As trips exhaust the weekend, and rotations & preparations for the former exhaust the days leading up, I am exhausted and have fallen behind on documenting daily my experiences. This has been a frustration for me as I found during the first week the reflection at the end of the day to be a helpful tool for a more meaningful experience. It allowed me time to think about my initial reaction, and thereby let me look at both my reaction and the day's experience from a distance - an average of the two if you will.
Since I wrote last, much has taken place. My gut finally fell prey to India's robust micro-organisms. I experienced my first Indian train ride, an overnight one no less! I travelled through the beautiful socialist state of Kerala. And I have picked up a common cold on the overnight train that has left me drained. I'll try to chronicle in the order I left off, and hope I can catch up.
The week started off stumbling my way through a new route in Vellore in grand CMC style... tell the bus driver where I want to go and jump off when he says so. Then ask random people nearby where to go. Fairly quickly I found where I supposed to go and after a brief introduction to the concept behind LCECU I was talking with a pleasant Dr. Sunil. I ended up shadowing him for the morning as he first saw staff members with medical complaints and then started seeing the growing line of patients. In between examing patients he also explained LCECU and his drive to be there. LCECU stands for Low Cost Efficient Care Unit, and aims to do just that. This branch of CMC is subsidized by the main hospital but the patients must pay some amount, however small. They feel this gives the patient ownership in their care, more responsibility for taking care of themselves, and feeds into the funds for the unit. A patient has a one time registration fee of 25 Rs. (~$0.50), after that the only thing patients pay for towards their care is for lab costs and medication; they pay no consultation fees for as long as they are patients at LCECU.
At first I was confused about LCECU role... it seemed quite similar to CHAD that I had rotated through the previous week. I soon discovered that the difference lies in the specialty operating the clinics. CHAD is community medicine (Public Health to us) and is the closest thing to a Family Medicine post graduate MD recognized specialty in India... or at least it used to be. Two months ago, CMC started a MD post graduate Family Medicine program with 200 participants. I believe this to be congruent with a larger movement in India to begin focusing unprecedented focus and monetary support towards primary care. LCECU is run by "Family Physicians" (as they call themselves, but I guess it's not a recognized post grad MD certification). They both do surgical procedures and deliveries, although LCECU doesn't do c-sections. In essence, they serve many of the same functions but their "missions" differ in scope - public health to the masses v.s. individualized primary care to the masses. LCECU provides basic services and coordinates with specialists to take care of anything they cannot. Tests are only allowed to be ordered if it will has the potential to change the diagnosis. Medication prescribed on effectiviness and affordability to the patient, not because it's the best drug medicine has to offer.
Interested in the large support going towards primary care, I asked Dr. Sunil what systems are in place or will be in place to encourage medical students to go into primary care... his response shocked me both in substance and in attitude. He said, nothing really. Sometimes students are sponsored by their local towns and therefor they return to work in repayment. Pushing the issue I asked about pay level, will there be any sort of pay incentive to go into family medicine? "No, were paid just the same as any other specialty... we all make the same amount." I thought, wow - that sure would make a difference in the states. But here in India, or at least CMC, it would be unheard of for one specialty to get paid less than another. To me that seems like it would leave medical students with the pure choice of what area truly called them, not how much will I make so I can pay off my massive debt. I wonder though, if more people would really go into family medicine under a similar system, or if i'm just seeing an oasis of greener grass from a distance. I'm scheduled to work with Dr. Sunil again, and hope to discuss this topic more.
I'll finish with an example of the kind of treatment a patient can get at LCECU, albeit probably an extreme one. A forty somethig female was diagnosed with breast cancer. She was referred to CMC main hospital and received a unilateral mastectomy with lymph node excision; cost 23,000 Rs. Her combined FAMILY income is 5,000 Rs. per month or 166 Rs. per day. She paid a nominal fee for what she could afford and received life saving treatment without furthering their financial hardship. I don't know how many days I can say that i've spent less than 150 Rs. while I've been here in India. Obviously, I don't know how or where the funding comes from - but with the system they have in place, the patients are getting pretty big bang for the Rs.
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