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Far and Away


The New Physician July-August 2000
By my fourth year of medical school, I longed to renew the enthusiasm I’d had when I first decided to become a physician. I could feel my passion and excitement for medicine ebbing in the face of the future I saw waiting for me. I knew it would involve piles of paperwork, time-consuming negotiations with insurance companies and endless hassles due to inefficient clinical systems. I was searching for some elusive ingredient that would add meaning and purpose to the day-to-day drudgery.

In February 1999, I left the snow- covered woods of New England and headed to sunny northern India for a primary care international medicine elective. My journey began with a mini-vacation to Calcutta, where I attended the three-day Bengali wedding of two of my classmates. From there I traveled to Shillong to find the house where my mother, the daughter of a British missionary, lived when she was a baby. I also visited a small church where my grandfather had been the minister.

Next, it was on to a guesthouse in Dehra Dun, a small city in the foothills of the Himalayas north of Delhi, where I started my clinical work with an American organization, Child Family Health International (CFHI). My day began with sweet, milky tea brought to my bedside, a leisurely breakfast followed by a yoga class, and a morning session in a nearby clinic or hospital. In the afternoon I ate lunch at an outdoor stall, went to another session at a different clinic or hospital, then enjoyed a delicious dinner back at the guesthouse. The evenings usually ended with playing card games or watching Indian music videos. It was not the physical hardship and deprivation I expected, though I will say that I showered in the company of very large cockroaches, so I wasn’t completely spoiled.

CFHI sent me to a variety of sites to give me a wide breadth of clinical experience. I worked in a modern, well-equipped hospital, a struggling community hospital, and the clinic of an Ayurvedic doctor who was the personal physician to the president of India. Many of the patients had medical problems I would expect to see in the United States: trauma from traffic accidents, unwanted pregnancies, meningitis, coronary artery disease, lung cancer and kidney stones. Other patients had illnesses I was less accustomed to: small bowel obstructions from abdominal tuberculosis, parasitic infections and wild monkey bites.

I did not see patients on my own since I had a poor command of Hindustani. Occasionally I assisted with a procedure. Sometimes I practiced my physical diagnosis skills, but usually I just observed. My ability to participate was complicated not only by my lack of Hindustani but by my foreign appearance. Certainly outside the clinical setting, my pale skin and American features attracted a surprising amount of attention, ranging from smiles and waves from bystanders as I passed in a vickram to the occasional unwanted grope as I stood in front of a tourist site. In clinical settings, too, my foreignness inspired varied and surprising responses. One patient upon meeting me took my hand tenderly in hers and kissed it. Other patients, however, were uncomfortable having me in the room and would not meet my eyes. I began to wonder about the practicalities of delivering health care to a population that viewed me as an outsider.

One clinical experience that helped shape my thinking and dispel my confusion occurred while working with Dr. Ghoshal, a slightly fierce retired army physician in his 56th year of medical practice, as he proudly told me within minutes of our being introduced. The first time I went to see him, I walked up the gravel driveway of his house to what I confidently, but mistakenly, identified as the garage and was startled to find patients sitting in chairs lined against the wall. Ghoshal had converted his garage into a clinic, with the main section serving as a waiting room, triage area and dispensary. A curtained-off corner provided privacy for the actual exams.

Ghoshal had lived in Dehra Dun since he was a young man posted at the local army base. Over the years he had gotten to know many members of the community and developed a patient roster that he felt he couldn’t abandon. So for seven days a week, Ghoshal would see one patient after another in his converted garage from dawn until 7:30 or 8 p.m. or until there was no one left waiting. He charged his patients a fee that was usually a few cents above the cost of the medications he handed out and sometimes gave the drugs without charge to families unable to pay.

In his modest clinic, Ghoshal had no laboratory or X-ray equipment at his disposal. His diagnoses were based solely on physical examinations and knowledge of the patients’ families and medical histories. Ghoshal told me several times that he was effective in his efforts to take care of his patients only because he had lived in his community for so many years and knew his patients so well. In some families, he had taken care of four generations.

At the end of my trip, as I sat on the plane, I took stock of all that I had experienced. Ironically, I felt like the heroine of an allegorical tale who travels around the world to find her heart’s desire only to discover it had been waiting for her at home all along. What I had been searching for was the connection Ghoshal had with his patients—a connection whose strength was derived from the fact that Ghoshal lived in the community he served and knew from the inside out. He not only knew his patients, he knew his patients’ spouses and children and cousins. He knew where his patients lived, which ones drank too much and which ones were having trouble at work. And, perhaps most importantly, he was one of them. He was their neighbor and friend. They saw him buying groceries and taking care of his garden. They trusted him. And that trust fundamentally formed the clinical relationship Ghoshal had with his patients.

Ultimately, I realized that I did not have to travel far from home to find a sense of purpose in my clinical practice. Perhaps the best way to find fulfillment was to extend my roots in my own community. I was happy to be going home.
Jane deLima, a 2000 graduate of the University of Massachusetts Medical School, is an intern in the Yale University primary care internal medicine program in New Haven, Connecticut.