Dr. Douaiher offers a personal reflection about his experience:
Ever since I found out about the possibility of doing an international rotation, I was intrigued. The idea of participating in surgeries in India excited me from several standpoints. From my readings on medical care in India, I found that patients tended to present in more advanced stages of their disease, which would mean that I would be exposed to more complex disease manifestations, and the challenges that would come with it. Furthermore, I was interested to see how physicians/health care systems would allocate care delivery, and design treatment plans, keeping in mind the limited resources available. I was also interested to say how techniques and approaches to surgeries differ from what I am used to and to see how surgical residency differs there in terms of resident lifestyle, education and experience.
I arrived to Hyderabad early December and instantly was greeted with warmth and great hospitality. In India there is a saying that equates guests/visitors with gods; hospitality is held to such a high standard. Everyone wanted to include me in cases, involve me in educational activities, show me techniques, show me interesting diseases, and most importantly share Indian food. It was important for my host to always make sure I had a full and satisfied belly! Although this was my first time visiting, and also during the Christmas season, there was never a moment that I felt strange to the country or felt alone. Everyone made sure I was surrounded with good company and I quickly made friends, with whom I still touch base almost daily to this day. On days off, my friends would take me out to try different curry flavors, the famous Hyderabad Biryani, and to experience Indian music and dancing. It was all amazing!
Going back to the OR; it was very interesting to see that esophagectomies were performed almost every other day if not every day when I was there; that was impressive! Women presented with breast cancer at progressive stages, and I saw much more aggressive disease than here in the US. Even if it was early or DCIS, they invariably all undergo MRM in fear of being lost to follow up. It was thought-provoking to see how clinical decisions were made taking into consideration the patient population and the resources available. One has to digress from textbook and be a bit more flexible/creative in such settings. During a patient’s hospital stay, physicians depend much less on labs or frequent imaging, than on physical examination and clinical acumen to decide treatment plans; million dollar workups are an unaffordable luxury.
I noticed that the general surgeon in India, is truly a jack of all trades; I saw the same surgeon perform head and neck operations, chest operations, whipples, orchiectomies, and hysterectomies. Surgeons are truly general surgeons and can basically treat most surgical things. This definitely beats the routine, as the surgical list for the day is always an intriguing selection of a diverse array of cases. Of note, I got to do my first TAH-BSO.
Another very impressive observation was that even the youngest of residents were well versed with the latest surgical guidelines from both US and European guidelines. Residents truly challenge each other’s knowledge base. There is an unquenched thirst for knowledge and everyone is quick to cite the latest trials (even those that are pending/in progress); and there was the constant question to me in the OR: “is this how you do it in the US?”
A peculiar habit I found is that everyone takes off their shoe before entering the ICU and are given slippers. It is similar to entering a sacred home that one must respect.
And speaking of sacred, I felt like physicians were so highly respected by their patients and their families to the point of adoration. Patients and their family members would kiss their surgeon’s hand in gratitude, listen intently when they talk, never talk back, never complained; the physician-patient relationship was certainly unleveled. Also, the communication was always unidirectional, which could be criticized; however, I never witnessed any abuse of the surgeon of this holy power.
Certainly one cannot overlook the economic disparity between the typical US vs Indian patient; I saw patients and their families camped out for days outside the hospital throughout the perioperative period, especially if they were travelling from afar.
The experience was certainly eye opening. It made me appreciate even more the order, the resources, and the technologies we have in the US. However, I also realized that surgical principles are universal; they are not much different here than thousands of miles away. Even in more economically challenged societies, surgeons still hold up to their standards of excellence and give their best of care to their patients, while following universally agreed upon guidelines. Furthermore, being a bit more creative, adjusting to patient population and its demands might take you slightly off the book, but can prove to be beneficial and sometimes necessary. A good and experienced surgeon always has tricks up his/her sleeve when tricky situations present themselves.
Jeffrey Douaiher, MD
House Officer IV