After an extensive summer spent in sunny South India, I have made a list of notable observations. Health care and patient management is dramatically different in India than in the United States. Here’s a big picture of medicine in India.
- Aside from the reality that doctors are overshadowed by IT experts and computer nerds, doctors still play an integral role in patient care. They are flooded with a high volume of cancer patients at the RCC every day, Monday to Saturday. Like an assembly line, one by one, each patient waits in a long line to get follow-up and treatment. Every patient seems very compliant, hinging on the doctors’ orders. Quiet, obedient, and sad-looking, patients listen and follow what the doctors tell them. They get their 5-minutes time with the doctor, then they leave until the next appointment. Most times, patients come in, sit down, talk briefly about how they’re feeling, let the doctors poke them, and walk out without saying as much as a “Thank you.” Or maybe they do, and I don’t catch it because of the language barrier. Simply judging from body language though, they seem to leave without graciously thanking the doctor. It’s less of a personal connection with the doctor, almost more robotic and routine. There’s less patient autonomy and more implicit trust placed in the doctor. In the United States, however, patients are encouraged to ask questions, be educated about their disease and what to do, and work closely with the doctor to get better. It’s all about patient empowerment and dignity. If things go awry, patients and families blame the first person in the line of help – the doctor, the ‘savior’ – and shoot for the Benjamins…
- Which brings me to the next point: No malpractice insurance in India. Doctors don’t get sued and drained dry there like it’s a leech-feeding frenzy. Patients respect doctors, and no matter how poor they are, they don’t litigate like its their prerogative. Besides, suing requires money and lawyers; in impoverished states of India, neither are easy to acquire.
- Doctors are not paid as well as computer/software engineers, who earn up to four times more than medical professionals. At least at the Medical College, doctors are paid by salary, as opposed to a fee-for-service basis. The oncologists and surgeons work mostly a Monday to Friday job, 9 – 5 pm, in and out in a jiffy. Not bad for a lifestyle position in medicine. That also means that doctors choose medicine for the right reasons and not simply for the lucrative profits. If people have an ulterior motive to earn money, computers are the way to go, not medicine. Doctors hold a god-given mission to fight debilitating diseases and heal the people, and not just in India. People who dedicate 10+ years to medical education and training must be highly motivated and compassionate to pursue medicine. Once in a while, the socially inept or money-hungry doctor slips through the crack and somehow waddles through medical school and intense training, but hopefully most doctors of the future will be personable, charismatic, and devoted, like the special doctors I met in India.
- However, patients are less considerate of their doctors’ personal space and privacy. That is, they see you and come up, interrupting your conversation or coffee break with colleagues and without saying so much as an “Excuse me.” This happened on one occasion, while I was having a tea break with Dr. Roshni. She told me that in England, patients almost never approach a doctor outside an exam room or dare to interrupt the doctors’ personal time. In India, they can come up and start asking more questions about their health and treatment, all while doctors are dealing with other business, taking time off, or walking to their cars.
- Speaking of privacy, there are no exam rooms. No clean white walls, no personal exam table, no time, no privacy whatsoever. The medicine outpatient (O/P) clinics had separate areas designated for different parts of the body: head & neck, surgical, GI/chest, breast/brain, and gynecologic/urinary. Rotating through all of the units, I noticed the doctor’s room was a shared space for multiple patients at a time. Smaller units like breast and gynecology had one doctor man a whole morning-full of patients. One small room with a desk, chairs, and an exam table plus curtains. More busy clinics like head and neck consisted of multiple rooms and shared spaces. A large room would consist of three desks for three doctors at a time. Patients sat down in a chair before the doctor. That was basically the examination area, where three patients and families were crowded in, in addition to the doctors, nurses, and two lowly American students. No personal space, no privacy, no windows, no circulation, except for the buzzing fan to my left.
- The hospitals are congested like your poor nose during a bad winter’s cold. The general pediatrics ward was nearly filled with children. A new, more private alcove was recently painted and completed. Still, the pediatrics ward gets populated with sick, waiting children. Worse, the outpatient clinics are clogged and packed to maximum capacity, especially in the mornings. People come in early, some traveling from far distances, to get taken care of early. But when many people come in early, there’s a major plaque buildup in the inelastic, narrow hallways. Many times, I squeezed and battled through fragile bones, melancholy faces, and oppressing body odor and heat. Air conditioning was a godsend only in three places: radiation simulation room, GI/chest clinic, and surgery theatres.
- No white coats. Interesting. The only people wearing white lab coats are the nurses, or ‘sisters’ in India. If they’re not wearing white coats, they’re wearing white dresses and sarees. The classic symbol of the almighty doctor is not worn in India, or at least not at the RCC. The professional dress code for physicians in India is a head scratcher though. Men wear the classic black pants, belt, and fancy dress shirt. Slick, clean, and proper. However, women do not dress up in a professional manner. They do not set fashion trends with pencil skirts or Express columnar pants, paired to silk blouses or ruffled tops or belted cardigans. Nono, they dress like every Indian woman on the street: sarees, scarves, long light pants, and traditional dresses. The only ways to distinguish them from other women are the stethoscopes and their English.
- No proper procedure. Like in surgery, I’ve witnessed surgeons commit procedural skill sins. Take sterile gloving and gowning. There’s a careful way in putting on sterile gloves, but surgeons there end up touching nonsterile parts and gloving on ‘sterile.’ When they finish gowning and spin around for the final tie, they touch the card tag at the end of the string, which is NOT sterile. Only the nonsterile helper is supposed to be touching that tag. The anesthesiologist at Stony Brook would be blubbering in madness if she saw this…
- Along with the above point, there’s no wasting. That goes for gloves, surgical caps and shoes, papers, etc… (1) paper is kept under minimal use. When it is used, the paper material is dirt cheap and cruddy. Paper is thin, grayish, and plain. That’s already a luxury in India. (2) When I enter the surgical OR area, I change into area-specific shoes, whether they’re ugly black shoes or flip-flops, shared amongst everyone working there. I hate walking barefoot as it is, but having to share shoes with people really grossed me out. I had to suck it up, since I didn’t bring socks on this summer trip. More importantly, the chief concern is the fact that open-toed shoes are unprotected; broken shoes are worn into surgery! Flip flops! Open-toed! What would happen if there’s a needle prick or spillage of bodily fluids? What if the Foley catheter leaked right onto your precious toes?! To be honest, I failed to comply myself when I worked in the laboratory; I faced dangerous chemicals, and yet, I didn’t let the NYC summer heat and harried run to Penn Station hinder me from wearing short shorts and flip-flops. So why am I freaking out in India?? (3) Likewise, the anesthesiologists make minimal use of gloves unless they have to. That means, when they draw blood, make injections, or fix tubes, they do so without gloving. Now I venture to ask, what about blood bourne pathogens and diseases?!
- Let me respond to my outburst of questions with a personal account: One day, I was at the foot of the operating table observing an abdominal Whipple maneuver. I had a clear view of the show where I stood, the omentum and intestines exposed beautifully. I idled where the sterile tools lay. The nurse assisting stood to my left, next to the head surgeon. She was wringing the bloody gauze and when she squeezed it a certain way, blood gushed and squirted to my right. The blood splattered onto the ground, just fingerbreaths from my feet. Lucky my Hidden Tiger, Crouching Monkey reflexes kicked in! By instinct, when the nurse squeezed the gauze, I somehow, instinctively foresaw the projectile blood droplets. I immediately jumped aside and watched the blood’s parabolic trajectory down to the ground. One of the spectating doctors watched this scene unfold with me. He looked up at me and said “Be Careful” and walked off. Whew! Close call…
- See, danger does linger in the surgery rooms! I have plenty of reasons to worry more abroad. It’s because I do not want to get a disease in a foreign place. Coming out here, I had a checklist of vaccines and diseases to avoid, and that was plenty to plan (and pay) for. It’s also the reality that I am in an OR and people are sick. One of the doctors told me that patients get screened for blood bourne pathogens, such as hepatitis B virus (HBV) and HIV, and hence, the lackluster procedural adherence. When hospitals can save, they save on equipment and materials, even at the expense of occupational safety.