Internal Medicine

Yesterday and today I got the opportunity to see what the Internal Medicine service is like at the CMC hospital. Yesterday we had clinic. The clinic is located on the second floor of the non-airconditioned hospital. To get to the OPD (outpatient department) area we had to pass large waiting room areas. For every two rooms that made up the Internal Medicine Team II area there seemed to be at least 40 people waiting. This area was quite warm and stuffy. I'm sure the patients were thankful for the chairs. This part of the OPD is organized with six examining rooms on each side with a small inner hallway connecting the rooms. Doctors use the small inner hallway to get into the rooms because the waiting areas are very crowded. Each examining room is probably 12x12. Two residents share the room. They have two small tables facing each other against one side of the wall and they sit facing each other. Their desks are crowded with charts and other forms. They share a blood pressure cuff that looks like it was from the 1950's. It actually uses mercury! There is an old wooden examining table on the opposite wall. The only thing dividing this table from the rest of the room is a worn and dirty curtain. Aside from the dirty walls, scarce air, and minimal space the examining room looked much like the ones I'm used to. There were small bulletins informing doctors of clinical trials and a computer with the most recent lab results.

The two things that stood out the most to me were that the residents shared an examining room and saw patients at the same time. You can imagine that if the patient was there with a family member (usually the case) there would be at least 6 people crowded into this little space (without counting Anne and me). Forget HIPAA. There was very little privacy in this environment. The other thing that stood out is the number of patients seen by the residents each day. During a typical full day in clinic a CMC resident sees 40 patients!!!! This is compared to the 10 or so an American resident sees during a half day of clinic. What was more incredible is the number seen by the interns (first year residents). In the US it's usually 6 at the most (half day) while in India it can get up to 30 patients in a whole day!!! I can't even imagine having that kind of pressure on me during my first year of training.

Today we went to grand rounds with our team. This basically consists of the whole team rounding on each patient. Our team has 40 patients and it took over four hours to finish rounds. This includes a 15 minute tea break for the attending doctor. Our team was made up of residents, interns, medical students, nurses, visiting attending. 27 people in all!!!! As in the states the resident presents the patient to the attending doctor (head honcho) and then a discussion of the case ensues. This commonly involves the attending making suggestions and helping with the diagnosis and management as needed. The attending also asks the medical students questions (called "pimping" in the US) relating to the patient being discussed. This was much like it is done in the US except for a few minor differences.

The teaching during this time was excellent. I saw patients with many of the same conditions as in the US. Meningitis, pneumonia, thyrotoxicosis, stroke, diabetes to name a few. We also had two patients with snake bites! During Grand Rounds the topic of funding for the patient was openly discussed. I felt that these discussions weren't done with the purpose of withholding treatment. Rather it was done more as a realistic issue of which the family must be informed. Many times in the US it's seen as something taboo. Something that shouldn't by the doctor specially upfront.