Week 2: Dehradun

Hello folks!

Well week two was certainly an interesting one! The focus here in Dehradun has been mainly on medicine and I have stayed quite busy at the hospitals I am working at and have not done much sight-seeing. My day begins at 9am with Dr. BC Ramola, an ophthalmologist at the public government hospital here in town. At ~1pm I get a break to do as I wish and then I re-convene from 6pm to 10pm with Dr. Sanjay Gandhi, general practitioner at the private City Heart Hospital. Before I divulge my day-to-day, let me first tell you about the city.

Dehradun is unlike anything I have ever experienced or could possibly dream existed. All of the images and movies I had seen previously that I thought were exaggerations of stereotypes and Hollywood glamorization are right here in front of me every day. The pace of the city is  non-stop and there is action in every direction. My commute to work involves navigating the busiest street in the city. The transit time varies but it takes roughly 30-45 minutes to span 5 kilometers. The traffic here includes pedestrians, bicycles, pigs, horses, bulls, scooters, motorcycles, Vikrams, rickshaws, cars, jeeps, buses, and industrial trucks that weave in and out of one another while all the while honking their horns. In addition to the noise, a constant and palpable layer of smog/pollution and dust is present in the air. It's truly a fantastic spectacle and I've been trying to stay patient and tolerant. Earlier this week it was a daunting and overwhelming task simply to leave the house but I'm proud to say that after only a few days I can navigate my work commute without getting lost and my comfort level has already improved exponentially. Today I didn't even take a Tylenol.

Clock Tower in city center Dehradun 

 Side streets in Dehradun. 

The medical aspect of my week in Dehradun has been fascinating and the physicians I am working with are superb. I have seen a lot of interesting pathology but, more importantly, I have discovered a lot of insights regarding the health system here in India and seen first-hand the difference between private and public health sectors.

1. Dr. BC Ramola, Ophthalmologist - Doon Government Hospital
Dr. Ramola has 20+ years working as an eye doctor, first in Rishikesh and now in Dehradun. When I first arrived at Dr. Ramola's clinic in Doon Hospital there was a crowd outside his door that I later realized was a line of patients waiting to see him today. Despite the demanding crowd he ushered me into his clinic directly and made me feel welcome. I was pleased to meet a medical student and resident who were also working with him. After exchanging pleasantries the fun began as Dr. Ramola saw individual patients at a consistent plug that made my head spin. It was truly like a factory machine - very methodical - with hardly a greeting between patient and physician and very little dialogue. After 4 hours of clinic his registry book recorded 99 patients! There was a large range of chief complaints but the most common by far was cataract. Dr. Ramola told me that as India becomes increasingly developed and "westernized," the life expectancy continues to increase and, thus, the prevalence of cataracts naturally increases. The following day I joined Dr. Ramola and his team in the OR and the pace was on par with his clinic. In 2.5 hours Dr. Ramola performed 18 cataract replacements (or roughly one every ten minutes)!

Dr. Ramola, myself, intern, and medical student. 

 Dr. Ramola at work. 

Dr. Ramola is the only ophthalmologist in Doon Government Hospital. The rest of the ophthalmologist in Dehradun are private physicians. In the past calendar year he has performed just over 2,000 cataract surgeries while the closest colleague in the private sector is somewhere near 250 cataract surgeries. However, despite the long lines of patients and incredible surgery rate, Dr. Ramola will never become a rich man because he works in the public sector of India's health system, which involves universal coverage for all of it's citizens. While Dr. Ramola will never swim in a sea of Rupees, there is no waiting time for patients of Doon Hospital to receive cataract surgery and, from my short time with Dr. Ramola, I could sense his pride in this achievement means much more than any financial figure.

2. Dr. Sanjay Gandhi, General Practitioner, City Heart Hospital. 

City Heart Centre

What an awesome opportunity it has been to spend time with Dr. Gandhi. His life story is simply amazing. As a child Dr. Gandhi grew up in the slums of Delhi. For money he took to crime to provide food and clothes for his family. He went through school always being advanced but never passing on merit. When he was in 10th grade his father confronted him and asked him what he wanted to do: study or be nothing. When Dr. Gandhi answered his father that he wanted to sell vegetables from a cart his father beat him and stabbed him with a scissors. When his father visited him in the hospital afterward he cried and begged Sanjay to become something and advance the family name from nothing. Since then Dr. Gandhi excelled through school and earned a slot in the best medical school in India (100 spots for 1.5 million applicants). He graduated at the top of his class and began practicing medicine in the private sector when he was 21 years old.

Dr. Gandhi's demeanor - calm, patient, empathetic, compassionate, modest - can be explained by his childhood and his career success can be attributed to his demeanor. 

Not long after this he decided to start his own clinic, which began as a single room at the location in the photo above. Since beginning this clinic Dr. Gandhi has worked 16 hours per day, 7 days per week without a single holiday for the past ten years. With this hard work he has transformed the single room clinic into the City Heart Centre, a 23-bed (7 ICU, 14 general ward, 2 emergency ward). During a typical day Dr. Gandhi sees between 40-50 patients and manages all the beds in his hospital. Additionally, his phone never stops ringing (his ringtone is Bon Jovi's "Bad Medicine"- not kidding). I finally asked him what all the calls were and he told me he gives all of his patients his cell phone number. He fields somewhere around 200 calls per day. All summed, Dr. Gandhi takes care of 240 - 270 patients per day. His future plans are to give his practice to someone he feels is a worthwhile replacement and retire at 45 years old into a small house into the high Himalayas (awesome!) with his wife and... "perform the objectives of my 'bucket list.'"

I've seen some pretty fascinating and unique pathology this week while working with Dr. Gandhi. LOTS of Typhoid Fever (but no textbook rash, apparently this is rare), a good bunch of TB including Miliary Tuberculosis/ischemic stroke (tuberculosis so advanced it spread from the lungs via the bloodstream and created a clot the vasculature of the brain, causing a stroke), Hepatitis E, Rheumatic Heart Disease, several MI's (all of which were managed medically b/c the patient could not afford a heart catheterization).

 Dr. Sanjay Gandhi, outside his ICU (shoes off before entering)

 Dr. Gandhi with his 101-year-old patient.

The public and private sectors of medical care here in India are much different. The only real similarity that I found is that both see a very high volume of patients. The difference in facilities between the two sectors is probably the most striking difference. Doon Government Hospital is a very large facility with a multitude of shared patient wards and lines of patients waiting to be seen in clinics. The private hospital is a more controlled atmosphere, cleaner, and with private rooms. The medical students I worked with confirmed my suspicion that there is likely better quality of care in the private sector; and it makes sense - why else would you pay? Dr. Gandhi, the private physician, worked much longer hours as his accessibility is what patients pay him for, while Dr. Ramola, the public doctor kept strict hours and saw as many patients during them.

I've been learning a lot about medicine as well as myself. In just a short while I am headed to Rishikesh for the remainder of the weekend to take in the historic Yoga capital of the world alongside the Ganges River :-)

Next week I'm back into the mountains/hills in Mussoorie. I am welcoming the slower pace once again. And next weekend I make my way to the high Himalayas! The trek to Nanda Devi is snowed in but I am headed to a base camp in Auli and from there we will hike as the snow/weather permits. Exciting!

Thanks for reading -

Tim