Empowering the patient

Many apologies for the long, long delay in posting. Things have been very busy and the internet connection has made uploading pictures and postings a bit of a challenge. I will attempt to catch up on posting what I've been writing over the past stretch.

From 20/Jun/2009:

After two weeks of class work and an intensive introduction to the healthcare system here in India (and more than our fair share of the local, almost exclusively rice-based cuisine), we Americans were quite ready for a change of scenery/diet last weekend. We hopped on an early bus out of Vellore and headed for the small city of Pondicherry, on the eastern coast. Getting there and back was a bit of a journey, but a weekend away in this charming former French colony was entirely worth it. The bus ride was about 4.5 hours each way, winding through small roads and out through the countryside, and packing more people into that vehicle than you’d think possible (and infinitely more than anyone would deem comfortable). Safely in a seat, it was pretty enjoyable to watch the passing imagery… the bus stops oozing with frenzied commuters and hawking vendors… the sweating faces pressed against the bars on passing buses… the stoic pairs of oxen pulling their tired carts… the occasional building sprinkled in along broad stretches of dusty landscape, with giant advertisements painted on their square sides so it looks like giant cereal boxes dotting the countryside… the near-neon green squares of sprawling rice fields, stretching out toward the perfect blue sky… groves of palm trees bridging the horizon and breaking the silent tension of this chromatic brilliance…

Arriving in Pondicherry, I instantly felt like I was in a wholly different place. The first and most obvious sign was the relative cleanliness… Trash seems to be abundant everywhere in Vellore, while the streets of Pondi were lined with trash bins (effectively labeled “Use Me”), with trees and ornate little shop fronts. The French influence could be seen and felt everywhere… It reminded me a little of New Orleans (minus the booze, boobs, and beads). And there was even a beach. Well, a rocky coast… but it offered the smell of sea air I’ve been missing. We paid a visit to an Ashram during the afternoon, and saw a whole crowd of followers devoted to spiritual leader Sri Aurobindo. It was an impressively peaceful place, and I’m starting to get a sense for how/why spirituality (and the many forms it takes in this country) is such a significant component of Indian life. [ That’s a statement begging for further explanation… hm… may have to come back to that]. We had dinner at a really nice rooftop café, and the waiter had this delightful French-Indian accent (and was downright excited to exchange a quick few phrases en français). A weekend filled with croissants and seafood and wine, and an ever-elusive (in India) iced coffee. Throw in a blessing from an elephant (that’s not a euphemism for pee!)… I’d say it was a pretty nice getaway.

The Americans and the Dutch folks out for French in India...

Elephant blessing

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Getting back to Vellore… We started the first of our clinical rotations last week. This first posting was in the Low Cost Effective Care Unit (LCECU)… a small unit at a different site from the main hospital that caters (as you might imagine from the name) to the poor communities of Vellore. The unit is run by a small but remarkably committed staff of five doctors, with specialists and interns from the main hospital rotating through service here as well. Patients are entered into the LCECU system if they qualify financially, and a chart is made for them… consisting of a series of cards detailing the patient’s medical history, family information, prescription and procedure log, and a record of payments assessed and completed… All this is neatly and openly stated on 5X7” cards clipped together and, believe it or not, kept by the patients themselves. There are no medical records maintained at the LCECU… but I found it even more surprising to learn that—with the exception of the occasional house fire or flood over the years—they almost NEVER lose a chart. I can’t imagine this would ever work in the US. But patient after patient I saw would file into the Outpatient Department and dutifully produce their chart. I was amazed. The main doctor we are working with here (the inspiring Dr. Suschil) explained that this system serves not only as a highly effective record-keeping scheme, but also as a means of empowering a population of patients that is traditionally and tragically [and this can be said almost universally about the poor] underserved.

I sat in one of the small offices in the Outpatient Department with one of the junior doctors for most of the first day. This tiny area housed a desk, chair, several stools, an examining table, a blood pressure cuff, a stack of prescription pads, a flashlight, and a cash box. That’s about it. And in some of the other offices (of the same size and outfitting), there were even TWO doctors, seeing patients on either side of the desk (!). Over the course of the day, I saw a steady stream of patients come through the curtain to be seen by the doctor, pay a bill, clarify a prescription, or (as it seemed to the English-speaking medical student in the corner) make their impatient case for why they should be seen now… Many of these interactions often coincided with each other (yes, including the actual exam), with the young and surprisingly poised doctor holding court in an impressive display of multitasking/crowd-management. [I guess this is a good time to mention that the healthcare system in India doesn’t have the same practices and stringent legislation regarding patient privacy… to say the least]. It was such a constant flurry of activity that there was barely an opportunity to translate the gist of the cases as they came and went. Honestly, the average exam time was about five minutes. I followed along in the charts and was totally awe-struck by how thoroughly this facility seemed to be living up to the intentions of its name… This was a model—albeit a startlingly foreign one—in efficiency. And, as evidenced by the modest sums of rupees humbly deposited in the cashbox, extremely low-cost. Dr. Suschil explained that people all pay in accordance with their respective financial means, but generally pay at least some fraction (however small it may need to be) of the actual cost of the visit, test, or prescription. The rest? Subsidized by the revenue generated from the other paying patients… which includes funds from the entire patient pool of the big, money-generating, tertiary-care main hospital at CMC. He went on to explain that they call this the “Both-And” model, because it aims to meet the healthcare needs of both the very wealthy and the very poor… There is even a special unit (the ‘A-Block’) at the main hospital where, if folks are willing to pay for it, they can have private, AC rooms and whatever tests or specialty services they so desire. Meanwhile, half a mile away, the poorest residents of the town can receive all their necessary care at a price they can afford.

Now, before I get into the ever-controversial and oh-so-pertinent topic of universal healthcare, or start discussing things that sound dangerously like that ‘socialized medicine’ we all keep getting worked up about, I’ll offer the disclaimer that this is simply a description of one type of system at play in one small setting in rural south India. If you’re wondering… Yes, it does seem to work quite well, relatively speaking. And yes, it does make me wildly excited to see such a progressive system functioning here (considering there are so many other factors in this culture that are either quite conservative or just restrictively poor or outdated). But, of course, it’s far from perfect…

Another component of the LCECU that I was able to experience was the outreach efforts of the staff. In the US, the concept of “house calls” is all but entirely obsolete, relegated to remote locales or medical memory. Here, however, with a patient population that can’t always make their ways to a healthcare facility and thrives very much on their sense of community, the practice holds a unique importance. I accompanied Dr. Sushil on his village “walkabout,” an entirely informal but clearly regimented course through a few nearby neighborhoods… Dodging livestock and mopeds and sewer drains, we wove our way past cramped huts and crumbling buildings to pay visit to an unofficial roster of patients. Along the way, people emerged from doorways and shop fronts and alleyways and hurried to greet Dr. Sushil. He patiently interacted with them all, asking about their health and their families in a manner that was unbelievably efficient and compassionate. Many of them produced the now-familiar chart. He would quickly scan it, and make some recommendation about their medications or need to be seen in the clinic. After each of these interactions, he would share the vignette with me, sometimes asking me to remind him to tell certain, more delicate details later. I was struck by the circumstances of each of these lives… beyond anything I can hope to convey now in words (These are stories I need to digest for some time before I attempt to retell them). I was also struck by how aware this physician was of all the forces at play in the lives of so many patients—his debriefings on each individual included mention of their job, financial problems, alcohol use, diet, marital problems, family structure, psychosocial concerns, and even personality quirks… I have never seen a doctor so informed about and committed to his patients.

Some snapshots from the villages...

Dr. Sushil

I’m not sure how many hours we spent walking about through these lives… It was one of those experiences that, despite the sweltering heat, transcended the measure of a wristwatch. I am sure, however, that it was a glimpse of the human condition that will inform much of my future training as a physician.