few favors.
Sometimes we complained, but it was to no avail. Dr. Despot would parry every complaint with "When i was a Clinical Clerk..." and launch into a story that underscored how much harder it was back in his day and how lazy we were compared to him. Evidently, despite the pretenses, the customer was never right. Understandable and maybe even acceptable if we studied in a state-funded University (like he did), but in a private school where you have to shell out just under 50k a semester?!
Putragis! But we swallowed it all because we wanted so bad to be doctors
Dr. Despot said something INCREDIBLE (as in, not credible) at the beginning of Clerkship: that the student, because he (and his parents) payed ludicrous amounts of tuition, was the "customer" of the school and hospital. As "the customer is always right," that meant that we could complain about what we didn't like and the system would conform to us.
We quickly learned that he was lying.
From the beginning, we were told that Clerks are the lowest form of life. We would be expected to work hard and receive nothing in return. We would (literally) slave through the 365 days in the year (good thing it wasn't a leap year) and not have any vacation time. We would be berated and humiliated at every turn. We would receive absolutely no respect.
Naturally, being students, we were inquisitive at heart. On the first day, we asked about how to monitor, how to endorse patients properly, how to do prescribe, etc. Imagine our shock when every question would be answered with either " Dapat alam mo na yan," or "Basahin mo at sabihin mo sa akin ang sagot." We learned to keep our traps shut and not ask anything, lest we ourselves be asked.
The medical miseducational system is set up to penalize the learner for not knowing enough. The morning endorsement was exquisite torture. The history and physical examination being presented would be picked apart at every turn. The assessments and plans were criticized harshly without any redeeming or educational value. Students who "acted smart" were humbled under the onslaught of the almighty seniors.
And then there was the other kind of "endorsement," the more sinister kind. A Clerk who was not liked by his seniors would be marked and passed on for shabby treatment to other departments. It was not uncommon to hear " Endorsed ka na sa amin," before being given an exceptionally hard assignment or receiving a verbal beating. Interestingly, the smartest students with "bad attitudes" (i.e. threatening to the Residents) would receive these endorsements and the heaviest workloads while the mediocre ones with "good attitudes" ( i.e. sipsip, mahilig sa gimik) or sexy bodies (especially in Surgery) would breeze through the rotation with flying colors and more than a few favors.
Sometimes we complained, but it was to no avail. Dr. Despot would parry every complaint with "When i was a Clinical Clerk..." and launch into a story that underscored how much harder it was back in his day and how lazy we were compared to him. Evidently, despite the pretenses, the customer was never right. Understandable and maybe even acceptable if we studied in a state-funded University (like he did), but in a private school where you have to shell out just under 50k a semester?!
Putragis! But we swallowed it all because we wanted so bad to be doctors
Medical Miseducation, Part 3
Initially appeared on doktorko.com on 12/3/2005.
At the beginning of Clerkship, our school chaplain - in an astounding piece of spin - related "Clinical Clerks" to "clerics," likening us to members of the clergy who were appointed with the divine task of attending to patients. This of course bolstered our spirits, but later on we learned the truth - that "clerks" were really just clerks - that is, people who were charged with keeping records, filing, and other busy work.
One of our main responsibilities was keeping our charts in order. We were expected to place labs in the proper place, update the medicine sheets, do drug indexes, etc. As with our other responsibilities, this was passed off as being one of our more important "medical" tasks and therefore something we should do with gusto. It never happened to me personally, but i had heard of horror stories when the Despot would do rounds and toss un-arranged charts out the window for the hapless clerk to go out and collect with a lesson learned. This is unethical (and probably illegal) in more ways than one; for example - would you want to be the patient whose chart gets thrown out the window and whose positive HIV test gets exposed for the world to see? Of course if that ever happened, i guess it would be the clerk's fault and he'd receive one million demerits and keep on arranging charts until the end of time.
All this fostered was a deepening sense of fear and anxiety and a redirection towards mindless clerical (see?) duties versus any real medical and clinical learning. Before rounds we would scramble about making sure the charts were arranged and all the notes were filled in - regardless of the quality of the content. This promoted an attitude geared towards quantity versus quality. Something which i personally can blame for me not knowing enough about medicine when i entered Residency.
Other "medical" tasks we were required to do were push stretchers around ourselves and run downstairs for lab results and radiology films. We were essentially arms and legs for the residents and consultants - who, while they had their own troubles - mostly made it a point to make it clear that we were the lowest forms of life in the hospital.
And always, always, we were told that it was for our benefit, that it was part of our education, that we would appreciate it in the end.
Well, it's been four years since i finished Clerkship, and i still don't appreciate it.
At the beginning of Clerkship, our school chaplain - in an astounding piece of spin - related "Clinical Clerks" to "clerics," likening us to members of the clergy who were appointed with the divine task of attending to patients. This of course bolstered our spirits, but later on we learned the truth - that "clerks" were really just clerks - that is, people who were charged with keeping records, filing, and other busy work.
One of our main responsibilities was keeping our charts in order. We were expected to place labs in the proper place, update the medicine sheets, do drug indexes, etc. As with our other responsibilities, this was passed off as being one of our more important "medical" tasks and therefore something we should do with gusto. It never happened to me personally, but i had heard of horror stories when the Despot would do rounds and toss un-arranged charts out the window for the hapless clerk to go out and collect with a lesson learned. This is unethical (and probably illegal) in more ways than one; for example - would you want to be the patient whose chart gets thrown out the window and whose positive HIV test gets exposed for the world to see? Of course if that ever happened, i guess it would be the clerk's fault and he'd receive one million demerits and keep on arranging charts until the end of time.
All this fostered was a deepening sense of fear and anxiety and a redirection towards mindless clerical (see?) duties versus any real medical and clinical learning. Before rounds we would scramble about making sure the charts were arranged and all the notes were filled in - regardless of the quality of the content. This promoted an attitude geared towards quantity versus quality. Something which i personally can blame for me not knowing enough about medicine when i entered Residency.
Other "medical" tasks we were required to do were push stretchers around ourselves and run downstairs for lab results and radiology films. We were essentially arms and legs for the residents and consultants - who, while they had their own troubles - mostly made it a point to make it clear that we were the lowest forms of life in the hospital.
And always, always, we were told that it was for our benefit, that it was part of our education, that we would appreciate it in the end.
Well, it's been four years since i finished Clerkship, and i still don't appreciate it.
Medical Miseducation, Part 4
Initially appeared on doktorko.com 12/7/2005.
At our "charity" hospital, there were two call rooms for Interns and Clerks: one male and one female. Each call room had airconditioning (thank God for small favors) and four bunk beds whose linens seemed like they were never changed. Considering that there would be an average of around 15-20 people on duty every night (the smell of the linens would attest to this), this was nowhere near the vicinity of being enough.
At our main "pay" hospital, it was a lateral movement: each call room would have 8 beds (total of sixteen). Unfortunately there were at least twice as many people there as the other hospital, so this meant nothing. In addition, there was no airconditioning: there was only a small electric fan that could provide ventilation for only two beds at most.
(But of course, Dr. Despot always made it a point to tell us that we were neither supposed nor allowed to sleep when on duty anyway - meaning we had to stay awake for 24 hours straight and then round the next day for another eight to ten hours - so the call rooms were "irrelevant.")
One night when i was on duty, i went into the call room to grab a few minutes of sleep. I thought it was unusually warm, but when i went to turn the fan on, i found only a wall-fan-shaped clean spot on the wall were it used to be. Evidently, the management got tired of reminding the Clerks that leaving an appliance on 24/7 was a fire hazard and decided just to get rid of it.
Needless to say, this royally p!$$3d me off. Our school administrators, whose "vocation" was hospital administration, despite a vow of poverty, lived like queens (or at least princesses). They got chauffeured everywhere, lived in airconditioned cloisters, and wore immaculate white outfits whose detergent and bleach were bought and paid for by my parents' money. Tuition and hospital fees soared. Any attempts to get a new concessionaire into the cafeteria (creating competition, consequently driving down prices, and reducing the management's "cut") were blocked. The hospital expanded with new buildings and machinery. "The hospital" was so obviously making money -
And they couldn't afford to get a f*ck!ng electric fan with a timer for the call room!?! Where did our f*ck!ng 40k a semester go?!? Here we are slaving away for nothing - less than nothing! - and we can't even get a decent - HUMANE - place to rest in the dead of the night when our battered bodies and minds start stalling from sheer exhaustion?
(As an aside, there was an ugly rumor circulating that the administrators even wore Naturalizer - Naturalizer! - sandals; although this may well have been apocryphal, it got my goat nonetheless.)
After much reflection, i finally realized the awful truth.
At our "charity" hospital, there were two call rooms for Interns and Clerks: one male and one female. Each call room had airconditioning (thank God for small favors) and four bunk beds whose linens seemed like they were never changed. Considering that there would be an average of around 15-20 people on duty every night (the smell of the linens would attest to this), this was nowhere near the vicinity of being enough.
At our main "pay" hospital, it was a lateral movement: each call room would have 8 beds (total of sixteen). Unfortunately there were at least twice as many people there as the other hospital, so this meant nothing. In addition, there was no airconditioning: there was only a small electric fan that could provide ventilation for only two beds at most.
(But of course, Dr. Despot always made it a point to tell us that we were neither supposed nor allowed to sleep when on duty anyway - meaning we had to stay awake for 24 hours straight and then round the next day for another eight to ten hours - so the call rooms were "irrelevant.")
One night when i was on duty, i went into the call room to grab a few minutes of sleep. I thought it was unusually warm, but when i went to turn the fan on, i found only a wall-fan-shaped clean spot on the wall were it used to be. Evidently, the management got tired of reminding the Clerks that leaving an appliance on 24/7 was a fire hazard and decided just to get rid of it.
Needless to say, this royally p!$$3d me off. Our school administrators, whose "vocation" was hospital administration, despite a vow of poverty, lived like queens (or at least princesses). They got chauffeured everywhere, lived in airconditioned cloisters, and wore immaculate white outfits whose detergent and bleach were bought and paid for by my parents' money. Tuition and hospital fees soared. Any attempts to get a new concessionaire into the cafeteria (creating competition, consequently driving down prices, and reducing the management's "cut") were blocked. The hospital expanded with new buildings and machinery. "The hospital" was so obviously making money -
And they couldn't afford to get a f*ck!ng electric fan with a timer for the call room!?! Where did our f*ck!ng 40k a semester go?!? Here we are slaving away for nothing - less than nothing! - and we can't even get a decent - HUMANE - place to rest in the dead of the night when our battered bodies and minds start stalling from sheer exhaustion?
(As an aside, there was an ugly rumor circulating that the administrators even wore Naturalizer - Naturalizer! - sandals; although this may well have been apocryphal, it got my goat nonetheless.)
After much reflection, i finally realized the awful truth.
Medical Miseducation, Part 5
Initially appeared on doktorko.com 12/12/2005.
Two words: financial viability.
Consider: hospitals (except for government- or non-profit-organization-run ones) are essentially financial corporations. Physicians (or anyone else with an interest and enough cash - such as really rich people who want to be considered "philantrophists") buy stocks which finance the initial outlay required to put up the institution. From there, it becomes the adminstration's duty to support the hospital financially: laboratory equipment is bought and the expenses recouped by doing CBCs, etc.; the same thing with imaging machines, monitors, and all the other equipment. The final goal is to make money to eventually pay "dividends" to the "investors." From what i heard on the grapevine, the time to break even is usually around five to ten years. Some hospitals cut corners by stealing electricity and water ( i.e. illegal connections), which can shorten the break-even point to around two to three years. Regardless, after a certain amount of time, the undertaking becomes profitable - at which point reinvestments and expansion take place, and more profit is made. Just like a regular business.
The "engine" that powers the hospital (as everything) is labor - nurses, residents (more on this in the future), aides, etc. Usually they dance to the tune of "vision-mission statements" fed to them by the powers-that-be; statements like "striving to improve medical care," and other BS to make them feel like they're actually contributing to a good cause. All the while they're underpaid (many nurses in fact make only minimum wage or even under - this is even more prevalent in the provinces) and made to feel guilty whenever they ask for what they deserve ( i.e. "responsibilidad mong alagaan ang pasyente kahit walang overtime pay!"). In the meantime, the lords of the land continue to buy their gas-guzzling BMWs, Benzes, and SUVs. Make it better: cut costs even more by not employing any nurse aides, increasing nurse-to-patient ratios, and not raising nurses' salaries by passing their jobs off to someone else. Sounds hard? Sounds like a "sweatshop?" Ah, it's easier than you or i would think.
Consider again: medical students doing nurses' (and aides') jobs like taking vital signs 24/7, drawing blood, and putting in all sorts of tubes; a mindless workforce who cannot complain about the job that they do because it's an "initiation" into doctorhood. With threats of demerits and extended rotations hanging over their heads, they will do whatever pleases you - every Despot's dream. You will have, in effect, slaves. Free labor that you can coerce into doing anything. To make it even more profitable, charge them tuition: to the tune of 100k pesos a year.
Suwabe. Slaves that actually pay for their servitude.
Two words: financial viability.
Consider: hospitals (except for government- or non-profit-organization-run ones) are essentially financial corporations. Physicians (or anyone else with an interest and enough cash - such as really rich people who want to be considered "philantrophists") buy stocks which finance the initial outlay required to put up the institution. From there, it becomes the adminstration's duty to support the hospital financially: laboratory equipment is bought and the expenses recouped by doing CBCs, etc.; the same thing with imaging machines, monitors, and all the other equipment. The final goal is to make money to eventually pay "dividends" to the "investors." From what i heard on the grapevine, the time to break even is usually around five to ten years. Some hospitals cut corners by stealing electricity and water ( i.e. illegal connections), which can shorten the break-even point to around two to three years. Regardless, after a certain amount of time, the undertaking becomes profitable - at which point reinvestments and expansion take place, and more profit is made. Just like a regular business.
The "engine" that powers the hospital (as everything) is labor - nurses, residents (more on this in the future), aides, etc. Usually they dance to the tune of "vision-mission statements" fed to them by the powers-that-be; statements like "striving to improve medical care," and other BS to make them feel like they're actually contributing to a good cause. All the while they're underpaid (many nurses in fact make only minimum wage or even under - this is even more prevalent in the provinces) and made to feel guilty whenever they ask for what they deserve ( i.e. "responsibilidad mong alagaan ang pasyente kahit walang overtime pay!"). In the meantime, the lords of the land continue to buy their gas-guzzling BMWs, Benzes, and SUVs. Make it better: cut costs even more by not employing any nurse aides, increasing nurse-to-patient ratios, and not raising nurses' salaries by passing their jobs off to someone else. Sounds hard? Sounds like a "sweatshop?" Ah, it's easier than you or i would think.
Consider again: medical students doing nurses' (and aides') jobs like taking vital signs 24/7, drawing blood, and putting in all sorts of tubes; a mindless workforce who cannot complain about the job that they do because it's an "initiation" into doctorhood. With threats of demerits and extended rotations hanging over their heads, they will do whatever pleases you - every Despot's dream. You will have, in effect, slaves. Free labor that you can coerce into doing anything. To make it even more profitable, charge them tuition: to the tune of 100k pesos a year.
Suwabe. Slaves that actually pay for their servitude.
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