CMC - Day Fifteen

It was a busy day in the Child Health Out Patient Department (OPD). Their were at least a hundred children to see and only a few doctors to see them, the registrars off to study for upcoming exams. I spent most of the day with Dr. Winsley Rose. The son of two teachers and a Tamil native he's as gentle an individual as his name would suggest. It is a name you're no longer likely to find, even in England, and it's illustrative of that persistent and paradoxical Indian fondness for the days of the Raj (when the British ruled). He's also one of the newest consultants at CMC. In fact, i've been here longer than he has. He moved here with his wife, a community medicine physician, and their three year old daughter, not two weeks ago. Over the course of the last week i've had a chance to get to know Dr. Winsley and to learn from him about India and the medicine practiced here.

A relatively tall and thin man with square wire rim spectacles, a neatly trimmed goatee and a charming smile, Dr. Winsley has a demeanor that the children seem to love. He told me over lunch that, while it was difficult to say what it was that made him go into medicine, he knew the first day of his pediatrics roatation in his intern year that he wanted to work with children. For one, most children overcome their illness; furthermore much of their illness is through no fault of their own. It provides a health working balance between preventative, acute and chronic care. And he seems very good at it. He finds a way of performing the most thorough exam on the most uncooperative child and half the time, in the end, they seem happier than when he began. This is a rare talent. When it comes to teaching, he is able to stretch the residents' and my own knowledge to its limits without making one feel stupid. Furthermore, he seems like a nice guy to be around. He's invited me around to his house next week and I'm already looking forward to it.

At lunch today he told me about his sister's brother, who lives in Allentown, PA. I asked if he'd every been to the states to visit. "It's too expensive for us," he said. "Aren't you able to save money working at CMC, as housing, food and other expenses are covered." "The only way people find to save money is to go work abroad. And at CMC, we don't make that much money." He explained that at the hospital he just left, the boss who held a job that could soon have been his makes 1.5lakh rupees per month (1 lakh is 100,000). Even senior consultants at CMC only earn about 15,000 Rs per month. That's just under $400. He made much more than that before. "So why," i asked, "did you want to come to CMC?" "I don't think," he began, "that you could find greater job satisfaction than by working in a place like this. Not only because of the variety of cases but also because of your ability to do something about them, even in the most severe cases. In community practice you won't find in a lifetime the types of cases you find here in a week. In a government hospital, you will find them, but you won't be able to do much about it." I am impressed with his pure dedication to good medical care in a profession in which the pursuit of money often seems more common.

I understand his satisfaction, especially in terms of the variety. In today's clinic i saw more children with congenital heart disease - 2 with Tetralogy of Fallot, 3 with ASDs (Atrial Septal Defects), 1 with a large VSD (Ventricular Septal Defect) and 1 16 month old with a PDA (a Patent Ductus Arteriosis, not a Palm Pilot) - than i saw in a week of sub-specialized pediatric cardiology at home. One child had a liver so large it could be felt starting somewhere just above his hips - most of ours are hidden by our rib cages. I wonder if, reading my daily emails, many of you have picked up on this fascination we seem to have in medicine with the bizarre, the extreme, the rare. When an unusual case is presented to a team of physicians, here or at home, you'll often hear people say "good case," or something like that.

I think that it says something about our medical education. In addition to all the things that happen commonly we're also charged with knowing the the most bizarre, rare and unusual causes of any given set of symptoms. We call them zebras. Common things happen commonly, they say. And "when you hear hoofbeats, think horses not zebras." Here in Vellore i feel like i'm on safari. And there is some satisfaction in that, maybe only because it allows one to use the small pieces of information that normally seem so impracticle. Today the consultants were collecting cases for next weeks undergraduate pediatric examinations. Dr. Mammen peaked into the room where Dr. Winsley and I were seated: "Winsley! I've got a child here with celiac sprue," a gluten sensitivity that is not uncommon in white populations of northern European descent. He was genuinly excited. What for them is a zebra is for us a horse. And vice versa. The guy who developed the protocol for treating Small Single Contrast Enhancing Lesions (SSCELs), which he proved in an enormous case series to be (almost always) Neurocystercercosis, is here at CMC. Until coming here, i'd only ever seen cases in books. Here i see children with this, and the seizures that often result, on a daily basis. The problem with our education is that this fascination with the 'fascinomas', as their called, is more likely to make us see the illness before the adult or child that suffers from it: "check out the 'liver' in room three." It objectifies, turning people in patients. And yet it is part of what makes our job potentially more interesting. I'm certainly not the first to write about this conflict, and i will not be the last. But it's something about which we must be acutely aware.

Speaking of arcane knowledge...the exams for medical students and residents here are brutal. For the medical students, a child like one identfied today is brought before them and a panel of four physicians, one from CMC and the rest from outside. The student is told to examine the patient and is then subjected to a barage of questions about the physical exam findings, the differential diagnosis, the probably lab findings, the medications for treatment, etc. The residents' exams are similar, if more difficult. On our morning rounds the other day I saw what exactly these exams can be like. As the rather shy resident stood their shaking...."What is your diagnosis? Why? How can you differentiate between an empyema and a bronchopnemonial effusion? What bacteria is most likely to cause this illness? How do you identify this bacteria? What shape is the staphyloccus? What does the "aureus" in "Staph. aureus" mean? Who described it? What test distinguishes catylase positive and catylase negative bacteria? How do you perform a gram stain? Do you stain with an acid or a base? Or neither?" It was a battery of questions that spanned an entire medical education, including a history of medicine to which i was barely exposed. I can't imagine having an exam like that. It is no wonder so many of the physicians here seem to have encyclopedic knowledge. They have to. If the students or residents fail the test, they cannot start work again and must spend the next 6 months studying until the next exam period comes around. Theirs is an impressive and daunting task. I'm quite grateful for our relatively humanistic (and humane) education, even if i can't wax poetic about gram staining.

I had dinner this evening with some new arrivals, two medical students from the U.S. and another from Australia. As so often happens among people away from home, the discussion made its way in the direction of the restroom. The discussion began with the pros and cons of eating with ones (right) hands, as they do in India, versus eating with a cutlery. James, the australian, noted that a rickshaw driver refused to take money from his left hand, that being the one that is generally used to clean oneself post toileting. It's problematic for him because he's left handed. He went on to declare his disgust at the idea of cleaning oneself with one's hands, and not toilet paper. Kevin, from St. Louis, admitted his ignorance about how the Indians do it, with just a bucket of water and their (left) hands. Thad, from Kansas, couldn't understand it either. In a pinch, Kevin had found himself in a hospital bathroom with only a squat toilet and a bucket. In the end, he sacrificed his sock to the toilet. Laughs all around at that one. An Indian would find that ridiculous. James wondered, if he were in a similar situation, if he would be tempted to use the Indian currency, given its relative lack of value. The others chortled in understanding at his quandry. I may look back someday and think i'm being oversensitive, but i find that kind of talk intolerable, even angering. Ten rupees to us may be a quarter, but for many here it's a days wages. When my proposal that "when in Rome..." was rejected by the three, i informed them that the Indians find our use of toilet paper disgusting. "So what do you think about that?" They didn't think much at all. I have to say that i carry my own toilet paper around in my pocket, or in my bag, because i know it's not likely that i'll find it when i need it. But that doesn't mean i should !&%# on someone else's notion of personal hygeine.

Another weekend arrives. My first and last one in Vellore. I'll be out shopping for the things to bring home. Any requests?

justin