In this week's entry of Doctor Diaries, Dr. Animesh, pens down his experience of pursuing a postgraduate degree in the US, drawing comparisons between the American and Indian medical education and healthcare systems.

As an Indian medical undergraduate student, I have, like others wondered what the differences might be between the health system of a developed nation like USA and one like ours. This may be due to the various reasons our own government fails to match the bare minimum or the rising social media exposure of fascinating technological advances showered upon our minds.

After a series of experiences in my own institute which was known for massive patient load throughout the state, I was kind of pulled towards the American health system. Now, I am not criticising my own country’s shortcomings, but the “Patient-oriented” and “Evidence-based Medicine” approaches were a few of the many reasons my expanding mind was lured towards such a country.

The only way to enter the country and pursue a master’s degree in medicine was via clearing ‘United States Medical Licensing Exam’ (USMLE), which is a 3-tier exam testing your knowledge comprising of the basics and extending up-to simulating a safe and mannered doctor-patient encounter. These are some of the gruelling exams one must clear to enter the choice of stream he/she wishes to pursue.

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Just like a fresh undergraduate with no foreign visits and being the first doctor of the family, I took this decision of pursuing my post-graduation overseas. This is easier said than done, as the logistics and planning are tedious and lengthy, let alone the financial decisions one must take at such an early age.

After the unceasing application process, I got my first acceptance at “Icahn School of Medicine at Mount Sinai” situated in Uptown New York in the department of Cardiology. It was a great news as I was about get exposed to one of the best healthcare systems and understand why is it that way.

On my first day, I met my fellow undergraduate students from various parts of the world who almost shared the same common interest when I curiously asked them about their reason for being there. We were assigned in groups under dedicated new and elderly fellows in various departments.

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Conference

In Cardiology, the day started with a morning conference which had compulsory attendance required by all the fellows and even the professors and chief of the department.

The level of promptness shown by the physicians from every hierarchy and the amount of respect shared by each other in that room was so casual that for those present over there, it was just another day meeting in the same place and sharing knowledge as if it was a routine.

The conferences were short, for about 45 min where the speaker asked pertinent questions to the audience and anyone could answer it without any hint of potential egoistic confrontation.

One thing I learned on my first morning is that age is simply a number in America; although you are considered a senior and an expert in that field, approachability to anyone made the transfer of knowledge easy and efficient.

The conference contained a detailed scenario of a case which the fellow or the associate professor came across in their time and was appropriately documented. Sessions were interactive, and everyone was heard, as reaching to a final diagnosis within that time limit was a challenge in itself.

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Morning Rounds

After the mindboggling session, we had a 15-minute break to have some coffee, but I used to use this time to interact with the fellows and doctors present over there.

We would move to the nurse’s station where we were accompanied by two nurses, two anaesthesia fellows, one internal medicine fellow, and the chief of cardiac critical care.

This was the time where we would quite literally go to each patient and talk to them briefly about their latest complaints or subjective progress. However, this was always done once somebody from the team presented the case to the chief of cardiac critical care.

The presentation used to be quite brief with only the:

• Previous night events
• Current complaints
• Pertinent lab results (very important)

And if the patient was admitted recently then a descriptive presentation was done where the entire history was narrated and then time was spent on diagnosis.

During the rounds, the chief normally asked associated questions to the fellow which indeed is also directed towards us (immigrant students).

Whenever anyone of us used to answer, he used to nod with a smile, which was just enough to ignite the fire of healthy competition within me and it made me work harder and read a lot more than my peers. This obviously gave me the willpower to be a step ahead of my peers.

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ECG lectures

After spending 3 to 4 hours discussing patients, we had one of the best times learning ECG from the best doctors out there who had received laurels for being the best in interpreting ECGs.

It was exciting and intimidating at the same time. It was a structured 4-week program where the difficulty level increased once the basics were taught.

We were given lots of ECGs to read and a platform to explain what we saw and some evidence supporting our findings.

By the end of the course, I was decently well versed in reading ECGs with typical patterns which I would find extremely difficult when they were explained in my institute.

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Weekly schedule (Post-Lunch)

• Congestive heart failure
• Consults
• Dr. Fuster clinics

Congestive Heart failure

These were rounds specifically involving patients with heart failure. There are various pathophysiological processes which can lead to this condition and thus one can never know enough of it.

These rounds were essential as one is alone with the entire team, so any sort of input from a student comes in real handy to impress the attending physician.

The doctors and the fellows used to give me small assignments and then asked me questions about them the following day.

I couldn’t believe that someone with no knowledge of my background took a few simple steps to make sure I learned properly under their guidance.

Over here I learned the various guidelines used to treat CHF and post-treatment plans for each patient. No two patients were alike considering them presenting with various comorbid conditions viz. acute/chronic kidney failure and thus one must be at the top of their game to prove their mettle.

Consults

This is mimicked even in our government sectors where the department on-call that very day must consult all the various cases from every other department.

So for example, if a patient from the Nephrology department develops a cardiac complication, the cardiology team on call has to handle that particular complaint and thus has to travel the entire hospital attending to various complications.

This was very interesting as we saw and understood secondary cardiac complications due to other primary diseases.

Due to different demographics, the diseases recorded were quite different along with the similar ones seen in India. For example, syphilitic myocarditis (Tertiary syphilis) and Lyme carditis were really prevalent unlike ever seen in our government set up.

Dr. Fuster’s Clinic

Dr. Valentin Fuster is 75-year-old Cardiologist who has over 200 publications and is the Director of Mount Sinai Heart. He has revolutionized Cardiology and authored tons of books in many domains.

Students get a first-hand experience with him for a week where he only examines patients in the exam room who mostly come for follow up.

His job was to make us understand the basic exam room etiquettes and how to deal with the patients in a more comfortable manner. That man was as transparent as a friend of my age and I could ask him anything that came to my mind.

He is the editor in chief for the Journal of American Cardiology and offered me a copy of the latest published journal to take home as a memento.

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Indian government medical college schedule

• A battery of tests are ordered every day
• Interns and junior residents are made to work erratic hours, thus decreasing efficiency
• Rounds are given the least amount of time considering all the medical procedures done in the hospital
• Transparency is rarely present between two different strata of doctors
• Attending physicians never get the time to teach their subordinates
• There is almost no intellectual discussion between an intern and a doctor in a government set up; thus, the learning never actually happens
• Research is given the least importance and thus one never gets updated on the latest guidelines

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In the US, my day used to end with tons of experiences and quite literally some homework. I grabbed opportunities of presenting a few cases to my fellows and doctors which I couldn’t have imagined doing over here. I learned so much, got the respect I deserved as an immigrant and was constantly trying to be on top of my game.

In the hospitals over there, I had to be well-versed with the latest research and constantly keep reading as this was a part of daily activity done by all the junior residents and fellows.

The end of my first month in this hospital was overwhelming, but I was excited to take on further challenges and start my rotation in the next hospital.

It is hard to believe, but I used to consider myself an introvert and when I was thrown into this massive sea of eminent people where the medical approach used was straight out opposite to where I had worked earlier and where you had to ask and struggle for whatever you desired. I seriously gained a lot of confidence, had better command over language, let go of social inhibitions, and had a new-found love of striving for knowledge. It was one of the best decisions I had ever made.