The Last Free Summer - Conclusions
Mark Clapp, Neal Viradia, Emily Gifford, Poonam Patel, and Suzanne Weaver, now second year medical students at the University of North Carolina (Class of 2011), share the final part of their series of three articles about their experiences in India and the Himalayas. The first and second installments can be found here.
The team
India is definitely a country of extremes from the snow capped towering peaks of the Himalayas with ancient monasteries carved into cliffs to the dense tropical forests of Goa and chaos of Delhi, and we were fortunate to experience all of these extremes on our last summer. We had decided to do some touring on our own before meeting up with the other students going on the Himalayan Health Exchange Expedition. Our plans, all prebooked from the United States, included a day in Delhi, and then on to Jaipur and Agra for a few days before returning to Delhi. Once we arrived, things changed since all the roads were blocked to Jaipur due to some unrest, which allowed us to travel to Goa and spend a few exciting days among tropical spice plantations and spectacular sunsets over the Arabian Sea. After our mini trip it was on the Himalayas and our great experiences there. Below are some of our overall thoughts on the trip and our last free summer.
Neal
Getting off the plane the warnings of my parents flashed in my head. This was my 3rd time going to India, and the last time I had gone was 10 years ago. However, this was my first time flying there by myself. Suzanne, Mark, Emily and Poonam all had different flights from mine. Stepping on to the jet bridge I was hit with the oppressive humidity and smell. It brought back memories of my last time in Delhi, and spending 10 hours in an unairconditioned airport. Going through customs, I was surprised how nice the airport was and the progress that has been made until an “airport official” tried to take my customs form and “help” me with my baggage in the baggage claim area in exchange for payment. Originally I had laughed at the warnings of my parents, but wow it had actually happened. I knew from then that this was going to be an exciting trip where anything could happen.
We met the rest of the team at a hotel near the train station in Delhi. This area, known as Pharj Ganj, was one of the craziest places I have ever seen. The streets were too narrow for 2 lanes of traffic and all you could see were neon lights poking out from the sides of the buildings. I could imagine the feeling of being overwhelmed that my colleagues probably faced, if I was feeling shocked by the place. However, this was in stark contrast to the Himalayas. Our crew would pile into the Jeeps and venture out on the narrow mountain roads and often not see any sign of human settlement for hours. The scenery was just breath taking. You would often see hands sticking out the windows with a camera trying to get the perfect shot of the passing waterfall or snowcapped peak. I really felt special to be able to witness such a beautiful place. I also got in touch with my naturalist side and found myself examining the rock formations and change in landscape as we ascended and forged deeper into the mountains. It was really nice to be able to get away and focus on something not related to medical school.
Working in such a remote place definitely had its share of challenges. We often did not have the proper tools or the perfect drug, which would all be readily available in the United States in a clinical situation. It helped me to learn how to improvise and work with what we had to still be able to help someone. However, the people in the villages in which we had clinic were truly astounding. It was surprising how they lived their whole lives in these remote places. They were really grateful of our presence and appreciated anything that we could provide for them, even if it was just vitamins. It is rare to see such thankfulness in every clinical encounter in the United States, though it does exist on some level. I also particularly enjoyed the ophthalmology tent. I will never forget the look that we received after giving someone glasses so that they could see again. There were also the school kids who would come in and see who could get the most pills for feeling sick or ask you to take a picture of them to see on the digital camera, which provided a fun distraction. Additionally, I was really glad that I was able to brush up on my Hindi skills by traveling before. You would be surprised how much language you will pick up when you are forced to use it. The fact I could communicate with the patients with out a translator and be able to explain what I or one of the team members was doing helped to put the patients at ease and allowed me to pick up on the subtle nuances of the history, like concern in their voice. The clinic provided us with a great place to learn and witness the practice of medicine in action.
It was a rewarding feeling that we were working to improve these people’s lives, and that I, after completing one year of medical school, was able to make a difference. The whole Himalayan Health Exchange experience really allowed me to look past the book learning, that we were entrenched in, to the practical humanistic side of medicine and helped remind me why I choose to be a doctor.
Suzanne
Mark, Emily, and I were looking through pictures a couple of days ago, and I think our reactions were the same: it is hard to believe that not only were we actually in the midst of the incredible scenery captured in our pictures, but that the pictures don’t even come close to doing it justice. However, despite the surroundings that inspired awe, the friends that were made, the clinical skills that were learned, the fun that was had, ironically, the main thing I brought home with me was the fact that I am not cut out for short-term medical missions. This is not in any way meant to belittle the good that short-term clinics accomplish; I know without a doubt that we helped a very substantial number of people who uninhibitedly responded with abundant gratitude. It just means that I discovered that my personality does not necessarily mesh with the factors that are inherent in short-term missions. For example, I had a really hard time talking with a patient, diagnosing them, but not being able to treat them and having to just tell them to go to the nearest governmental hospital (sometimes 3 or more hours away). I would worry throughout the trip about various people and think, “I hope he/she is able to find a ride to the hospital and that the hospital has the medicines/equipment necessary to treat him/her. This self-discovery was a very important one for me to make, because I had always envisioned myself as one who would take a month off after I was an established doctor every year or two and go abroad somewhere to help. Now, I know that it would be more personally fulfilling to involve myself in building clinics or training doctors in an underserved area of the world. Interestingly enough, the Himalayan Health Exchange has also just added this as a goal and is planning to build a permanent clinic in the city of Manali. I am going to use this knowledge about myself to shape my career choice as well- I should pick something that allows me to follow the progress of my patient from the beginning to the end of their journey with an illness, or at least as much as possible.
The other most memorable part of the trip for me was how much the people there respected us as doctors or even doctors-in-training. The deep respect from that population brought into sharp focus the lack of respect that US citizens seem to have for doctors here. I think this sentiment is perhaps best captured in the show Scrubs. Dr. Kelso says, “remember when being a doctor meant that people would look up to you? When I first started out, I could take this white coat out, get a free hair cut, nice table at a restaurant…I never got a speeding ticket” and Dr. Cox responds with “Today people think of us as drug-dispensing walking lawsuits who are, in fact, less informed than their internet phones.” I am by no means advocating that doctors need free haircuts anymore or that we return to the paternalistic ways that characterized times in the past, but I feel like we should take a good look at the things that have gone into this decline of respect. Whether it is our patients fearing our alliances with pharmaceutical companies that will bias our treatment plans, the much too high rates of negligent mistakes that occur in hospitals, or just a feeling that we don’t have enough time to just listen to our patients anymore, I will be extremely attuned to avoiding these things so that one day, I might get the same look from a patient here as I did from the “cutest grandmother in the world” in the most beautiful place in the world.
Poonam
Stepping off the plane in Delhi, you are greeting with the muggy aroma of spicy sweat, urine and the toilets (which happen to be all the way down the hall but you can still smell them - GAG). So why does this stench make me smile when I get off my crowded 14 ½ hr flight? Well for me, I expected it. Having been to India a couple of times, I take that step off the plane fully expecting the blast of hot stinky air to say, “Welcome to the India Poonam!” As I walked off the plane, I silently chuckled to myself envisioning the expressions on the faces of all my future HHE colleagues as they took their step into the unexpected. Here I was thinking that I’ve been here, done this, but the one of many things that I got out of this trip was to expect the unexpected.
Some of the unexpected was the amazing beauty of Himanchal Pradesh. Some students from our school had told us about how beautiful it was - but in my mind I was like, “Poof - I’ve been to Alaska (gorgeous), been to Victoria Falls (majestic), been to Bahamas (glamorous) …. How much better can this be? “So when I woke up in the morning graced with snow capped mountains and when I was lulled to sleep by the sound of a raging river below - I realized that I totally underestimated the beauty of this hidden gem in India. The India I knew - was dirty bustling Bombay, feisty Delhi and buffalo/cow populated villages. But this place, these people, the monasteries - WOW. I must say that I am extremely grateful for the organizers of HHE, for their consideration in allowing us to experience more than the medicine. I remember going to a monastery sitting while the Buddhist monks were chanting, I sat there (for I don’t know how long) and felt at total peace. To feel peace is something that I haven’t had in a long time and to shed a tear is something that I definitely don’t do too often —– I guess this translated to me being happy and peaceful. We walked (maybe 5 of us) out of the monastery and sat on some steps as the wind gusted in our faces and didn’t say a word as we looked around at high mountain passes and what looked like divine sunshine making the streamlets of water in the dry river bed glisten.
So I knew that we were going to be facing lack of resources when dealing with our patients - but the reality of it is that you do not truly realize it till you are faced with a situation whereby you think to yourself, ” had I been in the states, this would never have happened in the first place or had it happened it could be fixed.” It was a source of frustration for me, till I came to the realization that I was not in the States and that what we were trying to do for them was better than nothing at all. One of my most memorable aspects of the trip was our patients’ appreciation for everything we did for them. No matter how long they had to wait in the blazing sun or whether we sent them home with only vitamins - they always had that charming little toothed smile as they walked away.
I must say that my Himalayan Health Exchange experience has to be one of the best experiences that I have had yet. The medical experience was priceless (considering our limited first year medical knowledge), but what was more priceless for me was the bigger things that I got out of it. Yes, I Poonam ZZ Patel had to use a toilet that was a hole in the ground (with no flush!). I hiked ~20km (in mountain woman clothes - you would be very surprised if you knew me). I did not get car sick. I did not get sick (well on the HHE part of the trip at least). I slept in a tent (yes- this adds to my mountain woman points!) I found peace. I lived happily without my cell phone, facebook, stilettos etc. I made friendships that I think are going to last a long time. I could go on, but I think you get the point - this trip was priceless.
Emily
Every single day in India was full of new surprises and experiences. There really is no such thing as “routine” there. We would arrive at clinic never knowing whether to expect a building, a tent, electricity, or even interpreters. Himalayan Health Exchange did an amazing job of planning for all circumstances, but there were times when resources just weren’t available. Typically though, we arrived at the clinic site prepared to work on one of the seven teams for the day. Those teams included Internal Medicine, Pediatrics, Obstetrics and Gynecology, Ophthalmology, Dental, Triage, and Pharmacy. A physician from our group led each team, and spent most of their time teaching us medical students. The education was one of the greatest benefits of the program, as each of us students was able to perform the history and physical and then propose an assessment and plan. Through the course of the program we were finding that we were really comfortable making diagnoses such as GERD and pterygium.
Many of the patients’ complaints were related to their environment. Due to the altitude and the brightness of the sun, many patients had visible sun damage, chronic headaches, and dry eyes. Other common concerns included intestinal worms, body aches from working grueling hours in the fields, and coughs. After making our diagnosis and plan, we would send patients to the pharmacy tent to receive medicines and/or vitamins.
Our interactions with the Indian health care system were also very educational. We were able to meet some of the local physicians and tour the community hospitals. The hospitals were small and with very limited resources, but the doctors there were very knowledgeable and skilled at treating all of the problems that a patient could have.
Days in clinic were typically very rewarding and educational. For me, the entire experience was worthwhile because I learned a lot about how to practice medicine in the context of a new culture without the benefit of Western technology. I also enjoyed the having the opportunity to talk to physicians about making choices about specialties and residencies.
Now that I am back in class I am grateful for all of the clinical experience that I gained this summer. Experiences in the classroom and in the clinic have helped me learn much more than I would have in either in isolation.
Mark
Reflecting on my experiences this summer, I am amazed that only a few short months have passed. It feels like a few years have passed since I was at 14,000 feet in the Himalayan Mountains or trying to stay calm in the bustling city of Delhi. When trying to describe my experiences to friends and family, I can’t help thinking how surreal the trip truly was.
If you were to ask me if I was every going to return to India while I was there, I would have given you a conditional answer, “only if I can go straight to the Himalayas.” I found that our time before the HHE program started in Delhi, Agra, and Goa to be not as relaxing as I expected on a ‘vacation.’ I was amazed at the attention-many times unwelcomed-that we received due to our clothes and skin. This constant feeling of being watched coupled with the ongoing digestive issues and intense heat made for quite an experience and some great stories. However, once we joined the HHE Spiti team and headed north to the Himalayan Mountains, the atmosphere changed significantly. In the small villages of the Himalayan Mountains, I felt that our presence was welcomed and we were always treated with overwhelming hospitality. These communities in the backdrop of the dramatic Himalayas draw me back to India.
In these small communities, Emily describes our ‘everyday routine,’ if you can call it that. It was indeed full of surprises. In the clinics, I greatly improved my clinical skills. I learned how to communicate with patients without speaking and to read their pain, concern, and trust by the look in their eyes. I was able to perform histories and physicals on patients of all shapes, sizes, and ages, improve my presentation skills, and begin to formulate differential diagnoses based on my findings. Our clinics reinforced the collaboration and continuity of learning involved in medicine. I returned to North Carolina feeling more comfortable and confident in my skills as a future doctor.
The time we spent caravanning through the Spiti Valley was a blur. Time passed quickly during the trip and has continued since my return. And while my five weeks in India seem five years ago, I retain the memories of our fabulous team, our work in the indescribable Himalayas, and the many skills I learned in India.
Overall, the trip to India and the Himalayas was a rewarding experience for all of us. We have made a series of lasting memories that we will cherish and learned many things what we will continue to use and remember in our practice medicine. We truly feel that we made the most of “our last summer” and hope you enjoyed reading about our travels.
Corresponding author, Neal Viradia, second year medical student, University of North Carolina nviradia@email.unc.edu
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