I.
I am not entirely sure how common it is to get so bored on vacation that you voluntarily return to your old workplace and accidentally start practicing medicine. Probably not very. But recently, thanks to certain flight disruptions in Dubai which I do not need to elaborate on, I found myself stranded at home in India far longer than anticipated.
I was going stir crazy. My parents, who maintain a baseline level of mild disappointment that I ever emigrated, suggested I go informally shadow the psychiatry department at my old hospital. "See what psychiatry is like at home," they said. "Maybe you will learn something."
I was already experiencing a profound disillusionment with psychiatric training in the UK, and my previous exposure to the Indian equivalent was highly idiosyncratic. During my internship at this same teaching hospital, my psych rotation had collided perfectly with the initial Covid lockdowns. Outpatient services were entirely shuttered. Any ward patient capable of bipedal locomotion was immediately discharged.
I spent those two weeks checking vitals in the female suicide ward and conversing with a very pleasant schizophrenic gentleman who had a hyper-specific obsession with light fixtures. He had been living on the ward for a decade (no next of kin and nowhere to send him after discharge except to the streets, and then the cops would drop him right back on our doorstep) and had somehow become a genuinely competent amateur electrician. I personally witnessed him replace multiple malfunctioning bulbs. He did very solid work.
So when my parents broached the idea of visiting, I agreed. It was mostly curiosity mixed with a bit of nostalgia. That intern year was almost certainly the worst year of my life, but people assure me this builds character. I thought it would be nice to show up as a glorified medical tourist and see what my Indian counterparts were up to.
II.
After pulling a few strings, I arrived at the outpatient department. It was exactly as crowded and poorly ventilated as I remembered, though stopping just short of actual asphyxiation. I located my point of contact, a second year postgraduate trainee, and optimized my posture to fit onto a partially vacant seat without crushing a colleague's purse.
The initial wave of patients presented with the classic poorly differentiated psychosomatic complaints that are the norm in developing countries. When your native language lacks a dedicated lexeme for "depression", psychological distress predictably routes itself through somatic channels. It manifests as a vague stomach ache or random peripheral tingling. We prescribed pregabalin, gabapentin, or amitriptyline, depending on mood, handwriting and the current phase of the moon. The patients were generally just thrilled to have seen a doctor at all.
Eventually, more interesting cases arrived. Because I was actively peering over my colleagues' shoulders, they generously suggested I take a crack at handling some of them myself. Sure, I thought. Why not?
I quickly came to regret this decision. I have a laundry list of complaints about British psychiatry, but I was not quite prepared for the reality of the Indian clinic.
First, the documentation varied from poor to completely nonexistent. My once finely honed ability to decrypt physician scribbles into valid pharmacological interventions had totally atrophied. Furthermore, the patients were terrible historians. I do not mean this as a moral failing; it is just a downstream consequence of local selection pressures. Government hospital care in India is free. This strongly selects for patients who are overwhelmingly poor, undereducated, and often separated from the physician by a formidable language barrier. Add the baseline communication difficulties of psychiatric patients, and taking a history feels like trying to reconstruct Herodotus from a copy that fell into a blender.
But it was a good challenge. I wanted to prove I could still read between the lines.
Almost immediately, I encountered a truly spectacular case of polypharmacy. We had a lady on lithium, valproate, and approximately a dozen overlapping medications. When were her lithium levels last checked? My best guess is shortly after the universe discovered helium-helium fusion. Thyroid function? The only confirmed fact was that she theoretically possessed a thyroid gland. She had coarse tremors, which could have been caused by literally any combination of the chemicals in her bloodstream. I consulted a senior resident, and we agreed to slash the regimen down to the bare minimum and demand some actual blood work before she returned.
III.
The cases only got weirder. Consider the medical tourist from Bangladesh. He had early onset schizophrenia, but he was relatively stable on his current regimen. Why had his parents brought him across an international border? They claimed they could not source brand name amisulpride in Bangladesh. A quick Google search suggested this was highly improbable, but here they were.
To make matters worse, the family was incredibly vague about his actual medication list. Besides his known antipsychotics and thyroxine, he apparently took a mysterious pill every morning. What was it for? They had no idea. What was it called? A mystery. What did it look like? It was a small tablet.
It is a miracle I did not tear my hair out. After another consult with the attending, we switched him to a more easily sourced variant of amisulpride and advised the family to stockpile six months of it before going home. As for the mystery pill, we essentially applied Chesterton's Fence to psychopharmacology. Chesterton's Pill was deemed structurally load bearing for this mixed metaphor. It clearly had not killed him yet, so we left it exactly as we found it.
My final patient was a six year old boy. His mother presented a constellation of complaints: he was hyperactive, liked staying up late, and lacked focus in class. It looked like a textbook case of ADHD. But given his age, I thought it was worth digging deeper. I learned he was functionally illiterate, possibly dyslexic, and his teacher had explicitly told the mother to get him evaluated.
Then the mother casually mentioned his "fright."
During normal daily activities, the boy would suddenly freeze. He would look incredibly distressed, and then he would get the human equivalent of the zoomies. He would sprint around the room. After the running stopped, he would approach his mother or older sister and bite them. Sometimes he bit hard enough to draw blood. He could not explain why he did this or what he experienced during the episodes.
I looked at him again. He was a perfectly normal, fidgety kid missing a few baby teeth. There were no obvious signs of hydrophobia, though I mentally filed rabies under "highly unlikely but technically possible."
I had absolutely no idea what I was looking at. I debated the case with a colleague. I suggested ADHD comorbid with Oppositional Defiant Disorder. My colleague argued against ODD because the kid was perfectly well behaved in the clinic. I countered that ODD typically manifests at home first, and is usually restricted to familiar adults. Then I floated the idea that his bizarre running and biting episodes might be complex partial seizures.
My colleague theorized it was an intellectual disability or learning disorder, perhaps part of a broader genetic syndrome. I shrugged. He was probably right. There might be a perfectly neat clinical label for this waiting in a dusty textbook somewhere. Or perhaps this is just another reminder that our diagnostic categories do not actually carve reality at its joints.
We eventually compromised. We prescribed clonidine to manage the behavioral symptoms and cover ADHD to a limited extent, then referred them to a clinical psychologist and an ENT specialist for good measure. I had spent more time on this one child than on my previous three patients combined, and the clinic was simply not built for that level of investigation.
I still have no idea what was actually wrong with him.
To avoid ending on a downer, I was happy to hear that the amateur electrician had, in fact, been discharged sometime in the past five years. None of the current trainees had heard of him. Right after I'd "treated" him? I'll take the credit, if no one's looking.
My parents, for what it's worth, were pleased I'd made myself useful. They remain cautiously optimistic about my eventual return.
I remain unconvinced, but I did find the pace to be California Rocket Fuel compared to my usual fare. Who knows? Maybe I'll get bored of making ten times the money, one day.
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Notes -
Basically the issue is that the required case volume to become proficient in modern surgical modalities is a lot more than with classic open cases. Decent surgical residencies can theoretically get you enough cases for bread and butter procedures but for less common things it gets harder. Consider how much harder it is to orient and to appreciate anatomy through a lap, and with a lap to ably use your technical skills (less of a problem with robots).
Surgical residency is already long and miserable enough, adding more years just isn't feasible.
Additionally things don't go wrong enough, which is good, but you need experience with things going wrong in a controlled environment to be able to provide quality care when you are on your own.
This means that many junior attendings aren't really fit for purpose and need hand holding, academic work, or enhanced engagement from their partners. None of which is good and it isn't really a solvable problem, especially with the push to condense training.
Also, usually the intern year for surgery is wasted on floor monkeying only pretty much.
Thank you for elaborating, I'm appreciative.
Ah. So this is universal, speaking from experience in the UK and India. I've heard even other postgrad trainees (in the UK) make the same complaint.
alarms blare
You've activated my attending trap card. Basic intern year scut work (both inside surgery and outside of it) isn't actually wasted. You learn valuable tools like "writing that fucking note quickly" and "nurse management" and "sick vs. not sick."
Certainly the modality has some yield issues at times, but the gain in fluency and skillset is real, with variable spaced repetition of more traditional surgical skills.
Also is what separates us from midlevels.
I can see what you're getting at, in theory, but I think that if that was the driving impetus behind an entire intern year, then I feel like the lesson would be learned in 2 months. I know that you meant that there's actual clinical learning going on, but it didn't take me very long to learn to do the attendant drudgery on command.
Of course, performing surgery as the primary surgeon after graduation (without the necessary postgrad qualifications) is nominally illegal in India, so our bosses and seniors knew that too much effort teaching us actual procedural skills would be wasted time.
The situation is very heterogeneous in India, sometimes the interns do do just scut work and make no meaningful decisions, sometimes they're effectively in charge and winging it, which hopefully does teach them something. In the UK, FY1s are glorified secretaries, FY2s are thrown into the clinical crucible, IMO too abruptly.
Don't mind me I'm just walking uphill both ways to work (in the snow).
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