Reflections from international visiting students
“Tuesday, 2nd September 2014
Today it was the orientation day! I met Sonya and another international student from Saudi Arabia at the international medical education office. The first thing I thought was that I was going to meet people from all over the world during September and that seemed amazing!! After walking through the campus, I realized that the buildings were beautiful, the people friendly and helpful and the campus huge and really nice. There were obviously some differences from what I had already seen in Greece. I think that a great experience had started even before the beginning of the rotation. Then, OR orientation followed. Dee introduced me and another international student from Kenya to the world of operating theatres of UIH. I also learnt how to scrub in procedures! Extremely excited and grateful for the opportunity given I went back home.
Wednesday, 3rd September 2014
6.30AM and my day had already started! The students’ schedule here is so different from the one in Greece. The first day of the rotation was pretty exhausting but also rewarding. I met a lot of students and doctors, all from different cities around the world and a lot of patients, each one of them with a different story to tell. The attending doctors and residents were very kind and helpful anytime I came up with a question, though no one would teach me things, unless I asked for it. The computerized patient database was another new thing introduced to me, since students don’t actually use any similar software in my home University Hospital. Doctors in the U.S. work minimum 11 hours per day, more than in European countries and I was astonished to see that actually happening!”
“Regarding my thoughts throughout the elective, there were 4 main ideas\thought patterns that kept coming to mind:
- Something that I noticed both in Israel and in Chicago was the dedication of the physicians and nurses and all faculty to really help patients. It’s not just about providing the information and direct care, but genuinely looking into the patient to see how to best provide that care for their specific lifestyle, and taking the extra steps to make sure it will reach them in a meaningful way. It was always inspiring to see this and continuously reassures me of why I chose this career path.
- One main difference between my experience in Israel and what I noticed in Chicago was the relationship between students and residents. Because of the language barrier and structure of my program in Israel, we didn’t have the same close teaching relationship with the residents, which is some-what of a shame because they understand the students mindset the most and as a student we could gain so much from learning how to interact with patients at that next stage.
- Another main difference was that UIC has a strong HIV clinic, which was my first real exposure to pediatric HIV. The hospital where I did my pediatric rotation in Israel doesn’t have a similar patient population with the same HIV risks and prevalence. This was extremely interesting for me to learn about and get involved with at UIC.
- My time with infectious disease at UIC was especially interesting because it overlapped with much Ebola talk in the news. The world was being overwhelmed with scares (at least I was) and in my mind the infectious disease faculty would be the most afraid\concerned. But it was fascinating for me to watch the infectious disease faculty address this issue with logic and reasoning and without unnecessary concern. I came to UIC petrified I would get infected wherever I turned, and left UIC more grounded in my understanding and more realistic about my concerns.”
Reflections from students studying abroad
“Our average day began with participating in rounds at 7am. We would meet on the 18th floor of the Medical University of Vienna’s primary hospital site and listen to “chart rounds” before meeting with patients and conducting bedside rounds. Afterwards, we would go to “radiology rounds” and go over relevant films and studies, covering all the patients within the entire Orthopedics department. After this, we would have a choice of either going to the clinic, or going to the operating theater.
If we went to the operating theater, we would change into scrubs and help the preoperative procedures, including examining the patient, studying the relevant radiology imaging and then scrubbing in a sterile technique. We often would participate by retracting and facilitating the creation of the surgical field and observe the procedure as it took place. We often scrubbed and worked with the Orthopedics department chair or the section chief of Orthopedic Oncology, along with Austrian and Open Medical Institute (OMI) fellows and residents. After the procedure was completed, we would walk the patient to the post-anesthesia care unit or scrub into the next case. If we went to the clinic, we would go to the 7th floor outpatient center. There, we would observe patient visits and participate in the follow-up care of patients we had previously operated on. Additionally, our supervising fellow and primary mentor, Dr. Hobusch allowed us to interact with patients directly and help in outpatient procedures, such as suture removal or steroid injections.
This once in a lifetime experience was tremendously impactful, not just as my first experience in Europe – it will shape my desire for research collaborations and for cultural understanding and experiences.”
“Having the opportunity to complete a four-week elective at Galway University Hospital in Galway, Ireland, was a learning experience that I will carry with me for the rest of my career. I was able to gain a greater understanding of another country’s medical system, as well as their structure of schooling. It was illuminating to see the different structures of wards, clinics, and multidisciplinary interactions. Also, I had great mentors in the physicians I worked with in terms of patient interactions. Finally, I was able to see patients with very rare disease pathologies which I have never encountered before.
In Ireland, the health care system consists currently of both public and private sectors. There is a public system, which every citizen is entitled to for free, that is covered by taxes. No one with this will be turned away for emergency care; however there may be waiting lists for elective procedures. Some choose instead to purchase private insurance, which is expensive. This fragmented approach exists because enough people do not have faith in the public system. To rectify this, Ireland has a plan in place to institute universal health care by the end of the decade. When this is instituted, every citizen will have a public health plan, for which they will pay a small amount annually. The goal is to equalize access to care and costs of care for all.
Dr. O’Brien, my preceptor for the month, is an endocrinologist, so I was able to spend time in the clinics and in the hospital. Each clinic day is organized to a certain demographic of patient. For example, some of the clinics I attended were as follows: prenatal diabetes, young adult diabetes, pediatric diabetes, endocrine (thyroid), endocrine (adrenal), diabetic foot. Another endocrinologist, Dr. Dinneen, was also a mentor of mine while I was there. He was a great inspiration due to his passion for his patients and care for the diabetic foot in particular. Every week, he would round in the inpatient wards with a multidisciplinary team for diabetic foot rounds. He would see patients with a podiatrist, an infectious disease doctor, a surgeon, and nursing. This was an approach to a complicated problem which I had never encountered before, and seeing all the disciplines working together to solve these issues was inspiring.”
“I had the wonderful opportunity and pleasure to live and learn Medical Spanish for four weeks in Quito, Ecuador during the fall semester of my fourth year of medical school. Because I have had interest in global health and learning Spanish for many years, I searched for an international rotation that in which I could have exposure to both. On the AMSA website I found a Spanish school at draws people from around the world and also has a Medical Spanish course. Finding this my perfect opportunity to learn more Spanish and get exposure to health care abroad, I applied to the program and registered for credit with UIC.
I can happily report that my Spanish skills improved, I learned a lot about health care in Quito, and I also had an excellent experience living in and exploring Quito and other parts of Ecuador. Each weekday I had 4-5 hours of Spanish instruction (I signed up for group classes, but because it was the slow season I got one-on-one teaching) after about 4 hours of clinic time in the morning. In addition to my formal learning experiences, I spent time practicing Spanish with my host family and Quito residents I met when touring the city. I found the Spanish classes greatly improved my Spanish abilities. I had had little Spanish experience since my four years in high school, and now I am able to understand about 75% of what I hear and read in Spanish, and I am able to communicate some information to Spanish-speaking patients. I have continued working on my Spanish skills back home by taking the Clinical Medical Spanish elective that UIC now offers.”
“As a third year medical student interested in pursuing obstetrics and gynecology as well as working in an international setting, the experience was an invaluable one. The two weeks in Cap Haitien, Haiti fit perfectly into the last two weeks of our Ob/Gyn 6 week rotation as third years. Once arriving in Haiti, the faculty we had traveled with were amazingly supportive and helped us settle into the house at which we stayed for the duration of the program. The showers pumped only cold water and the electricity sometimes cut out, however it only added to the experience of really feeling what it was like to live in the community. Never did I feel in danger at our house, at the hospital, or moving around within the community. We commuted to the hospital nearby Monday through Friday of the first week and began immersing ourselves in the residency program, operating room, and labor & delivery ward. We were invited to participate in the morning reports with the residents, and even though they were presented in French, a resident was assigned to us to translate into English. We also attended weekly Grand Rounds in the afternoon. We each were able to do a Power Point presentation on topics chosen by the residents.
Between the two students, our time was roughly split between L&D and the OR. My first week was spent in the OR where I gained exposure to procedures I would never have seen stateside. We performed a Le Fort, drained and removed a 10cm x 14 cm sterile tubo-ovarian abscess, and repaired fistulas created by 4th degree tears that had never been addressed. The surgical teams were comprised of American and Haitian doctors, medical students, and Haitian residents who spoke many languages. Some procedures were carried out entirely in Spanish as the only uniting language between the American and Haitian contingencies.
That weekend we were able to explore the city more and experience some of the historical sights. Monday, we traveled over 4 hours over the nearby mountains to a small village in which we set up a field clinic. With the help of an interpreter and under the guidance of Dr. Durkee, I saw 64 patients in 4 hours. We saw GERD, blindness from cataracts, severe hypertension, and children with malaria, amongst other maladies. We were also able to conduct a similar clinic at a nearby orphanage on a separate date.
The rest of that week, much of my time was spent on L&D. I participated in numerous deliveries, many of them in which I caught the baby and delivered the placenta and attended to any tears or episiotomies. I participated in D&Cs for spontaneous abortions and observed the management of pregnancies complicated by placental abruption or severe pre-eclampsia. Not all of the deliveries went smoothly, however, and we were present to help in an incredibly sad case of hydrocephalus that went undetected until delivery due to lack of access to ultrasounds and presented as a breech stillbirth with entrapment of the aftercoming head. During all of our experiences, our American doctors were close by to guide us through suturing vaginal tears and the residents would grab us to help in deliveries and teach us how to listen to the fetal heartbeat using only an adult-sized stethoscope and correctly perform Leopold’s maneuvers.
All in all, it was an experience I would repeat a hundred times over. The opportunities for learning and growth were present in every patient and every interaction with the residents.”
Pouring water on the floors of the crowded 20 bed internal medicine “room” in Mt Meru Hospital, the nurses tried their best to keep everything clean every morning when I visited the wards. Witnessing many scenes similar to these morning experiences in Africa taught me plenty about the practice of medicine and helped me to appreciate the privileges, tools, and resources available to me in the United States.
Looking back on the experience, I came to realize that there is a fine line between ordering too many tests to make a diagnosis and not enough. In Mt Meru Hospital the physicians don’t have the materials available to order blood test, CT scans, MRIs on everyone. In fact they don’t even have a CT scanner or MRI machine for use.
Patients would come in with headache, fevers, shortness of breath, fatigue and mental status changes and leave after being treated for cryptococcal meningitis from AIDS, CHF secondary to HTN, malaria or HIV dementia with no tests performed. Whether or not the diagnosis were correct every time seemed irrelevant to the physicians because patients symptoms would improve after being treated. Whether this was placebo affect or patients just getting better on their own was not a concern. They only cared that patients felt better. Witnessing such patients made me realize that all the tests were not necessary all the time, however having the options to perform tests is a privilege the physicians in Africa did not have.
Reflecting on the experience I can say that I feel there is a spectrum on how to make a diagnosis. In the United States it seems tests are ordered quite often to a point where they may have not been necessary. In Africa tests are not available when they are necessary, meaning physicians do their best to try and come up with the diagnosis only by H&P.
In my mind the perfect physician is a balance between the two. A physician that mostly uses the history and physical to make a diagnosis, and only orders tests when necessary. My experience in Africa taught me this more than any classroom in the US could. Everyone should take time to go overseas and see how medicine is practiced in countries less fortunate than ours. This will provide experiences that will enable one to become a better physician by knowing what it is like on the other side.
On a less serious note, seeing the animals and climbing Mt. Kilimanjaro gave me a great break before residency starts!
Considering that Uganda has the 20th highest maternal mortality rate, 15th highest infant mortality rate in the world, and ranks among the top 10 countries for highest HIV prevalence rates, the Ugandan government has gone great lengths during the last decade in an effort to improve the health of its people. Project Bumwalukani is one of many projects that have been created to better provide health services to the Ugandan people. Foundation for International Medical Relief of Children set up this clinic in Bududa district, which is one of the poorest districts in Uganda. Before heading to Uganda, I looked forward to seeing how a sustainable project runs in a third world country, how the clinic runs despite a lack of resources, and how the Ugandan people react towards health care overall.
During my clinical experience in Uganda, I found myself comparing the patient interactions with those I have experienced in U.S.A. There were similarities and differences with the patients, the patient-physician interactions, and the health care system. On the first day of clinic, I noticed that most of the patients spoke very softly to the clinical officer. Initially, I thought that the patients were afraid or ashamed to talk about their medical problems. However, I soon learned that as a sign of respect, Ugandan people speak very softly. Though the patients respected the clinical officer and his medical recommendations, there was no discussion about what the patient wanted in goals for treatment.
Another important difference I observed was the attitude towards vaccinations. Before I left for Uganda, U.S. headlines were discussing the growing number of unvaccinated children and parents’ reasons for not wanting to vaccinate their children. In Bududa district, mothers walked up and down the mountain and far distances with their babies on their back to come to the clinic for vaccinations. These mothers understood the importance of vaccinations because they have seen children suffer great consequences without them. On certain days of the year, the Ugandan government health officials come to villages and with the clinic staff visit homes, inquiring about vaccinations and ensuring that all children have had the appropriate vaccinations like polio. I was happy to learn that the Ugandan government is working hard with its people to promote healthy lives and break down barriers to access to health care.
This rotation was an amazing experience, and I am thankful to have had the opportunity. This international elective has inspired me to be more empathetic person and be a more compassionate physician. I do not have to worry about electricity, running water, clean drinking water, and access to health care but many people do, even here in the U.S.A. My experience in Bududa district has taught me to be more open-minded as a physician and community member. One of the best parts of this elective was my full immersion into the local community, traveling the distances that some of the patients go to come to clinic, eating the local food, and engaging with the local community members. I was inspired by all of the health care workers and volunteers who spend so much time educating patients and people in the community about public health, healthy lifestyles, and preventative health care. I wished that I could have spent more time in Uganda because I think it would have been more rewarding to create and initiate a project of my own. I hope to return to Uganda during my residency training to build on this experience and discover ways to improve the health of those who are in need.
I left for India with a true curiosity for what the experience would be like. I have been to India several times in the past to visit family, and while these trips were always fun, they did not offer me the opportunity to really experience what India has to offer. I would always spend each day with a visit to a different family member or family friends’ house, none of whom I know or remember, eat great food, sleep, and then repeat the next day. I never traveled India; never spent much time interacting with the people. This experience changed all that.
CMC Hospital was an amazing experience. While there, I rotated through internal medicine, pediatrics, emergency medicine, and Community Health And Development (CHAD) program. I came to appreciate so many differences in the way that medicine is done there compared to the states. For one, money is a significant factor that plays into hospital medicine. At the same time, the hospital was kind enough to those who were less well-off to give them discounted or free care, which is paid for by the wealthier patients who pay full price for their health care. On a more individual level, doctors showed a significant capability to use the physical exam to diagnose disease. I was very impressed to see them using every aspect of a pulmonary exam to diagnose post-obstructive pneumonia on my first day on the wards. It gave me renewed interest in refining my own physical exam skills, which could potentially help me avoid unnecessary imaging and/or labwork in future practice. CHAD was a phenomenal experience because we spent a few days doing house visits with a nurse to give primarily pre and postnatal healthcare to patients in nearby villages. It was quite an experience to be welcomed as guests into these strangers homes and treated so kindly. Besides spending time at the hospital, I also traveled to a leprosy clinic where I got to learn much detail about the medical care needed to care for these patients. It was an eye-opening experience.
Another amazing experience was the trip to Kalrayan hills during our first weekend in India. While there, we gave much needed, although limited, medical care to a few of the underserved villages. We were able to witness a people with a completely different lifestyle, with no quality medical care, living their lives. They were so appreciative of what little care we could provide; it was a truly humbling experience and an honor to get to meet and share the day with them. However, I do not know if I will ever forget the patient with intestinal worms who came to us for treatment because the worms were resistant to the medication he was already on. Watching him walk away dejected when he found out that there was nothing we could do to help him was one of the hardest moments of the trip.
The rest of the trip to India was something I will never forget. Traveling through Tamil Nadu, visiting my family in Kerala. It was all breathtaking. I absolutely loved getting to know all of my classmates so well and the rest of the international students at the Modale Hostel. So many new people in my life that I hope I can call friends for a very long time. And last but not least: the food was absolutely amazing.
While napping on my flight to India, I was awoken by the sound of hushed voices. I could not help, but overhear how the middle-aged male sitting behind me had developed chest pain after eating his meal. A physician passenger on board asked him questions, did a physical, and presented a detailed HPI to a physician on the ground by telephone. His pain was eventually relieved by Tylenol and at that moment, I thought at the root of it all, medicine is the same no matter where we go. However, throughout the month, my initial thought was constantly challenged. I struggled with 1) how money determined health care, 2) how different physicians practiced medicine.
From the poor patients in the villages and at low cost effective care unit to the individuals who could afford a semi-private room in the hospital, the wide ranges of poverty and wealth were seen throughout the trip. What shocked me the most was how one’s money had so much influence on the care they received. In the rural village, a young female with abnormal and very heavy menstrual bleeding was feeling weak and fatigued and this was starting to affect her ability to work in the fields. We diagnosed iron-deficiency anemia secondary to menstrual blood loss, but we could not do anything but tell her to go to the nearest hospital to get basic blood work and see an OB/GYN doctor. This was out of the question since the nearest hospital was hundreds of miles away and she could not afford this. Something as simple as getting iron pills or getting oral contraceptive pills to try to regulate her bleeding, could not be done because there was simply no resources to provide these medications or get them to her village. At CMC hospital, physicians had many conversations with the patient and family regarding costs and their ability to pay. This was most apparent in the emergency department where work up and treatment was usually delayed until the bill was settled. The physician would see the patient and then write orders for blood work/imaging/medications and this was given to the family. The family member would then have to wait in line at specific billing counters to pay the bill and purchase the needed supplies (even IV fluid) before returning to the physician and producing proof of payment. When a patient needed percutaneous cardiac intervention (the standard here in the US), a long discussion with the family and patient needed to occur because many could not afford the procedure and thus medications would be used instead to treat angina. I am still amazed at these stories and appreciate how our healthcare system functions. The US system as a whole may be broken (high costs, not enough primary care providers etc), but in this country one’s health and well-being is not based solely on the family’s caste and wealth.
Regarding how physicians practiced medicine, the level of knowledge and physical exam emphasis as well as the patient-doctor relationship left a great impression on me. Firstly, all the physicians at CMC hospitals were very passionate about providing good quality care and teaching. This was manifested by the detailed histories they took, and the amount of time that went into the physical exam. They noted slight neurologic deficits I would have easily missed, rashes and scars suggestive of disease in places that most doctors forget to check (between the fingers, under the nails, on the scalp covered with hair). Not only this, but their differential diagnoses were always large, expansive and they made sure to push the boundaries of their students’ understanding about medicine. This is something I feel has been lost in the teaching of medicine here in the US mainly due to electronic medial records. In India, despite how rushed the physicians are, their ratio of patient interaction time to charting is not as disproportionate compared to ours and that ultimately leads to better relationships, better teaching, and higher quality care. The second shock had was the paternalistic patient to doctor interactions. This did vary by physician, but there were office visits where doctors did not let the patients speak nor explain what the plan was before sending the patient off with a prescription or script. In addition, patients accepted whatever was told to them at face value and did not ask questions even when the instructions given to them were vague and unclear even to me. There was usually minimal dialogue and I felt the time that could have been used for patient education was wasted. In the end, I concluded that even though the knowledge and textbook medicine was the same, how medicine was practiced, the art of medicine, is what differed so greatly between our two countries.
After spending one month in Vellore, Tamil Nadu, India, I still find myself speechless when asked to describe my experience. It is difficult to describe the hundreds of new smells coexisting at once, eating meals without utensils, and feeling like I was going to be flattened by an auto rickshaw every time I sprinted across the street. It is difficult to describe what a few pills meant to rural villagers, how a HIV positive diagnosis ruins the life of a former nurse, and how despite minimal resources the hospital had, physicians could provide high quality care while carrying double or triple the patient load US physicians carry each day. I sit in my living room now overwhelmed by recent memories and think to myself: I am so fortunate – so fortunate to have so many opportunities and luxuries in this country, so fortunate to be pursuing a career I love, and so fortunate to have had this unique experience. I appreciate the simple pleasures of my life much more and am renewed by my dedication to underserved patient populations and to medicine overall.
The most striking aspect of my month-long rotation in India was not the differences between medicine in the US versus India as I had originally expected; rather it was how similar medicine was. From the informational sessions I had been to regarding the trip, I had expected a paucity of resources and lack of awareness of cutting edge technologies. However, most of the techniques and resources available in the US were, in fact, the same if not better than many institutions in the states. The difference was that patients had to pay for all aspects of patient care. So while the resources seemed to be available to the same extent as the US, it was not fully utilized to the same extent as the US, where often any and every step is taken regardless of who is and is not able to pay for treatment.
I had also expected medical treatment to be far cheaper than the United States, given how most things available for purchase are substantially cheaper in India. However, within ENT at least, I found this to be untrue. Many head and neck procedures were in fact the same price as the US. Large head and neck cancer removals cost upwards of $200,000 USD. Discussions with faculty and residents indicated that people and their families would sell all their possessions to receive treatment. On the one hand, this obviously resulted in disaster for families – literally the worst case scenario for families, in which one medical catastrophe resulted in complete bankruptcy. However, this system also discouraged the rampant waste of medical resources that is prevalent in the US. There was no excessive testing, especially in low cost settings such as the LCECU that took care of the urban poor.
Our experiences with the low socioeconomic populations were very interesting – expensive imaging tests were rarely ordered. Tests never seen in the US such as mastoid xrays, xrays in evaluating adenoid pathologies were used regularly. The million dollar workups seen in the US were never seen. In addition, there is a much greater emphasis on the physical exam to guide diagnosis and treatment. I learned many tips that I hope will stick with me throughout residency and into my career.
The culture, as expected, was enormously different than the US. Local customs, inter-gender relations, food, and sanitary conditions were a major shock. The sheer chaos of the major cities was overwhelming. The traffic far outstrips that of New York City or any other American city. Merely crossing the street can sometimes be daunting. The overpopulation and the resulting chaos also lent itself to more disordered social interactions. The concept of taking turns and forming lines was simply not present – when ordering food, for example, it was simply whoever managed to hand their order to the cashier or cook first. The conservative culture was also evident. At times, the faux paus of our group were so obviously out of place that it was somewhat embarrassing. The extreme heat made all of us reluctant to the wear long pants and collared shirts that are standard amongst the population and we certainly received our fair share of stares for wearing shorts and tank tops. All in all, it was an extremely interesting experience and I enjoyed comparing and contrasting the differences in culture and learning a bit about navigating south Indian society.
In conclusion, I am incredibly grateful for this month long experience. I learned a great deal about medicine, adapting to a different culture, and gained many new friends that I hope will last a long time. I also made professional contacts in the ENT world. One day, I may return to CMC once I am established and am able to contribute to patient care there. I feel that this enriching experience will help me become a better physician on both a personal and professional level and can only hope I will have similarly amazing experiences in the future.
I’ve been fortunate to have the opportunity of doing several medical mission trips abroad: First as a pre-med student in Nepal, then as an M2 student in Ecuador and now as an M4 student in India. Reflecting back on these experiences, it feels somewhat gratifying to realize my progress in learning medicine and being able to apply it clinically. I started this international elective in India with the understanding that the relationship between illness and its source is complex. Many factors play into this link including poor environmental conditions, low education levels and awareness of needed medical care, financial barriers in accessing health services, exposure to hazardous occupational conditions, and a lack of resources necessary to maintain good health status. I find it interesting to learn how, despite all of these adversities, different communities still manage to cope and address the needs of those with health issues to the best of their capacity.
Christian Medical College (CMC) is a good example of such a community. Given the hospital’s high volume and extensive pathology, many international students are recommended to rotate here for academic credit. Consequently, we learned about not only the medical education in India but also Austria, Germany, and Switzerland. The language barrier was an issue as far as being able to communicate and interact with patients and being able to take histories and do physicals. Thankfully all of the physicians and majority of the medical staff knew English. Because ward rounds, patient presentations and charting were done in English, this allowed for a more involved experience in other aspects as a visiting student.
During this international elective, I rotated through child health, Low Cost Effective Care Unit (LCECU), dermatology and ER. Very quickly I learned about differences in their medical practice compared to the US. For starters, infectious etiologies for disease are much higher in the list of differentials. Antibiotics are readily available over the counter and are often taken without prescription or doctor supervision. This has led to issues with antibiotic resistance (Ciprofloxacin as an example) and interference with accurate diagnosing and management of infectious diseases. Similarly as in Nepal, patients are responsible for their own medical records. I feel like this adds to some sense of ownership over their own health, at least from the patients’ perspective. What happens if they lose the records? “They simply don’t,” said Dr. Samil Abraham. “To get a new medical record card costs money and a lot of hassle so they know better.”
Due to the high prevalence of illiteracy in the population, it is customary for patients to buy the prescribed medication after an encounter and then come back so that the physician can point out what each medications is for and how much to take. This brings about the differences in the concept of patient privacy. Many a times the attending was interrupted during a patient encounter when a patient that was seen earlier would simply come into the room to ask about instructions on how to take the medication that was just prescribed. In outpatient pediatrics, I found myself with four physicians taking care of patients simultaneously in the same room. Clearly confidentiality ceases to be a priority when 230 patients need to be taken care of in one day.
Cultural aspects also influenced some of differences in their medical practice. Because consanguineous marriage is common in their population, it is always addressed as part of the family history. To make the correlation easier, pedigree drawings are typically part of their charting. It is also thought to be inappropriate to ask patients about certain aspects of their social history. Asking about smoking and drinking habits as well as sexual activity is considered offensive. They infer sexual activity from the patient’s marital status and generalize other information based on the symptoms they present. For instance, I saw a patient at LCECU who was admitted in their ward due to hepatic encephalopathy. The patient’s drinking habits was never inquired and most of his evaluation was performed based on the clinical picture and laboratory results. Because of the high prevalence of infanticide, the sex of the fetus is not disclosed in prenatal evaluations. Also, the mother’s family covers first pregnancy expenses.
Reflecting on the overall medical care I witnessed in India, it was apparent to me that providers in this country have a good grasp on physical exam techniques and evaluations. This is reinforced by the limitation of available resources and the patient’s financial barriers to pursue other modalities for diagnosis. One aspect, however, in which I found some shortcomings was in the approach to clinical reasoning. I think this was more apparent to me during our time with Dr. Beulah in the Kalrayan Hills. Throughout my medical education, I’ve been often told to treat the patient and not the number or just the symptom. In this manner, it seems to me like medicine is more individualized since the patient’s evaluation for a symptom is dependent on many factors (onset, location, duration, quality, severity, family history, social history, physical exam etc.). When we worked with Dr. Beulah, the patient’s evaluation was pretty much narrowed down to protocol. If a woman presented with suprapubic pain, the diagnosis was PID and she was given a prescription for Doxycycline, Flagyl, Ranitidine and Paracetamol. If someone presented with joint pain, the diagnosis was arthritis and was given a prescription for Paracetamol, Ranitidine, and calcium supplements. I can understand this approach, however, given the circumstances, as previously mentioned, where resources and access are limited. Treatment is thus based on prophylaxis and management of the most common illnesses and, therefore, most likely diagnosis under this setting.
Overall, I definitely enjoyed my experience in this international rotation. I would definitely encourage fellow med students to consider this opportunity as an elective in their fourth year. For the longest time, I’ve been captivated by global health and public health and I think after this rotation this interest has been reinforced. I look forward to the next time I can go abroad to learn about international medicine in underserved populations, hopefully this time as a practicing physician and a provider.
Before I started my rotation at the Christian Medical College in Vellore, I expected that there would be a difference in the resources available to patients and providers, such as diagnostic tests and therapeutic options. However, the most striking difference between the American and Indian healthcare system was not the discrepancy in resources, but the culture. I often found myself frustrated by the non-patient-centered approach adopted by providers and ancillary staff members. For example, when coming up with management plans, the discussion seemed mostly one-sided and physician-driven. Of course, given my inability to understand Tamil, I cannot definitively say that this is the case, but it did appear to me that the provider would tell the patient about the next steps and the patients appeared to go along with the “instructions.” This type of interaction mirrors the patriarchal model that was predominant in the U.S. until relatively recently. I see this as a problem still in the U.S., but it was more pronounced in India.
The provider-centered care was most noticeable in the specialty clinics, such as endocrine surgery and dermatology. My time at the Low Cost Effective Care Unit (LCECU) painted a slightly different picture. During outpatient clinic, Dr. Sunil Abraham posed a question to Maria and me, “If you ask a patient what their chief complaint is and you don’t interrupt, how long do you think it would take for them to tell you?” He illustrated his point by sitting back while he listened to his patient share her concerns about her chronic abdominal pain., which took all of less than one minute. Dr. Sunil’s interaction exhibits a more patient-centered approach that I really respected.
However, not all of the general practice doctors that I encountered at LCECU followed Dr. Sunil’s lead. One physician during an outreach clinic in one of the surrounding villages openly mocked an elderly woman as she wailed and raised her voice at the staff. I was not sure what the woman’s specific complaint was, but based on some of the staff’s comments (uttered in English), I would guess that she was unhappy about the wait time. This woman was clearly in distress, and may very well have had an underlying mental impairment/dementia, as she appeared to be somewhat confused by the situation. Instead of showing patience and using calming techniques, or even simply apologizing for the wait, the staff, including the physician, clicked their tongues at her and even yelled at her. The lack of compassion for this patient was very disturbing to me. Although it would be easier to see this as an isolated event of having an impatient team of providers, it seems to me that this is a systemic problem. It is likely a combination of limited resources putting higher demand on providers—putting them at risk for burnout—and limited emphasis on provider-patient relationships in the training curriculum. Anecdotally, I noticed that the doctors at CMC seemed to me, on average, superior to American providers on their understanding and retention of knowledge regarding pathophysiologic processes of diseases. They were very impressive when it came to clinical acumen and their ability to pull up names of genes, biochemical enzymes, and so forth. My guess is that perhaps compared to the American medical school curriculum, a greater portion of Indian medical school curriculum is allocated to learning the scientific aspect of diseases as opposed to interpersonal/communication skills.
Also, the issue underscoring the problematic patient-provider relationships I often saw in Vellore may be the lack of patient empowerment. Patient empowerment is a concept that is closely tied to health literacy, which is associated with education level and literacy in general. According to the CIA World Factbook, India’s literacy rate is just under 75%, which is almost 10% below the global adult literacy rate. The relatively low literacy rate is likely contributing to the health literacy problem. The health literacy and patient empowerment issue is most evident in the lower socioeconomic classes. In a country that is still recovering from the caste system, the disparity between social classes is striking. Although India has some of the world’s best universities, there is a huge difference in the education obtained by the middle and upper class population and that obtained by those living in poverty.
One issue that I feel ambivalent towards is the payment model. Since approximately 70% of healthcare expenditures is paid out of pocket by patients, there is patients have more “skin in the game.” This theoretically would drive down healthcare costs as patients would be more prudent in which services to get. More importantly, I believe that it also provides patients a greater sense of ownership over their own health. Along the same line, most of the patients I saw at CMC kept their own medical records and would come to their clinic visits with previous imaging and visit notes in hand. Personal responsibility in these patients was much more stressed than I have seen in the American medical system. Increased responsibility is more likely to produce patients, i.e. healthcare consumers, who are engaged in the healthcare system and in their own health. One of the issues of being passive healthcare consumers is that they are more likely to see good or poor health as something that “happens to them,” as opposed to something that they can work to improve or mitigate. Promoting higher engagement and ownership should ideally increase empowerment. However, as I mentioned previously, I did not see patient empowerment as a salient theme in the Indian healthcare system, or at least not at CMC. So, what I would expect theoretically may not add up to what happens in practice here. A downside of having high out of pocket costs is that it can make it prohibitive for patients to obtain beneficial tests and procedures. With that said, I was surprised to see that I did not see too many instances in which patients opted out of services due to associated costs.
In that vein, the focus on cost effective care is something that was very enlightening to see during my time at CMC. I am sometimes disgusted by the wastefulness of resources in American hospitals, such as disposable isolation gowns, suture kits, etc. While some of my classmates were put off by the use of reusable equipment and supplies, I found it to be a smart idea. If the surgical gowns can be washed and sterilized, why not use them over throw-away gowns that cost the patient $80 per pop? I do have to mention that I do not know if there is a difference in post-operative infection rates or how much of that is due to the difference in OR gears, so that is my one hesitation about wholeheartedly endorsing the practice.
I was also impressed by the involvement of family members in the care of patients. Almost every clinic patient was accompanied by at least one family member. I am a proponent of including family members in the management plan as people’s social support and networks play a huge role in patients’ adherence rates and outcomes. Having partners or caregivers present during the actual clinic visits help reduce miscommunication as well as potentially alleviate anxiety surrounding medical encounters. I also saw that family members were also called on to take part in caregiving activities in the inpatient setting. For example, I encountered a patient in the LCECU ward who was a 12 year old patient who developed a brain abscess secondary to an infection of a VP shunt placed to alleviate hydrocephalus resulting from TB meningitis. The patient’s mother and sister helped out with many of the nursing duties such as bathing, feeding, and pulmonary toileting. Although on one hand, this may be seen as an excessive burden to the family, there are perks to this set up. For one, shifting nursing responsibilities over to the family has associated cost savings for the healthcare system. Also, the patients are likely to feel a greater sense of comfort being taken care of by their loved ones, especially when they are in a strange environment (i.e. hospital). The family members also get the chance to nurture and care for their loved ones, and providing a greater sense of engagement with the patients’ health and the healthcare system. The hospital in the U.S. can often be a cold, sterile environment, and allowing family members to participate in the patients’ care can alleviate that feeling.
I returned from India with lessons that could be applied to the American healthcare system, as well as a renewed appreciation of the healthcare system we have here domestically. I had a truly memorable experience during my rotation, and I feel so fortunate to have had the opportunity to learn from the healthcare system in India and to have done it in such good company!
Besides the spiritual leaders in the hospital, Samsung Hospital also had an ample number of religious volunteers. For Christianity, there were as many as 70 volunteers who offered their time on a weekly basis. This was the spiritual manpower who went door to door to each patient room to see if they sought out any religious support or comfort. Patients who were interested had the opportunity to write down their prayers for the pastor, or even take the opportunity to reach out to the volunteers who were currently in their room for support and prayer. Although some patients did not enjoy the visits (or intrusions) very much, there were many others who welcomed the visit from a nonmedical staff. These visitors were not a herd of resident physicians in the mornings, a nurse who delivered medications, nor even a phlebotomist who poked their veins early every morning. These volunteers had the time to listen to the patients’ worries and concerns about their diagnoses, and they had their religious understanding to convey that there is an underlining purpose to human pain and suffering. And in a country where efficiency is highly demanded and outpatient clinics schedule appointments q3min, patients sincerely welcomed the unhurried pace of the volunteers.
The prayer requests from the patients were subsequently delivered to the chaplains. And while they prayed and reflected on each patient’s concerns, they also took the time and effort to visit each patient and speak to their family members. In such dire situations where one is required to be in the ICU or inpatient service, religious leaders received the same amount of respect (or even more) as the physicians. While physicians spoke in terms of statistics and new research, chaplains spoke in terms of hope and courage to give the situation’s outcome to an all-mighty God. And as the physicians spoke while standing over the patients who were sitting or lying in bed because they needed to see many more patients in the morning, the chaplains took the time to grab a nearby chair and sit at an equal eye level to the patients.
Reflecting as a future physician, I have come to realize that Korean physicians are more focused on seeing as many patients in a day as possible because the reimbursement system is organized in such fashion. In terms of training, there is less focus on patient care, how to speak to patients, or how to deliver bad news. Their training is rigorously structured around the science and medical knowledge since the medical degree is a longer and more competitive undergraduate program. And as a system, the patients do also enjoy the efficiency of outpatient clinics – they are able to see their physician for a quick appointment and then is able to head back to work. But in the inpatient services, I believed patients were mildly frustrated that they were not given an ample amount of individualized attention. These patients were sick enough to be hospitalized and from their perspective, they wanted to know what was going on in their bodies in plain, understandable language with time to ask questions. And for those who were religious or sought out religious support, I do think that these patients felt “better” that someone (let alone, a religious leader) came to speak to them in layman’s terms, show concern, and expressed hope even though they did not know each other.
Pastoral care delivered a more complete picture to patient care, especially in Korea where the physicians were too inclined towards filling their day with seeing as many patients as they could for compensation reasons. Through religion, patients were receiving a holistic approach to medicine. Indeed, it is an unfortunate reality that I will also need to worry about my compensation and billing with my time. But I do hope that as a Christian physician, I can embody a holistic approach towards my future patients.
I spent one month in Paris, France this year doing a rotation at a hospital, Hôpital Kremlin-Bicêtre. During this time I spent a month working in the inpatient psychiatry unit. This was particularly important to me since I am starting a residency in psychiatry this June. It was interesting to see that some of the same stigmas against mental illness in the US also exist in Europe. However, there were a couple of differences in the way patients were treated that I thought were really interesting. In the hospital I worked at, they have a mother-baby psychiatry unit just for mothers who need to be hospitalized, yet it gives them the opportunity still bond with their young children. This is something I’ve never seen or heard of in the US and loved that it provided an opportunity for patients to continue to connect with their familiars while simultaneously getting the necessary treatment they need. Similarly, patients on the inpatient unit get an opportunity toward the end of their treatment to find successful coping skills to integrate back into their communities. They spend weekends doing activities of their normal life before their hospitalization and get a chance to come back and process it before formally being discharged. It was powerful to see this take place since it’s something that doesn’t happen in the US that I think patients would greatly benefit from.
While working on the inpatient unit I was able to improve my French skills by interviewing patients and doing physical exams in French, and also got to help do ECT procedures. In the future I have the aspirations of becoming a child adolescent psychiatrist and would love to work in Paris. I have included a powerpoint that I gave the to French medical students that further outlines some of the differences between medical school in France versus the US in addition to some differences within the field of psychiatry.
In addition to working while in France, I had the opportunity to see many famous sites in Paris, and travel to southern France to the city of Marseilles. I had a nice weekend there as the weather was warmer and I was able to enjoy the beach since it’s close to the ocean. I also got to enjoy south of the things the city is known for such as “la bouillabaisse” which is a seafood soup, and delicious Italian food, due to its closer proximity to Italy.
My time in India was quite an eye opening experience not only for the differences I had expected but also for the similarities I hadn’t. When your medical education and training is constrained to one location, you tend to develop tunnel vision on the merits of your own program over others. Having only experienced medical education in the United States, I was pleasantly satisfied with the exposure I had at Christian Medical College (CMC). Attending grand rounds, journal club, and working up simulated patients was all familiar activities. I felt comfortable and knowledgeable in the environment that I was placed in, despite being on the other side of the globe. Reading and learning about some of the newest and advanced procedures that are performed at CMC was also an enriching experience. It really emphasized the contrast that was present when comparing the life inside CMC to the life of the public and shop owners just outside of CMC’s gates. However, it is the lives of the people who live outside these CMC gates that really awaken you to the medical experience here.
The initial surprise for me was the physicians’ freedom to bill patients based on the patients’ ability to pay. Physicians were truly taking the patients’ lives into account in their medical decision-making. They considered who worked in the home, how much money was made, if they can afford the testing/treatment, how far they had traveled to seek care, etc. I appreciated that the physicians were allowed to manipulate such billing without the need to frustratingly deal with administration. It was based in an inherent trust and respect in physicians that I tend not to see as much in the United States anymore. In my opinion, the atmosphere of healthcare in the USA has shifted to one where physician independence is blunted, patients are self-educating and everyone questions the decisions of healthcare providers. This is not entirely negative as informed patients who are knowledgeable about their own medical care is a good thing. However, this can sometimes lead to mistrust of doctors amongst patients. Contrastingly, the typical patient I saw in Vellore took their physician’s word as Gospel and strictly adhered to their recommendations. This isn’t to say Vellore doesn’t have its share of non-compliant patients, but the percentage I came across was far fewer than my experience in the United States.
Getting back to the clinical differences I experienced, I was quite impressed with the clinicians’ abilities. There tends to be an overreliance on testing and imaging in the United States, particularly for the upcoming physicians in my generation. However, a physician dealing with populations that may not be able to afford the battery of diagnostic workups that may be indicated must truly rely on the acumen of his or her history and physical. Watching many of the attendings perform physical exams masterfully inspired me to want to improve my own skills, so that one day I too may be able to pick up on subtle nuances seen in the ill patient.
The four weeks I spent abroad turned out to be some of the best 4 weeks of my M4 year. Although I have mentioned a few things that struck a chord with me, there are plenty more experiences I had that will also stick with me. The biggest takeaway I had from this trip is the importance of acknowledging the world around you and the wonderful potential for growth when you collaborate with colleagues from different backgrounds. These four weeks have not yet turned me into a superb physician, but I do believe that the time has added to my training and inspiration to one day become one.
Reflecting upon my time in India, my first thought is that I am so grateful to have had this opportunity. Four weeks in India flew by and here I am back in Rockford with so many lifelong memories to cherish and lessons learned to share. It’s easy for expectations and reality to differ, as many people find out while working abroad, but this trip far exceeded my expectations. When I look back at why I wanted to originally take part in this trip, it was about a commitment to service, the community, and the broader context of medicine. For me, medicine is truly about the people and the powerful connections to be made. The ability to give and receive in a mutual relationship, touching the lives of others, is one of the greatest privileges we have as future physicians. What India emphasized for me was that the core concepts central to the practice of medicine are the same anywhere regardless of the nuances. The essentials of medicine were the same in India, just with different tools and methods at times. Though I may never see so much acute rheumatic fever, tuberculous meningitis, dengue fever, or complicated leprosy in the United States, what I found most important to recognize was that all people are human, regardless of culture, race, ethnicity, gender, or other specifications, and we all share in common experiences, emotions, and endeavors that connect us.
One of the greatest challenges initially faced was not speaking the native language. Surprisingly, not speaking Tamil made my experience at CMC that much more valuable. I found that spoken language was not the only way to connect with patients. I can recall only 3 Tamil words I’ve learned (perenna/name, vaisu/age, and nandri/thank you), but even with my limited language skills, I still made best friends with a 13 year old boy whose father wanted us to keep in touch, wrapped the arm of a 3 year old burnt by boiled milk who wanted to wear my pink sunglasses and whose mother worried that I had not eaten lunch, and made plenty of gestures and motions to indicate what I meant while working with the villagers in Kalrayan Hills. Countless other connections were made, and those were some of the most meaningful experiences I had. My favorite part of every day was making friends with the patients, children, families, physicians, nurses, residents, interns, and fellow international medical students. They made my time at the hospital and in India so much more enjoyable and worthwhile.
Beyond the main hospital, the LCECU (low cost effective care unit) was a wonderful example of the future kind of setting I’d like to work in, providing a full spectrum of health care services to an underserved population with an emphasis on the bigger picture of medicine. Experiences like those I had in India truly helped me focus on becoming a better future physician in gaining greater perspective toward efforts to promote social justice and health equity all around the world, hopefully fulfilling the mission and vision set out by Ida Scudder at CMC. After four years as a medical student, I can say I’ve maintained the same passions I entered medical school with but now have a better understanding of global medicine and it’s various aspects as well as assets. I look forward to starting residency with a renewed fervor for service to the community and the practice of compassionate medicine.
Thank you to the Bertram A. Richardson Scholarship Committee for helping to support and make possible this international rotation. It was the opportunity of a lifetime and an invaluable experience that truly highlighted to me why I look forward to a career in medicine. I am excited for the future UIC-Rockford students to continue representing our institution at CMC and know they will find the experience as rewarding and exhilarating as I did.
My Scotland rotation was a trip of a lifetime – one I am very glad I had the chance to experience. I went to four different places around Scotland, starting in the Shetland Islands and working my way south, to a town right outside of Aberdeen. I experienced both hospital care and outpatient care, in all types of rural and suburban settings. I also learned about the National Health Service of Scotland on this trip, and I was immersed in the way the Scottish think of medicine and use of medical resources.
I started my trip in Lerwick on the Shetland Islands. It was a very unique experience, especially for a girl from northern Illinois who does not have easy access to large bodies of water. The islands are very isolated from Scotland – being an hour plane ride away. I worked in the operating room with the anesthesiologists, helping with IVs and intubations. They are the intensivists in this little part of the world, and when there is an emergency, they are usually there to stabilize the patient. It was a great few days to spend with them, and Lerwick is a very pretty town. There are very few trees on the Shetland Islands because the wind is so fierce that nothing can grow very tall.
I then moved on to the Orkney Islands, where I worked with a doctor who is responsible for 250 people on 3 small islands. He is the first responder for emergencies and he is on-call 24/7 for forty weeks per year. He also goes to the main city on the islands, Kirkwall, to see patients as well. Orkney is the “Egypt of the North” and has many burial areas of the Vikings. My last day in Orkney was spent in Kirkwall at the Balfour Hospital, where I worked in the emergency department, seeing a diabetic ketoacidosis patient and a patient who collapsed on a golf course. It was quite an eventful day.
Next, I spent time in Raigmore Hospital in Inverness, on mainland Scotland. This town is quite large, almost 90,000 people, but this hospital has a catchment area of much of western Scotland. I spoke to many patients who had driven three or four hours to get to their appointments. Here, I worked with orthopedic surgery, gastroenterology, and general surgery. It was very interesting to see the way the hospital is set up – there are eight patients in one large room and about 6 of these large rooms per medical floor. During this part of my experience, I was fully immersed in the National Health Service (NHS) and learned a lot about how students become doctors, how patients are cared for, and what “free healthcare” actually is in Scotland. On my last night in Inverness, the Northern Lights were bright, and I watched them just outside of the city with the other medical students who were based at Raigmore at the time.
Lastly, I went to Westhill, Aberdeenshire to work in a general practice clinic. I was in this area for two weeks, and this was definitely the most rewarding part of my trip. I saw patients on my own, running my own clinic times, and I also learned how to function within a different health care system. The doctors were all great teachers, taking me on home visits with them, inviting me into their clinic rooms to see interesting patients, and talking to me about their visits to the United States. In this clinic, I learned that patients are assigned to doctors based on geography, and they cannot choose their doctors like we can in the United States. They also may have to wait up to two years for non-urgent surgeries. These are a few of the detractions of the NHS, but the fact that everyone has access definitely seems to outweigh these inconveniences.
Overall, my trip was fascinating, and I am so glad I could go for a month. Learning the culture, the medicine, and just meeting the people there were all very rewarding and I believe they have taught me a lot about patient care and, unexpectedly, about myself. I learned how to be much more self-sufficient while traveling alone, and I also learned how to adjust quickly to new medical settings. I would go back and experience it all again in a heartbeat.
I have finally completed my one month surgical rotation at Black Lion (Tikur Ambesa) Hospital of Ethiopia. My 4 weeks were both short and long: short because I can’t believe I am already back to the cold weather of Chicago, but also long, because I experienced so much in just four weeks.
During my time at Black Lion, I rotated through three different surgical specialities: paediatric surgery, Neurosurgery and General surgery. My experience at Black Lion was educational, informative, and met all the objectives I had originally created. My entire goal for going to Ethiopia was to learn more about the national health system by working under the largest governmental hospital of Ethiopia. I strategically chose Black Lion Hospital for three reasons.
- It is the biggest and tertiary level hospital. Any medical condition from any corner of the country that cannot be treated locally is referred there. It is thought of as the ultimate place of death or healing in Ethiopia.
- It has a very rich human resource; the physicians that work there are the best of the best.
- Since it is a tertiary level hospital and everyone there is referred from all the corners of the country, one can collect very diverse opinions and ideas and meet people from very different areas of the country. The only group of people excluded from this population is the wealthy, with whom I found other channels to communicate. My travel to Ethiopia was very successful in that I was able to talk to very diverse populations from the wealthy to the poor, from the educated to less educated, from the young to the old, from all regions of Ethiopia. By doing this I was informed of the current condition and state of Ethiopia; which is both very poor and in so much despair.
It was a pleasure to participate in the care of medically and socially complicated patients with some of the most skillful, exceptionally patient, and caring surgeons.
As a visiting medical student I was to function as an intern under the supervision of another intern and attending physicians. I was to scrub into different procedures in addition to caring for specific patients on the wards. The routine of a typical day depended on whether we had to operate or not. It included morning sessions, bedside rounding and procedures.
Morning sessions involve detailed report of all surgical cases seen in the Emergency Department and the wards (admitted, discharged, operated, or deceased). Uncomplicated cases are usually discussed briefly whereas complicated cases are discussed in detail by the attending physicians. All surgeons, residents and interns on the surgical rotation are required to attend the morning session. After morning session, the different teams disperse to the operating room (OR) or round on each of their patients. On days where procedures are not scheduled, rounding involves a lot of education to patients and surgical residents by the surgeons. The afternoon then involves prepping patients for the OR the next day, minor bedside procedures, patient education and counseling by the residents and other small tasks. The day usually ends anytime between 5:00 and 8:00pm.
Night times are covered by interns, residents, and attendings on duty. On weekdays the person on duty stays 36 hours in the hospital, while on weekends the shift is 24 hours. The interns usually do much of the work in the emergency department and wards. I was on duty twice in four weeks. During these times, I participated in the admission and workup of patients in the emergency room and some bedside and OR procedures. Minor bedside procedures included suturing of scalp laceration, aspiration of abscess, and irrigation of traumatic urethral/bladder hematoma. In the OR procedures included evacuation of Epidural hematoma, subdural hematoma, elevation of depressed scalp fracture, repair of dural tear, appendectomy, and removal of aspirated foreign material from children.
Black Lion Hospital is a tertiary referral hospital. The patient population is extremely ill, with complicated medical and social problems for many reasons. Among them are lack of education in the general population, lack of enough health professionals, lack of infrastructure in the entire medical system (not just transportation but also level of communication), the presence of bureaucracy, presence of corruption; lack of latest medical equipment such as CT scan, MRI, ultrasound, laboratories, medications, pathological stains, etc.); and occasionally lack of curiosity and passion in the practicing health care professionals. I was struck to realize that there is no standard of care and that the well-being of a patient mostly depends on the goodness and ethics of the specific professionals taking care of the patient.
There are many reasons why patients present to Black Lion Hospital very late in the course of illness. According to the United Nations Human Development Resource report in 2012, the mean year of education for Ethiopians is 2.2 years. Because over 85% of the population lack the basic understanding of disease when they first get sick, they first seek traditional medicine that includes finding a traditional healer or “Tsebel” (getting washed with holy water) which are readily accessible. This usually takes a few years.
When traditional medicine fails, they present to their local clinic or hospital (usually rural). The local medical professional does the initial assessment and writes them a referral to a secondary level hospital. Many of the secondary level hospitals are located in smaller cities of Ethiopia. These secondary level hospitals can usually perform basic general surgery procedures. Very few have equipped staff and medical supplies to handle complex or subspecialized surgical cases; such as paediatrics, neurological, orthopaedics, and complex general surgeries.
The secondary hospital then writes a referral to the tertiary level hospital which is Black Lion. This process can take anywhere from weeks to months to years, depending on factors both clinical and logistic. Timeframe is determined by the acuteness of the medical problem; the educational and compliance level of the patients; the distance to the tertiary level hospital; the financial situation of the patients and their families; and the bureaucracy of the local clinics and hospitals. Once the patient reaches Black Lion, they make an appointment in the referral clinic.
In the referral clinic the physician assesses the patients and decides if the case is operable or not. If it is operable then the patients are stratified into two groups: urgent (something that needs to be operated as soon as possible because if delayed can kill the patient) or elective (less life threatening). More than 90% of the patients are urgent.
In a perfect medical setting with enough resources (medical staff and medical infrastructure) the urgent surgical case would be done within a few days of the patient’s presentation to the clinic. However in “low resource” countries like Ethiopia, the urgent cases usually take anywhere from 3-6 months to be operated on. Due to the high load of patients who are in line, many urgent cases are delayed, leading to disease progression, complications, and often death. Thus, the time elapsed from the first time a person notices symptoms, to the time the patient actually gets modern day medical treatment, could be anywhere from a few weeks (mostly in the case of trauma) to years if not decades (in the case of chronic diseases).
Hence, no one can deny the deeply rooted, and extremely challenging medical conditions that exist in the underdeveloped and developing countries such as Ethiopia. As presented above the barrier for patients from receiving proper medical care is multi-layered and extremely complex to fix.
When I first thought of working at Black Lion Hospital, I did my research about the hospital and learned that it was the biggest hospital in Ethiopia and is a tertiary level hospital. In my mind I took that to mean relatively well-organized, well-staffed, and well-supplied hospital. In practice, while Black Lion has very well trained, motivated, highly specialized, humble, and compassionate surgeons; their hands are often tied from achieving their highest potential in practicing the standard of care for their patients and doing ground-breaking research. They operate under a broken and highly dysfunctional system and are one of the most underpaid professions.
Black Lion Hospital serves thousands of patients a year, but even today does not have a functioning MRI machine. As of Today the Hospital has one dialysis machine, one CT scan, one Radiation Therapy machine, and one ultrasound machine. Illnesses that require anything beyond common medications usually have months of waiting time.
While it was painful to see patient after patient suffer not just from their naturally occurring medical condition but also a broken system; I cannot deny the beauty, positive attitude, level of care, and compassion that exists between patients and physicians. I was in tears when a five year old male patient with urogenital malformations walked out of Black Lion with his family after a successful operation. Never mind that due to an electrical failure and delay in retrieval of a reserve battery, the operation took place under handheld cell phone lights.
Despite the disparities, there were so many reasons to celebrate. Very complicated cases such as infiltrative goiter, massive brain cancers, abdominal cancers, and congenital malformations are surgically fixed every day. Only the few pictures included here would give you a glimpse of these cases!
At the end of my time, while I walked down the hills of Black Lion to Desta Hotel (where I stayed), I felt all types of feelings: chill, frustration, joy, hopeful, hopeless and when my body did not know how to feel, tears went down my cheek. I often asked “could there ever be a way to fix these dire conditions, while continuing the good work? How can I be part of the change?” I know sitting and watching never has been and never will be an option. But what is my role in this? How do I become the change I wish to see?
These are questions I am constantly engaged in as I approach the end of medical school and the process of choosing a specialty in the medical field. While it is very difficult to tackle these questions I also feel honoured, privileged, and blessed to look forward to a rewarding career in medicine, where one has every opportunity to impact individual patients and their families, as well as hospitals and societies at a larger scale. So “Whether our task is fighting poverty, stemming the spread of disease or saving innocent lives from mass murder, we have seen that we cannot succeed without the leadership of the strong and the engagement of all so let us work in partnerships between rich and poor to improve the opportunities of all human beings to build better lives.” Kofi Annan
For the past few weeks I have been working in a small medical clinic in the rural town of Quetzaltenango, which sits amongst the highest mountains of Guatemala. Mornings were spent staffing the three-room ward, working beside the two doctors and single nurse that operate the free clinic, and afternoons were spent with a Spanish tutor, laboring through a crash-course in medical Spanish. During my four weeks in Quetzaltenango I met dozens of interesting people. I saw interesting diseases that don’t present in the United States. I learned how to rely on second and third and fourth string medications depending on the resources available that day. I experienced total immersion in a culture wildly different than my own. But of all the experiences of my short time in Guatemala, the most interesting came from a single conversation with the clinic’s director.
The clinic I worked at, Pop Wuj, shares its name with a text of the Maya-Quiche people. Translated as “the book of time,” the text details the saga of the region’s native people. The clinic is one component of the greater Pop Wuj school, which also hosts a family center, mobile clinic, and a variety of community-oriented projects. The clinic itself is well-established and open year round, often hosting international medical students and doctors. However, what I found most interesting about Pop Wuj was the social-consciousness of its directors and staff. Specifically, one of the original founders named Ronnie, who spends time with every rotating student and physician in a short course he calls “cultural competency,” raised questions about my role and responsibility as a physician abroad.
Ronnie started a well-prepared lecture with the history of the region, but soon digressed into the centuries of oppression and violence suffered by the Mayan people at the hands of Spanish conquerors. I began to roll my eyes as he seemingly ranted about imperialism and Westernization, but eventually he turned the conversation to very personal questions about our motivations for coming to this clinic: Why travel 3,000 miles to work with strangers? Why help in Quetzaltenango when there is clearly suffering in Chicago? What privileges had allowed me to be in this situation, a future physician on a “medical mission,” that the locals did not have access to?
I spent the better part of my visit mulling over these and similar questions. For many of them I still don’t have an answer. But I was reminded of a lecture I had heard by a Peace Corp volunteer years ago. The sentiment of the lecture was that people don’t want to be saved. They don’t want to be rescued or delivered, and especially by a stranger, a foreigner, or, this in particular region, a Westerner. People want to work besides other good-hearted people as equals. They want partnership, not charity. They want to trade ideas and resources and not to be lectured or served. Having this mindset made me feel so much better about this trip, because this trip was more cultural exchange than medical mission. For every second I gave to clinic, I was given one back in Spanish language training. For every Guatemalan treated in clinic, an American patient, particularly a Spanish-speaking one, will benefit from the experience. And while I still wrestle with these complex ideas of culture and privilege and my role in the sphere of international healthcare, I feel comforted to know that I took so much away from this trip that will further me as a physician and individual. And I believe that this fair exchange is the difference between a “mission” and a partnership.
On my way to the airport in Chicago, my Uber driver asked me what I thought about robots in medicine. One of his earlier fares had been a surgeon who had went on about the possibilities of robotic surgery, and the driver became worried that in the next decade or two, all medicine will be conducted through machines. At the time, I told him that there were too many nuances and gestalts for machines to be able to make proper medical diagnoses and management plans. But in the wake of Google’s Deepmind AI defeating professional Go players (over a decade ahead of schedule), the prospect of an AI diagnostician seems much more credible than even two month ago.
So in a world where computers can be a technically proficient physician, where does that leave us? The fleshy, error-prone bits? I had traveled to Queen Square, the Mecca of Neurology, to learn new techniques and pathologies, and to compare the NHS with our extremely unwieldy medical system(s). Instead what I came back with (yes all those other things too, maybe not the NHS-thing so much (turns out the grass isn’t always greener)), is a deeper appreciation for the human aspect of medicine. Something we are repeatedly taught, but that never quite manages to sink in in the face of four years of grueling academic and clinical coursework.
To set the stage a little, I had long been interested in the correlation between visual art and cognitive pathologies. Neuroesthetics, a relatively new field of neuroscience devoted to the study of how and why we produce and appreciate art, just so happened to have gotten its start at the University College of London (the Queen Square academic affiliate). Although my research is more clinical, one of my objectives for the trip was to meet with the field’s founder, Dr. Semir Zeki . This I said as much to one Jac Depzcky, freelance artist, programmer, biologist, and my Albionoii landlord . After many discussions with him on the advances in neurology and medicine, he thought it would be interesting for me to meet with one of his friends, who was actively involved in using music to aid cognitively impaired patients. A date was quickly decided upon and an informal dinner thus planned.
Come the night of the meeting, my wife and I traveled to the south of London, and following a hand drawn map, arrived without fanfare at the apartment of William Longden, my convivial antagonist and the iconoclast of this reflection. A musician and painter in his own right, he has long been working with people of disabilities, creating specialized instruments and leading them in innovative musical sessions that lifted their spirits and more interestingly, brought out a cognitive reserve that should not have been possible given their learning and intellectual disabilities. Over a 4 hour home-cooked feast, we disagreed on just about everything from whence creativity arises (he likes to think of it as an external catalyst) to the plight of the human condition (his view is determinedly more fatalistic). Two things he said however, will stay with me for the rest of my career. And it is these points that I wish to share now:
- Patients with chronic illnesses, which one day we will all become, are managed, much in the same way that assets are managed in a business. Particularly for state operated health care systems, they represent a burden and a growing one at that. To this end, medical care is based on cost and time efficiency rather than optimal outcome in the individual patient.
- In diagnosing a patient with a disease, in telling a patient “you have X”, you alter the way a patient sees himself. Particularly for intellectually disabled patients, a diagnosis often comes with expected mental capacities, which the patient will eventually conform to, even if they are technically capable of functioning at a higher level.
Again, these are points that are repeated ad nauseam in our medical curricula, but are subsequently lost in the day to day management of our patients. William’s observation is unique in that his role is not of a trained medical professional, yet on a daily basis he gets to the know the person and spirit of our patients so much better than we do as physicians. This pseudo-outsider perspective lends an extra layer of saliency that is missing from the classroom setting. Moreover, in the setting of our clashing opinions, I was much more prepared to critique and find counterarguments to his theories. Yet on these points, I find that even with my heightened threshold, I am in fundamental agreement.
With these points in mind, returning to my driver’s hypothesis of a computer driven medical system, I wish to make the following addendum. While AIs may one day be able to diagnose with as much nuance as a flesh and blood physician, there is a human element to medicine, outside of what is in textbooks, that programming alone will be very hard pressed to replace. This patient-physician interaction and personalized attention is much more than lip service or to make the patient “feel better”, and has a measurable impact on their health performance and quality of life.
Ultimately, in the scope of international medical electives, what am I proposing by proxy of this dinner story with Mr. Longden? Keep your mind open and pay attention to goings-on outside of the hospital or clinical setting. Talk to the people, not just the physicians and patients, but those that you meet on an everyday basis. You never know who you are going to meet and how they might inspire and provoke you . I firmly believe that this is as important to our education and growth as any other aspect of our medical training, particularly if we don’t want to wind up a diagnostic robot with a head filled only with textbooks.
As I neared the end of my rotation at Korle bu Teaching Hospital in Accra, Ghana, I found myself wondering how practicing medicine in Ghana differed from practicing medicine in the US. I’m not quiet sure if this reflection is due to my own personal interest or whether it’s because it is a question that I was constantly asked during my four weeks on the Pediatric and Medicine wards. There is a great interest in how medicine is practiced in the rest of the world in Ghana; whether for comparison reasons or whether to figure out what can be done better. One major difference that is very noticeable is the lack of resources. I realized during my time there that we take many things for granted. Something as simple as starting fluids on a patient can become a financial burden on the patient or even the hospital. For the first time in my medical school career, I found myself taking money from my own pocket to sponsor the care of a patient.
During my second week on the general pediatric floor, I encountered a 13 y/o sickle cell patient that was presumed to be in crisis. This young boy eventually succumbed to his illness but the circumstances surrounding his passing remains one of the most heartbreaking moments I encountered while in Ghana. After presenting multiple times in the hospital for similar issues, his parents had exhausted their financial resources. They could no longer afford to pay for his treatment. The first time I saw him, I was worried. There were multiple ideas going through my head on how to treat him and make him more comfortable as he seemed to be in much distress. One of those suggestions was starting him on continuous cardiopulmonary monitoring. I recall telling one of my Ghanaian medical student colleagues this and was surprised to be answered with “we don’t do that here often, a patient must be really critically ill.” In my mind, I thought but he is critically ill; he has hemoglobin of 6 and a measured respiratory rate in the upper 40’s. If any patient is critically ill, it’s this patient. This remains the story of many of the people that present to the hospital. Many die due to lack of resources and the financial burden alone of treatment prevents people from seeking care when they are in dire need. Often times on the medicine floor, I encountered patients who for whatever reason had waited till the last minute to seek treatment; at which point nothing medically can be done for them.
Before my rotation in Ghana, I had a passion to practice medicine in underserved areas. This rotation has solidified and increased this passion. I realize that both domestically and abroad, there are many that lack the resources to have their optimal health needs provided for. I realized on this trip that we have a long way to go in providing universal care for patients. We must continue to strive for and provide care for those in need and that includes providing resources.
I would like to thank the donors of the Bertram Scholarship; you have greatly furthered my career in medicine and my passion to serve the underserved. For that I am very grateful. Thank you!
See Asia with my own eyes, witness pathology not existent in the U.S.A., go on a trip with my classmates before we all head our separate ways, and continue to explore whether my career will be spent in the U.S.A. or abroad, these were the reasons I wished to visit India. Now, four weeks later and with much on my mind, I am ready to go home.
In bio-statistics, whenever you wish to explore the trustworthiness of your data, you increase the power or “N” of your experiment by increasing the number of participants. In India, you do not need to worry about this dilemma as there is one overriding principle, India is the second most populated country in the world. There are people everywhere, from the alleys, to the mountaintops, you are never alone. Conditions considered rare in the United States are commonplace due to the sheer volume of patients. Everyday several thousand patents make their way through CMC, causing even a sub-specialized practice such as orthopedic hand surgery to keep two attendings as well as fellows, residents and interns busy. On Wednesday at CHAD, a “small rural clinic” which in truth is larger than some rural hospitals I have visited, the occupational therapy department must provide physicals for the pediatric department due to the vast mob of parents in search of government supplied vaccinations for their children. When the day is done, one must remember that the patients seen were only those who had the ability to transport themselves to the clinics and there are more patients in the surrounding area who are not so fortunate. Vellore’s populace would cause a logistical nightmare for most hospitals, and yet many would not even consider a city by Indian standards.
Even with the masses of patients, buses of students, nurses and doctors, one fact I truly appreciated in the midst of the chaos was the fact that the majority of the patients I saw were in true need of immediate medical help. Even those that were not in immediate danger were in great pain. This observation compared to my experiences in the United States made me feel as though I was needed, that a difference could be made through effort, a feeling I often found elusive in the U.S. This in turn pulled at my desire to make a difference, to go where I was needed.
The third impression with which I am left pondering is the poverty I witnessed, its causes and its solutions. Call it self-reliance, personal responsibility, community effort, investing in your future, having “skin in the game”, or changing from the inside out. Whatever you wish to call it, India polarizes these ideals like so many. At the end of the day, it is the question of whether the individual makes the society or society the individual. Is India a poor country because it has poor resources which were mostly taken from it by colonialism or is it poor because of the way it handles its resources? The answer to this question guides the second: would India (and other third world countries like it) be benefited from outside help and support such as national geographic and the media would have us believe?
In the same moment you see children helping their parents to sell their wares to provide a better life for their family, you will see them choke their rivers and streams with garbage and bodily wastes, poisoning one of their most precious resources. In one moment I was asked for money from an elderly, emaciated woman whose back was bent with age and an overweight middle-aged woman who appeared to be simply napping the day away. I was asked for money from a man with no arms and a 18 month old baby girl whose mother was teaching her to beg, even though she would rather run in a circle with her little dress twirling about her. Are people poor because they never had the chance to be anything else or because they made poor decisions with what they had? And at the end of the day, would you play judge and what would you change?
I pondered these things on my way back to the land of paved roads and Starbucks. My conclusion, driven by my few short years in medicine, is that I cannot “fix” other people’s lives, cannot heal them, cannot make them improve there lives or give them a new life, that is between them and God. However, I can do everything in my power to help them, so that when a person is striving to be healthier, to get well, to improve, to make a better life and community, they will find a group of people ready and willing to walk with them through the process. India helped show me this is where I belong, at least as part of my future, serving overseas with others students and staff of a like mind, and for this, I cannot thank the underserved pathway enough.
India is a country that is constantly chaotic, exciting, diverse, dated, and modern all at the same time. I have traveled to every continent except Africa, but India is the only country I have found to be in perpetual movement. These attributes can be best seen at the hospital. I was overwhelmed my first day of rotation at CMC by the amount of people running around the hospital grounds trying to find the right building and get to their appointments. Patients have sacrificed so much in order to be able to just see a doctor. I met one man on my Rheumatology week that had traveled 16 hours from Mumbai so that he could have a 5 minute meeting with his doctor in order to discuss his medications. He will make the same trip every 2 months in order to get his scheduled follow-ups. I wondered often how many of these patients were even able to afford some of these medicines/procedures. Most patient interactions dealt with discussing the costs of the treatments and choosing which ones were most necessary, but most times it still ended with the patient begging for a waiver for payment exemption. Many times the family avoids coming in to the hospital to avoid costs until it is too late; like the one patient I saw with advanced AIDS and TB meningitis.
The importance of physicians in India should not be underestimated. They spend more time working, seeing more patients, and getting paid less than their American counterparts. However, it is still a highly sought after career with hundreds of thousands of students every year taking entrance exams to see if they can be accepted into medical school. Because of the diversity of the population, the clinical material needed to learn is enormous. Alongside a growing diabetes and obese population are infectious diseases rarely seen in the USA such as malaria, filariasis, tuberculosis, and leprosy. With this diversity also brings the challenge of different cultures, languages, and religions. When doing rounds with the Dermatology group, my attending had to speak in three different languages just so her patients could understand her. When you add these challenges to the large volume of patients, being a physician in India seems overwhelming. I was working with a resident at the CHAD clinic who was asking me about the work life in America. I told him on an outpatient basis we max out at 40 patients a day. He says he is able to see that amount in just the morning and that he usually works well into dinner time. What bothered me the most in these outpatient clinics was the unruly nature of patient care. Waiting your turn was constantly forgotten as patients would barge into the room at any time and demand that the doctor see them now. Common courtesy was also thrown out the window because the doctor would get interrupted every minute by a patient who didn’t understand his orders, another doctor who had a question, or by a family member asking what room they needed to go to. Some services were so chaotic that one procedure day on Rheumatology, patients were pushing each other and throwing their charts in our faces in order to be picked next.
As my time in India wound down, I valued the time and effort provided for me to help further my education and medical worldview. What I will take away from this rotation other than a better understanding of infectious diseases endemic to the Indian population, is a deeper appreciation for the structural and financial support for medicine in the United States and the difficulties faced by physicians in third world countries.
When I first heard about the possibility of doing an international elective rotation during my 4th year of medical school, I was excited about the opportunity. I had been to India three times prior to this current trip, to visit my mother and father’s respective families. Twice as a child too young to remember and once during the summer before entering 5th grade. Now I was returning as an adult, close to earning my medical degree. I knew that my medical knowledge would be appropriate enough at that point to appreciate the differences between U.S. and Indian medical practice. As I made the necessary preparations to leave, I paused to think about the fact that I would be away from home for an entire month. Besides the fact that I was going to be doing a rotation at a different school, it was going to be an adjustment in activities of daily living as well. Eating food, drinking water, and using the bathroom were things that would be fundamentally altered by staying in this foreign land. In addition to the language barrier, having to worry about certain things that I took for granted back home was certainly daunting. Thankfully, the students of last year reassured us that it would be just fine, at least on-campus.
I did not have many expectations coming in to the rotation, other than what my classmates from previous years had told us. They had mentioned how the international students typically shadowed resident and attending physicians while they were at the hospital. On the first day of my Emergency Medicine week, I was assigned to one of the residents to follow around in one of the bays. I had a fellow international student with me from Malaysia. Growing up in an Indian household, I understood and somewhat spoke Urdu, which shares many similarities with Hindi. When the resident went to talk to a patient, about half the time they spoke in Tamil and the other half in Hindi. I started roughly translating for the other student what the resident and patient were discussing. I was glad that I could provide some sort of service to my fellow student. After a couple of hours of this, the resident noticed what I was doing and asked me if I would like to see some patients on my own. I gladly accepted and went to see a couple patients by myself while the resident was busy. This was how the rest of the week went. The next week, I went to the Anesthesia department and observed several general surgery and trauma surgery cases from behind the curtain. For the most part the experience was exactly the same as my week on anesthesia in Rockford. I asked if I could attempt an intubation and was rejected the first couple of times, but eventually I was able to try a few endotracheal and LMA intubations. My week on Endocrinology was the busiest, as there were several clinics going on at the same time. I attempted to observe as many different clinics as I could. I was awestruck at the amount of patients that were around in the clinics at any given time. I especially enjoyed attending the meetings with the Endocrine surgery faculty, as this is an area that I am interested in pursuing in the future. My final week on CHAD, I was able to spend time in the Trauma room and OPD clinics, as well as going on the village trip with the doctors and nurses. It was very interesting while going on the home visits as this is not something that I have had much exposure to in Rockford. I could see how much the people of the villages appreciated having these doctors come to their homes. The sheer amount of patients each doctor saw was astounding.
Besides attending rotations, we were able to visit several areas of India. The state of Kerala in particular was beautiful. At the campus, I was able to play basketball with other medical students and climb the college hill. Getting to know the other international students over weekly dinner was another amazing experience. I am truly grateful that I was able to travel to India during my final year of medical school and have such a rewarding experience learning and exploring with my fellow classmates.
I feel blessed for having the opportunity to travel to an internationally recognized medical institution at Christian Medical College in Vellore, India. I enjoyed the time spent at CHAD learning about healthcare delivery in a rural setting in another country as well as rotating through the various medical subspecialties. As a future physician, it will be exceedingly important to continually broaden my experiences with patients from a wide variety of backgrounds and cultures. I was unsure what to expect before the trip because I have only been outside of the country once before, and this was my first time traveling to Asia.
I plan on completing a residency in Ophthalmology following my medical school training. While I was at CMCH, I was able to spend a week with the Ophthalmology Department. I had the unique opportunity to witness surgical techniques not routinely practiced in the United States. There is a huge population of underserved individuals in India requiring proper eye care. With such a large population and limited resources, it is essential that exams be completed thoroughly and efficiently while maintaining the compassion and empathy central to our profession. This is by no means an easy task, and I was determined to use the time during my international experience to understand the methods of healthcare delivery in this overburdened healthcare system.
Another compelling reason for pursuing this international experience was to witness an extensive variety of advanced pathology. Many conditions are treated in their earlier stages in the United States, but in certain parts of India, especially rural India, the disease process unfortunately progresses to a much greater extent. Being able to see the full spectrum of disease will provide a foundation that will be crucial to my understanding of the underlying pathophysiology and of the application to the management and treatment of my future patients. I remember a documentary I watched about a group of ophthalmologists from the US who would spend a week performing up to 70 cataract surgeries a day because the need was so great. They were able to get the cost of the procedure to 20 USD. As I saw the huge volume of patients that suffered from stage four cataracts that have not seen a doctor in years come into the clinic I was able to appreciate the enormous difference between the healthcare delivery in the United States and what I was seeing on this rotation. One striking difference I noticed was the consideration of financial and social issues in India. Many doctors would not even begin to discuss performing a procedure or treatment options until these other factors were addressed. This made up a sizable portion of the physicians work and consideration. Doctors in the US often have to address these same issues, but the general culture and consideration of appropriate treatment, both socially and financially, is such that people could not imagine care not being given if it could not be afforded. I remember a conversation I had with a former college roommate who was a medical exchange student from Turkey talking about the healthcare dissemination in his country. If people were unable to afford care they were literally turned away at the hospital steps and people would either walk back home to their families to pass away or die on the steps outside the hospital. I could not even believe that this could be happening in the world today, but it reminded me of how I take healthcare for granted in the United States. When I saw the huge volume of patients seen every day in India, I was amazed at how efficient, organized, knowledgeable, and considerate all of the doctors were. Every clinic was bursting at the seams with patients, yet the physicians remained calm and worked incredibly hard to see everyone. It was a wonderful opportunity to be a part of the treatment team rotating through the various electives and to gain an appreciation that care can be efficiently delivered in an appropriate and intelligent way while retaining the compassion and socioeconomic considerations that are necessary to being a truly successful physician.
My goals for the rotation included gaining exposure to primary care health delivery systems in both urban and rural settings in another country, witnessing a variety of ophthalmic surgical techniques, and visualizing extensive pathology in order to enhance my medical education for the benefit of my future patients. Despite the growing population of individuals requiring eye care, especially among the expanding elderly population, the growth rate of ophthalmic training programs has not increased enough to reach these demands. With physicians retiring and new residency positions increasing minimally, new methods have to be developed for providing appropriate, accessible, and affordable health care to all patients. I was able to gain insight into alternative methods for handling a large volume of patients and will keep in mind the physicians that worked so hard in these high stress situations to deliver excellent care when I am working in a clinic back in the United States.
Traveling to India and working at CMC was a wonderful experience that I will carry with me for the rest of my life. While some things improved initially difficult and foreign to me, like bargaining over prices or trying to bridge the language barrier between English and Tamil, I feel that I am a better, more well-rounded and open-minded individual. I was able to see the cultural differences of the country both inside and outside of the hospital. I grew closer to the group of students that I worked with, and learned how to embrace change. I tend to be a very shy, reserved person that runs away from change. I enjoy my routine and often stay in my comfort zone. During this trip, I was completely thrown out of that comfort zone, and I couldn’t be happier that this has happened. Watching the physicians at CMC provide care in a compassionate and intelligent manner, working hard to handle the huge patient loads, always willing to teach and explain to the patients and the students the situation makes me incredibly excited to begin residency. I hope that one day I can bring the same level of care to my patients and use the experience that I gained from the doctors at CMC as a guide.
I have fond memories of my grandmother, a woman with contagious optimism and a way of nurturing each member of our family that can only be described as special. On my visits to India as a child, she would chase my brother and me around her small apartment, and we would end the game laughing and munching on her delicious homemade ariselu, an Indian dessert. All of that changed on a subsequent visit to India: she barely recognized us and couldn’t muster the strength to have a conversation, let alone chase us around the apartment. That was the last time I saw my sweet grandmother, who passed due to colon cancer. It wasn’t until years later that I understood what happened and was able to ask the right questions. Unlike my father, who now receives frequent screening colonoscopies in the United States, my grandmother did not have a single one before her diagnosis.
That first exposure to the Indian health care system left me with unanswered questions and a desire to learn more about the unique ways different countries provide health care. I majored in economics in college, absorbing everything I could during my health and developmental economics classes in an effort to better understand the process of health care delivery to my grandmother and billions of others living in developing countries.
In medical school, I have the privilege of working with fantastic attending physicians who emphasize the importance of taking a strong history and physical, rather than relying too heavily on imaging. When presented with the opportunity to rotate through an Indian hospital, I realized that this rotation was my chance to answer lingering questions about my grandmother’s medical management and the use of screening tools in India, to watch my theoretical lessons in international health economics play out before my eyes, and to contribute to my future practice of internal medicine by learning from physicians who provide high-volume, low-cost medical care without many of the resources that we are fortunate to have in the US.
In a few months, I will start Internal Medicine residency. I am proud and excited to become an internist, where I will collect and apply broad and varied knowledge of all the body’s organ systems. During my rotation in India, I was exposed to general medicine, as well as subspecialty training in cardiology, pulmonology, and gastroenterology. The entire experience was so informative and memorable, but a few general observations have stood out to me:
- The volume of patients that physicians manage daily. During my rotations in Rockford, I have seen physicians manage up to twenty patients per day. At CMC, each physician I worked with managed a minimum of fifty patients (including new patients!) per day. This led to a different style of practice: much more focused histories and physical exams with less counseling. Patients brought their own labs, imaging, and previous records with them and the physician quickly went over them with the patient. When I asked one of my attendings about preventive medicine, he explained that although he tries to address the obvious issues during visits, the responsibility often falls on the patient to identify and ask about preventive measures, even in the general medicine OPD. Based on the physician’s time constraints (and also the patient’s constraints such as transportation), I can understand the difficulty in addressing the patient’s lifestyle and risk factors. The physicians have just enough time to attend to the acute (and often advanced) condition for which the patient is presenting, and addressing the preventive medicine would likely lead to less emphasis on the acute issue. It’s unfortunately the same problem that we have in many places in the US. I’ve been thinking about it during my interviews, because I have been exposed to many different styles of resident clinics. It seems that the patient centered medical home model that we have at FHC is the best way to use teamwork in order to address the patient’s medical and non-medical issues. I don’t have a set opinion or answer to overarching question, but I am glad that the rotation at CMC has allowed me to collect more observations and experience about time constraints, patient volume, and its effect on preventive medicine.
- The way in which the patient’s social issues were considered and incorporated into the plan of care. Since CMC’s mission includes service, one of my attendings explained to me that they see a lot of underserved patients from all over India. I was shocked to see patients who took multiple trains over multiple days just to make it to their outpatient cardiology and pulmonology appointments! The physicians were so understanding of not only their home situations, but of the travel and other expenses required to get them to their appointments, and customized their plan of care around these restrictions. The patients, in turn, were so grateful to be able to see such understanding physicians. It was really inspiring to watch these encounters, and they will definitely stick with me.
- How different their differentials look due to the differences in prevalence for different diseases. If I put TB at the top of my differential when seeing a patient nonspecific symptoms such as cough and fever, my attending would think I am crazy! But in India, the world capital of multidrug resistant TB, it is a reality. I had the same experience in GI with the prevalence of intestinal parasites. It was fascinating to see the knee-jerk reactions physicians had to certain presentations and the difference in their investigations. I was very excited to see patients with TB and rheumatic heart disease, two conditions we have studied extensively but I had not yet seen in Rockford.
Overall, I am so thankful for the wonderful opportunity to see a high volume of diverse patients presenting at more advanced stages of disease. It gave me some insight into the medical care my grandmother may have received, and the ways in which her care was likely lacking since she did not have the opportunity to be managed by the highly trained physicians at CMC. It also allowed me to compare the patients I have seen in Rockford with those in Vellore, and to compare the physicians and the way that they work. The observations I have collected will allow me to be a better medical student, resident (soon!!), and physician. I’m already looking forward to my next trip to India and my next international rotation.