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From The Land Of The Pure To The Land Of Plenty: A Doctor’s Story – I

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Even though I was born and raised in Karachi until my graduation from Dow Medical College (DMC) in 1990, most of my working life later was spent in the US. In fact, those years in a developed country have completely transformed me. Not only did I become a better doctor, I even became mature in other areas, like driving a car – as I was driving on roads that were maintained; and drivers on these roads actually followed simple rules, like driving between the lanes! An encounter with a US friend is vivid in my memory, who I had promised to meet at a certain time in the evening, but never showed up; and when that friend told me straight that I had insulted him by this gesture, I realized how important was the value of time in life.

During medical school years in DMC, we had not much exposure to patient care, unless a student took the initiative on their own.

And following medical school, I had only a six-month training stint in pediatrics and dermatology as a house-officer in Civil Hospital Karachi (CHK) before I proceeded to the US. My hospital experience in CHK was limited, but I recollect substandard and disorganized medical care for the patients. Mostly the young trainees were left on their own, without much supervision by their seniors who were supposedly competent medical staff! Medical record documentation was scanty, history taking was superficial, and medical decision making was not based on the entire history and data of the patient. Consultant physician rounds were occasional, and instead of discussing what really was going on with a patient on the bedside, our discussion was centered around the information memorized straight from the dry textbooks of medicine.

Many of us would be openly demonstrating our memorized knowledge to each other, while some of us could even rattle off the page number of a textbook from where the information was spontaneously regurgitated.

We were not much aware of the standardized care of illnesses suffered by our patients, besides having no fear of accountability, totally ignorant of the fact that a bad patient outcome can potentially result in an investigation and punishment. If medical mismanagement occurred, nobody noticed it, and if someone had more depth of understanding, that was ignored.

In the pediatric ward, where I spent three months, many newborns were subjected to multiple attempts from us rookies on their scalps to place an IV infusion, leaving large hematomas on their head, while their parents who had come from far-flung areas in rural Sindh watched helplessly.

A typical pungent odour of hospital waste was easily discernible in CHK hospital wards and the facility which was spread over several acres had hospital waste and garbage scattered throughout. Patients’ relatives would camp outside the hospital on the floor, painting a desolate picture. Adding to the misery was the sultry, humid, Karachi weather. Last but not least, my pay-cheque was just enough to pay for the food consumed in the hospital and my motorcycle’s monthly gas bill.

It was really a fluke that I found a training position in internal medicine in New York City’s modern hospital, Beth Israel Medical Center (BIMC), in 1991, and that too six months early, in the mid-cycle of training, from January. I had just strolled in BIMC in the fall of 1990 in my attempts to find someone in the hospital who could guide me about how to apply for a residency position. I landed in the Chief Resident’s office, who after a few minutes of conversation asked me to join him for rounds. I spent a couple of weeks doing rounds with his team and amazingly enough, the internal medicine residency coordinator came to me with a contract and asked me to join the residency as they were short of a medical intern. During these two weeks, I had asked my attending physician to give me a letter of recommendation, who wrote; “Dr. Nadir is an energetic and motivated physician with good fund of knowledge, who demonstrated that he has the ability to overcome obstacles he will face during residency training.” Even with this reservation, my employer gave me a training spot, but the one who recommended me was honest and correct on his opinion. As my start date drew near, I was excited: literally walking on water, not realizing what I was entering into or what was really expected of me as a budding physician. DMC had not really prepared me for this ordeal!

The BIMC was comprised of two buildings, situated almost adjacent to each other, separated by a small street; and with two small parks in front of them. Despite being a big city, the area around the hospital was not polluted, and early-morning breath was fresh. Both the buildings had an impressive façade, high ceilings, porcelain floors and the facility was kept clean round the clock. We were in downtown NYC, not far from the hustle and bustle of the city, which was cosmopolitan, charming and full of energy. A Jewish deli sold hummus on pita and lox piled on bagels, literally a hand throw from the hospital. An American sit-down diner was not far away; and even a Pakistani restaurant a few blocks away had paratha/chai on the menu for breakfast. I was impressed, and also felt convinced that all my good deeds had been recompensed; and I had finally found my calling in becoming a “big doctor”, a title commonly used for doctors with authority in Pakistan.

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The hospital was organized to provide both – quality medical care to patients and a fulfilling teaching experience for trainees.

We rotated through different sections of the hospital including general medical wards as well as specialized areas like oncology, the intensive care unit (ICU), the cardiac care unit, the emergency room and wards specially dedicated for patients afflicted with Acquired Immunodeficiency Syndrome (AIDS) and for those who were drug abusers. Extremely competent physicians, many of whom were affiliated with medical schools; and who took lots of pride in teaching and caring for patients, were on the staff of the hospital. Most importantly, these consultants were available daily and monitored trainees like hawks, watching every step of their management, as they transitioned from their first to second year and then their final year of training, about to be unleashed on society as independent physicians. An hour-long morning report occurred daily, which one of the three chief residents would lead, and spontaneously ask the admitting team to present any case from overnight admission. A noon-conference was scheduled daily as well, where didactic lectures were presented, and free lunch was served; and many times we munched mouth-watering NYC pizzas while listening. An unbelievable experience for me was that I was getting paid reasonably well, fed and educated simultaneously. If this was not utopia where else could it be!

Many American medical graduates had come from all over the country to experience life in the Big Apple, while receiving cutting-edge medical training in Manhattan – the largest downtown of the world. Subsidized housing was provided to the trainee doctors within a couple of blocks of hospital buildings, so they could get enough rest while working a grueling 80-hour work week. I groped through the maze of the hospital ward – specifically created for the care of drug abusers – during the first month of training and demonstrated to all with my severe situational anxiety that I was ambitious and energetic; and thus my deficiencies were not completely exposed; and my chief resident was so pleased with me that he put me in the ICU during the second month of training. However, despite being in the relatively low-profile, drug-addict ward during my first month, some of my colleagues and my attending physician of the month had already realized I was quite green, particularly when I tried to present cases for morning rounds, looking right into my scribbled notes from the previous night, without making much eye contact, almost having a nervous breakdown!

My third-year resident in the ICU was a bit cocky and he did not like the fact that after rounds rather than quickly getting the job done on my patients; I was sitting in the call room, reading a book on the ICU! I had no clue about even my basic responsibilities in the ICU, and was immersed in a state of blissful ignorance. Since the devil was in the details in the ICU, when I presented my first case in front of the entire team of trainees, medical students, nurses and attending physician, they started grilling me about key questions regarding patient’s history and then asked me, “Did you review his old chart?”

I was stumped. I actually did not even know where to get the old chart from and my supervising resident had assumed that I should have been able to get the relevant information on a rather straightforward case of chronic obstructive pulmonary disease overnight. He knew that I was in second month of my training and this was pretty much third-year medical student stuff!

The whole month, when I presented a case, I realized that American medical students and residents were giggling behind my back, and I being a cocky desi would sometimes turn around and look at them, making them realize that I was not taking this humiliation lightly.

One rather exceptional incident occurred on my third night on call in the ICU, when my third-year resident asked me to follow a case of gastrointestinal bleeding and check the hemoglobin level every four hours, and I nodded in passive agreement. When he came back next day, he asked me tauntingly, “Is everybody alive in the Unit?” And I nervously said, “Yes” showing some confidence. He further inquired about the hemoglobin level of the bleeder, to which I promptly replied with even more confidence that it had drifted to 9 g/dl from 5 g/dl, overnight, and prompt came another question, “How much blood did you transfuse?” to which my reply was, “You just asked me to check the hemoglobin!” My resident stomped his foot on the ground, turned around and just walked away!

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As the reality dawned on me during my month in the ICU that I was not as smart as I thought, I became more humble, but starting losing confidence. I was unable to even perform simple tasks like opening tightly sealed IV tubing. However, I still had some hope that things might become better soon, particularly when I met an Agha Khan University Hospital graduate, six-months my senior, who told me that DMC graduates have a tough first year of residency. The American medical system was robust enough that mistakes committed by an inexperienced trainee like me would still not result in medical negligence because of checks and counter-checks from other medical providers, in the absence of attending physicians and senior trainees, including nurses, phlebotomists or even simple hospital clerks with more common sense than me. Somehow, the lead nurse of the ICU felt that I had worked very hard during the month and I was treated rather unfairly by the ICU team and he put in a good word for me to the ICU chief, who passed me in the rotation; and in fact, I did get a reasonably good evaluation from him.

In hindsight, I was rewarded for my display of insecurity; and the fact that I had become extremely compliant.

Month-after-month during my first year at BIMC, I hoped that one day I would gain some confidence, and would be able to remember relevant details of about 6-8 patients that I was carrying on a daily basis. But it was not happening; and I was making one mistake after the other almost on a daily basis. Once as I was rotating in a medical ward, a drug addict complained that she was feeling weak in her legs, which I jotted carefully in my notes, as I had learned to document everything in the chart, treating it as a legal paper. On the following day and the day after that, the patient continued to complain of leg weakness; however, it was progressive and now spreading to her upper torso as well. Our team felt that she was faking it, and ultimately, she was unable to even move her toes – and a diagnosis of spinal cord compression due to an infected abscess was documented! The case was investigated in detail, but I was let off the hook, only because it was confirmed that I was relaying the information to my superiors on a daily basis. Nonetheless, my medical judgment was questioned and I was taught that in the future, if something like this happens, I should escalate the matter and highlight it to one of the chief residents.

My performance remained below par, and I was nowhere near the other first-year interns or even far off, a fourth-year American medical student. One of the residents who had watched me closely in the ICU was made the Chief Resident, and he believed that I may not make it. He started watching me closely and during my sixth months in the rotation showed up one morning and asked me to tell him about the 10 patients I had that particular day. Somehow due to the daily grind of six months, I was able to give him pertinent information on my patients and soon he walked away!
(To be continued)

The author is a consultant gastroenterologist and transplant hepatologist at Maricopa Medical Center, Phoenix and Maroof International Hospital, Islamabad
Contact: [email protected]

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