Week 1 (June 18th – June 23rd)

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Dr. Mehta-Sewri-Afternoon

Dr. Batki-Kalina-Night

It has been a week already since I arrived in Mumbai.  Clinical rotations have been keeping me occupied starting at noon at Dr. Mehta’s office located in Kurta, a neighborhood in Sewri. It is a 30-minute train ride from Sta Cruz railway station. Dr. Mehta is a family practice doctor. He has been a physician in India since 1980. He is also the president of the Midtown Medicos Association (MMA) in Mumbai, India. As we arrived to his office, I noticed how small doctor’s clinics are. There are just enough seats available to have more than half a dozen patients in the waiting room, with their shoes off, of course. On the left corner of the waiting room, there is a sort of patient’s reception desk with a little window facing the room. This is from where his assistant is also connected to his office and communication between them flows back and forth. She also dispenses some medications if they have them available. We entered into his office through one of the smallest doors I have ever seen. His desk is to the left. There is an examination table to the right with a curtain around it so there is some privacy for the patient when there are other people in the room.

You don’t need much space to practice medicine in India. You only need the “appropriate technology” to do it, determination, and compassion for patients. As the patient comes into the doctor’s office is greeted with cordiality and as if they were a member of their family. As he speaks to the patient that just came in, his wife tells us that Dr. Mehta knows the patient since she was a child, but now, after many years, the patient brings her own child from Panvel, which is about an hour train ride, to be seen. The relationship that exists between doctor and patients is based in trust through time. Patients are more than just a number in Dr. Mehta’s office. Shouldn’t it be this way? I have noticed that he is not bother by the amount of time he spends with his patients.  He gives time to each one of them according to their needs, and no one seems to complaint about the waiting time.  During my clinical rotation at his clinic, patients’ age vary from newborns to adults. One of them was an 18-month-old boy with an infection in his belly button. I was told that when babies are born, there are given oil massages, which they are believed to benefit their bone growth; apparently this baby was given oil massages and it could have been an accumulation of oil, and dirt that caused the infection. There was a yellowish discharge surrounding the belly button.

There was also a 25 year old-female that arrived to the office in tears because she just found out that she was pregnant with a 4th child, after 3 children. Here in India, women do not have much too say about whether they want to keep the child or not. It becomes a family decision; that includes husband, parents-in law, brothers and sisters. A woman is only allowed to have an abortion under one condition: only if the husband approves for an abortion. Legally, abortion of female fetuses is not allowed, however this type of abortion culturally it is accepted because families preferred to have a male child.

This female patient was given iron supplements and pregnancy vitamins, of course, she is having the baby. She came with her sister in law. Women never got to a doctor’s appointment by themselves; there is always a family member with them, most of the time of the same sex. Wives come with their husbands and the husband is the one that answers the doctor’s questions when assessing the patient. Many times it depends to what religion group they belong to; some are more likely to discuss their health concerns openly than others.

Dr. Mehta’s office is located in a suburb area where many, if not all, its residents are from very scarce resources and belong to the working class. He spoke to most of his patients in Hindi, and others in Marathi, which is the state language. He translated to us the cases as he was finishing the patient assessment. He answered my questions promptly, reviewed the symptoms, decide on a diagnosis, and prescribe the appropriate treatment.

One of his patients, difficult to forget was a 28-year-old male that came to be seen on Monday. He presented chills, high fever, body aches and weakness. The doctor thought that could be a case of influenza, however he want to rule out a bacterial infection, so he ordered a blood test to analyze the levels of neutrophils. In countries where infectious diseases are a main concern, a blood test screens for the presence of bacteria that causes malaria and dengue fever. 2 to 3 hours later, Dr. Mehta diagnosed this patient with malaria because it was detected on his blood, and the level of neutrophil was at a high range abnormal. Dr. Mehta told us that this is usually common during monsoon season. Malaria is diagnosed in a daily basis since it is still a current infectious disease in India.

There were more common cases as colds, cough, bronchitis, diabetes, and fungal infections of the skin.

To get to the train station, we had to walk through an elementary school, some tailor shops and a small market where I always find a way to look for new items that call my attention. Make sure to have a strong will power to walk away from any bargains or shopping areas because the merchants will convince you that you “need” to buy their items. You will be followed to your destination until you tell them otherwise, wait, not true…they will still follow you regardless, shouting a lower price every time…

In the evenings, from 6:30 to 9:30 pm we went to Dr. Batla’s office. His office was conveniently located within walking distance from where we were staying. I used the walk to his office as an immersion into Indian culture because I learned the way the locals live like. On my way there, I crossed through the neighborhood where I found little groceries stores, what we call in America “hole on the wall”.  They stock the necessary items that a housewife happens to run out every once in a while and she needs to buy to cook and clean. American style grocery stores are located farther away. There are no cold cuts, beef or chicken on these stores. Most Indians are 100% vegetarians. There were also stores that only sell dairy products, (my favorite store!), dahi (yogurt), milk, butter, and paneer (cottage cheese). I passed apartment buildings, single homes, a   mini soccer field where the neighborhood kids played in, and a Hindu temple. There was an elementary school that its dismissal time was at 6:30pm. As they came to pick up their children I felt the flow of women wearing their beautiful sarees passing through me. I was almost lost in the crowd because you can still recognize me from my western-style clothes, which I only wore during this first week. In India, men and women celebrate life with clothes, fabrics and colors. And I want to be part of their celebration. My clothes were exchange for a pair of kameez and kurtas. The kameez is a long shirt or tunic. The side seams are left open below the waistline, giving me greater freedom of movement. Kurtas are worn as blouses, usually over jeans pants. That is the way I wore them, like every woman in India.

Dr. Bathla's OfficeDr. Bathla and meKalina's MarketWearing Kurtas

I passed a street food cart that sold samosas, and vegetable fried rolls. It became impossible not to surrender to the temptation of trying them out. The smell of the hot oil bubbling spikes your brain with hunger from far away. They are made fresh by one of the local women that live near by. She takes her street cart in the evenings to sell this Indian delicateness. Samosas can be served with a sweet or/and spicy sauce and as a filling in bread. She wrapped my order in a piece of newspaper to keep it warm and crunchy.

Samosas!

Once you get to the main street where Dr. Batla’s office is, you have to go through Kalina’s market. It is full of street vendors on both sides of the road. Fruits, vegetables, hair products, shoes, clothing, and flowers are available for sale. Whether you decide to walk on the street or sidewalk, just do it with a purpose and at a prompt speed, because you will find people coming in the opposite direction just with the same or maybe faster pace than you. Honking is at the order of the day. Motorcycles, rickshaws, cars, buses honk to each other back and forth to indicate their direction on the road. Pedestrians have no right away, so be cautious, you were warned!

The waiting room at Dr. Batla’s office is quite small but it looks cozy and comfortable for his patients. A little window into the assistant’s cubicle faces the waiting room and the busy street. There is a small door that leads into the doctor’s office where you will find a desk shared by sliding curtain, and two doctors can attend patients at the same time with the littlest of privacy. There are many cabinets all around inside his office. As his assistant gets ready to take a blood sample to assess the glucose level of a patient, I see him opening multiple cabinet doors at the same time from everywhere, some from the top, some from the bottom. Space is limited, so they use it wisely.

Dr. Batla is a family physician; he has been practicing medicine in India for the last 15 years. His clinic is located in an area where many middle class Indians live. Many of his patients speak English, which really allows you to learn about the different type of question that Dr. Batla asks to assess and diagnose his patients. You don’t have to speak Hindi to understand the close relationship that exists between his patients and Dr. Batla. It was difficult to differentiate which patient was a new patient and which one was not. Dr. Batla has charisma, and seem open and up front with all of them from the very beginning of the consultation. From what I have observed in Dr. Batla’s interactions with his patients, medicine is based on the trust that exists between physician and patient, compassion towards the patient, and how competent the physician is when diagnosing a condition. To be confident in diagnosing, you need to be competent. This confirms my personal belief of what is needed to become a physician: the importance of the three C’s: compassion, competency and commitment. Dr. Batla is very much liked by all his patients; many of them bring them gifts and Indian sweets that he so kindly shared with us and other patients. What I saw during the clinical rotation at his office remaining me when my grandmother used to take me to her doctor’s appointments. She used to take a gift or something she made to her doctor as a symbol of appreciation for his care. It has been examples like this that have inspired me, at very early age, to want to become a physician.

During the clinical rotations at his office, I was able to take the blood pressure of some patients and auscultate for heart and breathing sounds. Some of the most significant cases were:

A 45 year old male that came for a physical routine examination; he had a history of diabetes. As part of the routine exam, Dr. Batla always measures the levels of glucose on diabetes patients. In India is not as easy as in the United States for the common diabetes patient to owe a glucose-monitoring device. At the consultation, they all get an estimate reading of their blood glucose to better assess their symptoms and if the medication they are taking is effective in controlling it. This patient has 484 mg/dL, which was astonishing to me because the normal levels of glucose range are in the low to mid 100s   when taking a prescribed medication.

The patient mentioned that he has been taking a homeopathic medication for his condition. Dr. Batla order a blood glucose test to have more accurate results, and the result was just as high as the previous one taken by him. The patient was advised about his results and consequences of having such high levels of glucose. He was also counseled about a more effective treatment for his condition. Dr. Batla discussed about this case because I have known of other patients that when their blood glucose levels are as high as this, they are at high risk for a diabetic comma to happen. As he shared with me, India has more diabetics than any other country in the world. According to the International Diabetes Foundation the disease affects more than 50 million Indians, 7.1% of the nation’s adults and kills about 1 million Indians a year. The average age on onset is 42.5 years. The high incidence is attributed to a combination of genetic susceptibility plus adoption of a high-calorie, low-activity lifestyle by India’s growing middle class.

Another significant case was of a 60 year old female with a large abscess in her back that had appear 3 days ago with an acute pain and inflammation at the site. This patient was diagnosed and treated for Dengue fever a year ago. The abscess was drained and disinfected accordingly. An antimicrobial ointment was applied at the wound site and properly bandaged to avoid any further infection. There was no history of diabetes or high blood pressure, although because of the inflammation, the patient had a blood pressure of 136/90. She was prescribed an anti-inflammatory to relief the swelling and an antibiotic to eliminate any traces of possible infection.

This has been an exciting first week of clinical rotations in Mumbai, India. I have learned different ways to obtain the same goal: an accurate medical diagnosis to achieve the best results for the patient. In circumstances where technology and sophisticated medical equipment is not readily available, there are options. Medical care is dependent in patient history, analysis of signs and symptoms and a relationship between physician/patient based on trust.

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