Dermatology at the All India Institute of Medical Sciences

By Amit Sharma, MD, 2011 India Elective Scholarship Recipient

Outside the AIIMS Hospital

Amit recently graduated from New Jersey Medical School as part of the BA/MD program. He will be continuing his medical training at Harvard University with a preliminary medicine year at Brigham and Women’s Hospital and then a dermatology residency at Massachusetts General Hospital.

On my flight to New Delhi, I was filled with excitement. Not only had it been over five years since I visited “home,” but I was also going to have my first experience with the Indian health care system. As a budding dermatologist, I was engrossed by the idea of actually seeing a range of tropical diseases that seemingly only existed in textbooks. Dr. Robert Schwartz, the Chair of Dermatology at my medical school, had arranged for me to spend one month with Dr. Neena Khanna and the other faculty members of the Dermatology Department at the All India Institute of Medical Sciences (AIIMS) in Ansari Nagar, New Delhi. For the most part, my knowledge of AIIMS stemmed from references in movies and conversations with relatives. A revered institute, AIIMS was held as the gold standard of Indian medicine: only the best students graduated from that medical school and only the best physicians received Professorships in the affiliated hospital. As a soon-to-be doctor, I was curious to learn of the norms of practice in India and the expectations for care by patients and their families.

A line forming outside of the clinics

Though I was impressed by the development that had taken place in Delhi, there was nothing more practical than the expansion of the Metro. With a 5 minute walk to a nearby Metro station and a 10 minute air conditioned ride, I arrived at the entrance of the Hospital of All India Institute of Medical Sciences. I was struck by the number of people entering the premise. My family had told me that AIIMS was a town in itself -- “AIIMS-nagar” was no stretch from reality. Passing through the entrance gate, a canteen was a few feet to my left. In the shade, people with hep-locked lines awaited their orders. Continuing towards the outpatient clinic, I noticed a cue that stretched several yards into an entrance. On the pavement, patients lay in stretchers as their close ones stood under the full extent of the Indian sun, hoping to reserve a bed in the hospital. A few individuals, who may have travelled thousands of kilometers to reach AIIMS, had set up camp with gas-burning stoves, bedding, pots and vegetables.

Navigating through the many people, I made it to the outpatient clinic for the “skin” department. The senior resident ushered me into his room as he finished with the final patients of the day. The room was simple: a table surrounded by four chairs and a bench against the wall. Patients, in groups of five, were called into the room and waited on the bench. A resident sat at either side of table and patients were examined at the ends. Privacy and confidentiality were not highly guarded as conversations and diagnoses could be heard by all in the room. Yet, the volume of patients that needed to be seen demanded restructuring of the typical American patient-physician interview. People from all corners of India would arrive at AIIMS, seeking therapy for diseases that may have gone unseen or improperly treated for years. Each morning, a resident would examine 50 or more patients -- an incredible number, especially considering the severity of some of the presentations. Compared to the 15 minute dermatology visit at my medical school, visits at AIIMS would rarely last more than 5 minutes.

A usual encounter consisted of the resident calling for the patient to sit at the end of the table. The resident would then confirm the patient’s identity and ask to see the rash. After quickly examining the skin, a few additional questions were asked as a brief note with the findings, diagnosis and treatment was written. The patient was handed his chart, a prescription and a follow-up appointment. Unlike our health care system, in which there is a constant concern regarding malpractice, the Indian system seems to be free of the trials and tribulations of lawsuits. Thus, more time is applied to providing the correct diagnosis and treatment than in practicing defensive medicine. Moreover, the Indian system allows the physician to see more patients, which is necessary in AIIMS and other government hospitals where treatment for thousands if not millions is provided. Though not much time could be invested in solidifying a physician-patient relationship, the large volume of people was adequately cared for in a cost-effective manner.

The cases I saw in the outpatient clinics were phenomenal. From a port-wine stain that malformed most of the face to a neurodermatitis that spanned much of the leg, the diseases and their severity were shockingly memorable. Many patients had first ignored their symptoms to only then try homeopathic treatment. If that failed, a majority of these individuals would consult a doctor of ayurvedic medicine. And, if ayurveda had no effect, the patient would finally see a certified dermatologist. In going from one place to another, a person could spend nearly five years before actually seeing a medical doctor. Hence, fungal diseases that could have easily been diagnosed and treated in their early stages were allowed to grow into rampant conditions that covered large surfaces of the body. Fear, distrust and denial were common underlying reasons for delaying timely and appropriate care.

Unlike hospitals in the United States, AIIMS has a dedicated in-patient dermatology ward. The thirty-six beds in the ward were often filled with those with critical illnesses. Pemphigus vulgaris and severe drug reaction cases demanded constant supervision and well designed treatment plans. My first patient in the ward had several large fungating masses growing from his leg. The patient to his right was blinded from cicatricial pemphigoid, while the one on the left had post kala-azar dermal leishmaniasis. Often family members stayed next to the patient and would respectfully stand and answer questions during rounds. As I spent my mornings mostly in the clinics and afternoons in the wards and on consults, I was exposed to numerous rare, tropical dermatoses. Dermatology is primarily a visual field; thus, seeing the disease instead of reading about it truly impacts one’s ability to diagnose and understand.

My primary mentor, Dr. Neena Khanna (Professor in the Department of Dermatology)

My month at AIIMS taught me much in terms of tropical dermatology and the Indian healthcare system. Witnessing the struggle and suffering some of the patients experienced while waiting for treatment, I have become more cognizant of my role as a caregiver. My four weeks in India provided me with some of the most educational and changing experiences in medical school. It was Osler who once said, “A good physician treats the disease; the great physician treats the patient who has the disease.” To accomplish the latter, it is essential for one to not only know the person, but also appreciate his or her culture and heritage. By partaking in the International Externship Program, I gained insight into the intricate elements of care provided in India. Thus, I feel more comfortable in attending to the needs of my future patient population. I would like to thank AAPI for providing support in the form of a Scholarship for International Externship. Furthermore, I am grateful to Drs. Neena Khanna and V.K. Sharma for making my stay so memorable and providing me with seemingly unlimited learning opportunities.