Tuesday, 3 January 2012

LVPEI, an Elective Posting to Remember

“Sure, come to India and see how we do it,” Dr. Sangwan from LVPEI warmly told me when I asked about a potential visit. Little did I know that my stay at LVPEI would leave such lasting impressions! For over three years, I had been researching about limbal stem cells and their properties. I had extensive experience in growing the cells and made exciting discoveries. Each time I spoke about or presented my work, I began with the devastating disease that is LSCD (Limbal Stem Cell Deficiency) and the unbelievable surgery that allows people with this disease to see. It was this amazing clinical application that drove my interest in my research. Each day, I knew my findings had the potential to enable someone who had lost vision to regain their sight.

When I saw Dr. Sangwan's keynote presentation at IOSS (International Ocular Surface Society), I was convinced that to see this work in person was the most fitting culmination to my full-year Doris Duke research experience. I could see that Dr. Sangwan was very driven and his passion to heal and cure was clear. Dr. Sangwan seemed somewhat of a lone voice at the conference, as many people were researching LSCD but few, if any, were putting this research to use in the real world.

My trepidation on the flight to India fell away as Dr. Sangwan smiled and introduced me to some of the fellows. I was anxious about being in another country and wondered whether I had made the right decision in visiting for an entire month. In our first two hours, we saw 25 patients, many of whom had ocular disease I had only read about and that I would likely never see back home. Within two hours of my arrival, I had seen a patient with LSCD! At the end of the day, I was a little jetlagged but running on adrenaline from the excitement of the patients I had seen that day - we had spent 12 hours and seen over 100 patients.

Each day, I was able to see cases that are extremely uncommon back home. I read ophthalmology texts daily and due to the sheer number of patients, I would inevitably see two or three diseases I had read about, hours after my studies. I cannot think of a better way to learn, I gained experience with the slit lamp and read much more enthusiastically, as everything, even the rarest of diseases, came up day after day in the clinic.

One of the things that impressed me most was that Dr. Sangwan and LVPEI place a lot of significance on knowing how all aspects of the system work. It was clear to me that this intricate knowledge of the basic workings of the hospital is both essential and invaluable. I decided to use this approach to learn more about all of the tests I would eventually prescribe to my patients. This proved to be extremely helpful. In one visit to the B-scan room, I saw 20 patients with all types of pathology, from RD to phthisis to normal eyes. The techs were surprisingly helpful and took time to explain each aspect of the test in detail. Similarly, I was lucky enough to lean about the OrbScan, Anterior OCT, and several other tests that allowed me to understand much more fully the applications and limitations of each test. LVPEI's specialized nature and high clinical volume make it a unique place in which this is possible.

The combination of a plethora of diagnoses and such a large patient load meant that I got to see more patients and types of diseases than I ever had before. I have no doubt that this experience put me well beyond my peers, as ophthalmology is a field where visual learning and memorization of visible pathology are invaluable tools.

The experience that gave me the most valuable insight into the LVPEI system was the day I spent seeing each part of the LVPEI pyramid. LVPEI has an unbelievably well thought out system for reaching every single person in the area. The system begins from the lowest level in the villages, one of which we visited. This level consists of one person per village who goes door to door measuring visual acuity (VA), glucose levels, height, and weight. The same information is recorded by teachers and headmasters, who are taught to spot children with low vision and given flashlights and VA charts to check their students. The data is then used to forward diabetes and low vision suspects to the next level of care that we visited, the village center. There, technicians measure vision, refraction, ocular pressure, and look at the patient using the slit lamp. Anyone with refractive error is prescribed glasses, free for those under 16 and very cheap for others. These centers see about 450 patients a month and give out glasses to 250 of them. Those who have a visual deficit that cannot be corrected using glasses alone are sent up the chain to secondary centers.

At the secondary centers, medical care, such as drops and medicines, and basic surgical care, such as cataracts, DCR, and pterygium, are handled. Students from the major/tertiary centers spend six months to one year being second doctor at these centers. These centers have an outpatient clinic and inpatients as well. The center we visited saw 1100 patients in clinic and performed 140 surgeries per month. If treatment at a secondary center is not able to correct the issue, they are sent to a tertiary center where things like glaucoma surgeries and vitrectomies are done. The most complex cases, in turn, are sent to centers of excellence such as the KAR campus at which I spent the majority of my visit. In all cases, patients pay what they are able. More than half do not pay at all, while some of the richest pay for luxury rooms and subsidize the cost in this way.

I spent one day seeing each of these components, and it was amazing. We drove two to three hours out from Hyderabad, a major city, to a tiny rural village. I'm glad I got to do this before leaving the country. I had a fantastic experience at LVPEI and would like to thank Dr. Sangwan and the other doctors, residents, and staff for welcoming and hosting me. I will most certainly be returning to LVPEI, especially once I have more experience working in the field of ophthalmology, as the experience will be invaluable to my growth as a doctor and a human being.

As narrated by Alexander Barash, a final year medical student from Mount Sinai, NY, who spent one with LVPEI for his elective posting.

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