By Zubair Chao, MD
I had an opportunity to visit India as part of George Washington University’s International Emergency Medicine & Global Public Health Fellowship Program in April 2013. I gave lectures on endocrinology and HEENT as teaching faculty. I had already planned to go to China with my residency program and ultrasound fellowship directors, Drs. Cook and Hunt, respectively, and it was an easy decision for me to combine the trips for a firsthand view of emergency medical services in the world’s two most populated countries.
Emergency medicine is new in India, and it is not widely accepted as a recognized specialty. Only 20 emergency medicine residency positions have been approved by the Medical Council of India. George Washington University has set up a few clinical training sites, and it confers a master’s in emergency medicine on graduation. The program is essentially a three-year residency. Applicants come from a wide variety of backgrounds; many are straight from medical school, and many more are general practitioners, who are not required to complete residency training in India.
I was sent to Calicut (Kozhikode) and Kolkata (Calcutta). Calicut is a relatively small city in the south Indian state of Kerala, a place known for its greenery and the dubious distinction of having the country’s highest rate of alcohol consumption. The state has historically been a port of entry for commerce. It was also the place that the Portuguese explorer Vasco da Gama first landed, and Portuguese influences are still seen in Kerala. The city is known as a model of diversity and tolerance; Christians, Hindus, and Muslims live peacefully side-by-side.
Kerala has seven multispecialty hospitals, two of which are government facilities. I worked at the Malabar Institute of Medical Sciences (MIMS) and Baby Memorial Hospital. The George Washington program was established at MIMS many years ago, and it has already graduated a few classes of residents, some of whom have stayed on as faculty. The ED has 15 beds and a two-bed trauma bay, and it sees between 75 and 150 patients a day. The program at Baby Memorial is in its inaugural year, and it only has a class of seven interns right now. The faculty at Baby Memorial is also new; one is a recent MIMS graduate, and the program director is an orthopedist. Both hospitals have a full complement of subspecialty backup and residency programs in other specialties.
Kolkata is in the state of West Bengal in eastern India, not too far south of China. I worked at Peerless Hospital, one of 15 multispecialty hospitals. The hospital has more than 400 beds, and the ED has 18, six that are monitored and two that are isolation beds. This program has 15 second-year residents and 11 first-years as well as one third-year resident who transferred from another program. The city is known for its congestion, and has a great deal of poverty, even by Indian standards. Kolkata, the city where Mother Teresa worked, is rich in history, and was Great Britain’s seat of power during its colonial rule. The capital was subsequently moved to New Delhi after protests and clashes became too much for the British.
Emergency medicine is new to India, but the residents I saw were proficient. They came from many backgrounds, and most had clinical experience, either working in casualty, a small triage area attached to a hospital, or in other specialties. I noted immediately that residents have a great deal of autonomy, much more than we do in the United States. Part of this could be because many have had experience practicing clinical medicine. Another could be that India is less litigious for physicians. Indian practitioners also use their health care resources more judiciously, with none of the defensive medical practices that characterize medicine in the United States.
Allopathic medical education in India is different from that in the United States. Medical school graduates are awarded an MBBS degree, and they may then practice as general practitioners. They may also pursue post-graduate training in various specialties, such as cardiology or neurosurgery, which earns them MD certification. Many medical students pursue their MBBS education outside of India; I spoke to a few who went to Russia, and many go to China. Lessons there are in English, but clinical rotations require at least a basic knowledge of Chinese. This blew my mind because medical school for me was difficult enough. These guys had to do it in a completely different language. I had a difficult time communicating to some patients when I rotated in a busy Chinese ED last year, and I speak fluent Mandarin. I don’t know how these medical students do it; one person told me that they are encouraged to get a local girlfriend to work on their language skills so maybe that is the secret to learning a new language.
The residents’ attend didactic sessions, and each month a resident is assigned a topic to present. George Washington University also sends faculty members to give lectures, teach at the bedside, and prepare them for oral boards. Part of my role was to cover a series of lectures on endocrinology and HEENT. Residents rotate through other departments like we do in the United States, and residents from other specialties also rotate through the ED.
The selection process for applicants is different from the American match system. I was invited to observe on applicant interview day. Nearly 50 applicants took a test, and its results were combined with their previous training scores to provide them with an objective score. They were then interviewed by a panel, and each panelist gave them a subjective score. The top 10 applicants were offered a spot in the program. It was all done in one day.
These young physicians do not face language difficulties only when they travel abroad: India has more than 1,600 languages. Applicants were always asked what languages they spoke; most spoke at least three: English, Hindi, and another local language. Those who did not speak Malayalam, the language of Kerala, were asked how they expected to communicate with their patients. The usual response was that they would commit themselves to learning the new language. This is not as unreasonable as it sounds; some were able to learn it in as few as just a couple of weeks.
The hospitals where I worked were all modern, and the equipment and specialty backup were similar to the United States. Private hospitals in India largely had better facilities than government hospitals, and their resources were easier to access. These facilities were within the financial means of many middle and most upper class residents. A large number of Indian citizens are quite poor, meaning that a large segment of the population cannot afford this level of care. Their only recourse is to go to a government hospital because India provides national health care for all its citizens, and it is significantly less expensive. Care provided in government hospitals is lower quality than in private hospitals, in part because of the significant number of patients that flow through their doors. (Maternal hospital residents told me that women shared beds and delivered babies on the floors in Kashmir.)
Family expectations in India also seem to be significantly more tempered by reality. A family would consider the financial consequences of pursuing a particular medical treatment, choose to go to a government hospital, or proceed with a less aggressive approach (especially if the prognosis for meaningful recovery was poor) if a terminally ill patient needed intubation or an aggressive (and expensive) ICU course.
Unfortunately, I did not have much time to sightsee, but I did visit the Wayanad Sanctuary in Kerala. It is a beautiful forest reserve containing Mount Chembra, the highest peak in the state. Majestic peaks soared over pristine valleys, and verdant fields of fruit, coconuts, and tea stretched as far as the eye could see.
Calicut was rustic and green, but Kolkata was about as urban as it gets. You can truly appreciate the density of the country when walking there, and understand why India is on track to become the most populous country in the world. Poverty was visible everywhere; even Park Street, a posh area with fancy hotels and restaurants, was just a few blocks from alleyways where many people eked out a living selling small knickknacks and bathed in the streets beside communal water pumps. I passed through slums where people lived in shacks made of corrugated sheet metal supported by tree branches. I was unable to communicate with the majority of these people, but I did get a sense that the majority of them seemed content despite the abject poverty in which they lived. I would hesitate to say that all of them were happy because I think they all recognize that poverty and wealth distribution is a problem in India, but no one is sitting around feeling sorry for himself because he is poor.
What I saw was a great deal of resilience: the people living in slums took care of themselves by washing their clothes, brushing their teeth, and bathing in nearby ponds. They worked hard, exhibiting feats of manual labor that most of us from the West would have to see to believe. I saw many old men weighing no more than 120 pounds riding converted bicycles with loads of water containers on vast stretches of bumpy, unpaved dirt roads. Women would walk out of these slums with beautiful and clean saris to tackle the day.
Children played cricket in a nearby field with other kids from the slums. My observations and discussions with physicians there led me to understand that Indians do not have a great deal of mental illness, such as depression and anxiety, that we see quite often in America. A psychiatrist in Kashmir told me, though, that he saw a significant amount of post-traumatic stress disorder. I don’t know if they have a fatalistic outlook on life, find comfort in religion and spirituality, or just have a national sense of acceptance that that is the way things are. Maybe they are just too busy trying to get by to worry about it.
Dr. Chao graduated from the emergency medicine residency program at Palmetto Health Richland in Columbia, SC, last year, and is currently a fellow in emergency ultrasound there.