In the antimicrobial resistance (AMR) crisis, the medical professionals are at an equally precarious position as the patients with AMR infections. In their careers of saving patients’ lives, the medicos need to keep the antimicrobial drugs like antibiotics working for them. However, in our conversations with students of medicine through the AMR Frontline Workshops at Superheroes against Superbugs, we see how little these future medical practitioners understand AMR, its gravity and their own roles in solving the problem.

I spoke to four medical students who have participated in our workshops in detail to gauge their understanding of antibiotics and what they see among their peers in terms of antibiotic usage. These students were in their final year of MBBS or were medical interns. They had all studied about the different antibiotics, organisms they act against and mechanisms of their action in detail in their pharmacology courses. Despite these, many of them have seen how their seniors and peers dispense or even self-administer antibiotics for viral infections.

Shamama Firdous, a medical intern at VRK Women’s Medical College said that she got to know of the gravity of AMR crisis only through one of our workshops. If generalized, this paints a scenario of medical students not very aware of the problem of AMR. She also said, and other students admitted that they don’t know when to give antibiotics and when not to.

Hruthika Reddy, a final year MBBS student, from Government Medical College, Mahbubnagar said that the textbooks tell them what antibiotics are to be used for Gram positive and negative bacteria. But doctors don’t have such details when they are treating outpatients. According to her, many a times, the doctor’s decision is shaped by the antibiotics that are available in surplus. This can even be the third generation antibiotics, which otherwise should be kept under watch, according to WHO’s AWaRe classification of antibiotics.

The correct prescription of antibiotics can only follow accurate diagnosis. Such accuracies have traditionally come from microbial culture tests where the microbes from patients’ samples are grown so that individual microbes in the samples can be identified and their susceptibility to different antibiotics can be tested to choose the right antibiotic to be prescribed to the patients. Culturing the microbes takes 2 days and susceptibility testing adds 2-3 days more. Such diligence is followed mostly for serious cases such as tuberculosis, urinary tract infections, and infections in Medical Intensive Care Units and Surgical Intensive Care Units. These procedures also make the experience more expensive for patients, especially for those without insurance coverages. For the common infections, it is the doctors’ predisposition and experience that define the treatment regimes.

Navjeet Kumar, a medical intern at AIIMS, Nagpur thought his peers (who are also medical interns now themselves) are used to taking antibiotics for cold and flu since their childhoods. He also thinks that they still don’t fully understand the consequences of misusing antibiotics and the gravity of AMR. Navjeet comes from a village himself, and says they didn’t grow up with the habit of taking medicines for everything. This is possibly why he finds it easier to not take antibiotics for every ailment.

He also suggested that not only patients, doctors also might not be fully aware of the importance of completing the entire course of antibiotics. And, to top it, antibiotics are expensive medicines – a 10-days course of a common antibiotic can easily cost from Rs 200-300. In such a scenario, it becomes acceptable to stop antibiotics when the symptoms disappear as well as save some money by skipping the doctor’s visit and buy antibiotics over-the-counter from a pharmacist.

Similar to the pharmacology of antibiotics, the MBBS syllabus also prescribes antimicrobial stewardship program. Through this, the students are expected to appreciate the importance of collaborating with the microbiology departments of their hospitals that maintain records of AMR patterns in their organizations. However, it seems that the students hardly pay attention to the topic given its rather low priority in their exams.

If weightage of a topic in an exam is instrumental in shaping students’ focus on specific areas, some teachers are utilizing it to spotlight on AMR. Students have to choose electives that allows them 15 days to work on their interest before beginning their final year of MBBS study. The Government Medical College supported AMR awareness work as a part of an elective for Hruthika. It is the personal interest of a teacher in the same college that ensures students pay more attention to the correct use of antibiotics and prevent AMR. The college made their MBBS students read about infection prevention and control, generally meant for postgraduate students, and give presentations on the topic. They insist the students feed in AMR data on the WHONET system, which is a part of the National AMR Surveillance Program.

A final year MBBS student from a college in West Bengal (names undisclosed upon request of anonymity), highlighted the importance of discussions  with seniors on what antibiotics are working for the patients in their hospital. Through these discussions, they also learn of the different kinds of tuberculosis cases, and understand that antibiotics need to be chosen and prescribed judiciously.

Efforts towards tuberculosis elimination have also set examples of many good practices. Faster DNA-based diagnostic tools have been developed and are used in healthcare settings. Tuberculosis was notorious for extremely long culture periods. Those have been now reduced to 12 hours. Doctors have been trained to counsel patients to finish the long antibiotic regime. These can inspire similar efforts for other infectious diseases too.

But these will happen when the medical community takes a lead at tackling the AMR crisis going beyond the theoretical learning of the problem in the medical classrooms. The senior doctors and teachers have a role to play in shaping behaviors of the younger doctors. They have to champion for rational use of antibiotics. They have to acknowledge that in a country like India with a high infectious burden, they cannot use antibiotics as a silver bullet. They have also set examples of patient counseling and making them aware of the good practices of antibiotic use. They have to also be willing collaborators in medical research so that affordable healthcare interventions such as diagnostics can be developed and deployed. We urgently need a critical number of medical professionals to be Superheroes against Superbugs.