On our second day of the rotation, we had the pleasure of going to City Heart Hospital founded by Dr. Sanjay Gandhi for an evening clinic. Now, I want you to stop and take a moment to consider the mental image conjured by that previous statement. What did you picture? A small-moderate sized hospital with multiple wards, an ED, a lobby, a nice designated clinic space, a board of directors, students/residents, swarms of doctors/nurses, and a nice portrait of Dr. Gupta on the wall commemorating his role as founder? If so, I can’t blame you…. but it is time to think again.
Dr. Gupta is a cardiologist by training and a generalist in practice. City Heart hospital began as a single rented room out of which he started his clinic 15 years ago. Slowly, he has single handedly built up his one-room clinic into a hospital with up to 30 beds. These beds are scattered across 5 disjointed rooms some with 2 beds and others with 8. Around the side of the building and up a giant ramp is the “ICU” (and you must remove your shoes before entering….. you can only begin to imagine our disgust with this if you have ever seen what goes on in an ICU) with another 5 beds. It is nearly impossible to tell who is who as all the employees are wearing normal street clothes with no identification. There is even a resident who is completing her training as a generalist and a fully functioning OR staffed by a variety of on call surgeons. On site imaging includes an X-ray and ultrasound. If a patient needs a CT or MRI all they have to do is walk (on their own…… even when having a stroke……) across the street to one of the numerous private imaging companies and then bring back their images.
Clinic is still conducted in the same room where it all began. Dr. Gandhi’s office is equipped with his desk, an exam table, a chair for the patient, a couch for guests, and walls covered in degrees, picture, and awards. He ushers us into his office and has the four of us students sit on the couch to observe clinic. Patients are brought in one by one and sit down in front of all of us plus Dr. Gandhi as he works his magic. If they need an EKG, a “tech” will come in and do one in the room as we all watch. A patient encounter can last between 30 seconds and 5 minutes but hardly ever any longer. Sometimes it seems that if I blink I’ll miss an entire patient encounter. We asked him about the speed with which he sees patients and he laughed while telling us that this was slow because we are in the “healthy season.” If this is slow I would hate to see what busy is…. as far as I could tell there were almost always 3-5 people in the waiting room at any given time.
Next was time for making rounds at the hospital. As I mentioned before, he has space for 30 patients, but because of “healthy season” and demonetization he is hovering around 12 admitted patients. First we go up to the ICU to check on a man with respiratory distress on BiPAP and his neighbor who had just had a STEMI treated with TPA. Downstairs we round on a septic patient, a man with pneumonia, a gentleman with fatigue and a new lung mass, and then a man with possible Tb. The breadth of illness as well as the range of acuity was impressive, to say the least. The rounds were rather surreal – the patients we lying on shabby beds with dust and dirt on the ground, monitors that were 15 years outdated, and overall conditions way worse than any hospital back home and yet they were receiving first world care with modern drugs, guided by advanced imaging and 21st century practice guidelines. Simply put, the juxtaposition was striking. It really makes you wonder about what truly is essential to providing good healthcare. Are all of our fancy rooms and technologies necessary? Or are they simply luxuries with little added benefit? Do we really need all the bells and whistles or should we maybe do a better job of practicing clinical medicine and actually talking to and working with the patient. I think Dr. Gandhi said it very precisely when he described medical practice in India as much more “clinically based” rather than “investigative medicine” as we practice in the U.S.
Although we only had a few days to spend at City Heart Center, they were a great introduction to medicine in India. We saw how invested a physician becomes in his office, hospital, and patients. We saw some incredibly sick patients receiving top notch care. And we saw medicine practiced in a way quite different from what we are used to. As a fun aside, I have to say that it did feel pretty cool to be reading the chest X-rays on old-school plastic films rather than a computer monitor like back home. For all of the perks computers have to offer, it is so much more satisfying to hold up a chest film to the light and have a good look at it.
If you were to hop onto the nearest vikram and go for a ride down one of the streets of a Dehradun you would find yourself driving past a chemist shop (pharmacy) on every corner, a mixture of doctors practicing homeopathic, Ayurvedic, and allopathic medicines, and countless billboards for imaging centers and health “checkups.” Every day you see fliers that resemble a fast food menu offering “basic,” “deluxe,” and “super-deluxe” healthcare screenings. Turn down another street and you might come across a cluster of diagnostic centers with ultrasonography, CT scanners, and MRIs. Around the next corner will be a small hospital tucked in the mess of buildings sandwiched between a shoe shop and a gas station. In keeping with India’s general theme of “anything goes” the entire healthcare industry seems to have just popped up wherever there was space, with little rhyme or reason. I feel a bit overwhelmed looking at it all from the perspective of outsider…. I can’t even imagine what it would be like navigating the system as a patient.
Two things that has made me feel somewhat uncomfortable were the lack of respect for patient privacy and the refusal of treatment for those without money. In one of the clinics we went to there were literally five patients in the office at a time lined up next to each other waiting to be seen. Their entire clinical encounter took place in front of the crowd with literally no respect for privacy or sensitive issues. Couple this with the fact that we students were sitting in the office observing the encounters (with no introduction to the patients) and I actually felt a little guilty. Going to the doctor is stressful enough by itself but having to be seen in front of a group of foreigners and the other patients is almost dehumanizing. Because we were stationed in private clinics and hospitals we had a good chance to observe the monetary aspect of healthcare and the firsthand impact of demonetization. What I witnessed on numerous occasions left me stunned and somewhat angry – many patients did not receive treatment because they couldn’t pay. I can recall one patient who was literally having a STEMI be refused treatment because he couldn’t pay the cost of 5000 rupees (~$75) up front. We asked the doctor about it and he was practically indifferent to the patient’s situation and simply said that the patient would be a fool to leave but couldn’t be treated without paying. As a future emergency medicine doctor, it is difficult for me to imagine practicing in a place where patients can be turned away when having a true medical emergency. Despite all of the red tape and paperwork it creates, I now have a much greater respect for the EMTALA law in the U.S. since in India there are no laws to protect patients in life or death situations and nothing that prevents doctors from turning their backs on patients in need. Countless times I witnessed patients sitting there trying to decide if they could afford treatment or risk the consequences. Honestly, I found it somewhat unsettling that the doctor was so indifferent to the patient’s plight – how could someone be so cruel and heartless?
The answer to this rhetorical question is one of the many lessons I’ve learned while in India. The tragedy of one man is inconsequential in a country with a billion persons; from the beggars on the street to the patient dying of a STEMI right in front of us, there is nothing but indifference towards them from the government and society at large. There is little concern for the struggles of others when you are too busy trying to get by yourself. How can you have time/energy/money to spend on others when you need to spend it on your own family? In so many ways, it would seem that there is a sense of “every man for himself” that pervades throughout all aspects of life in India. This realization is quite disheartening because the country has so much potential. If the idea of a “social contract” could be established, life in India could improve greatly- from the trash on the streets all the way up to healthcare and government. After talking to the locals, there is a desire for such change. They themselves speak of the possibilities while at the same time they admit that there will never be enough buy in for any meaningful change to the way things are.