Winding Down: Medicine Continued

My final week on medicine has been ok, although I must admit a little more routine than I would have liked. It has been cool to experience diseases that are only read about in the US, mostly related to infectious disease. I have seen a fair amount of scrub typhus, an endemic tick-borne disease that presents with severe headache, high fevers and black eschars on the body and can often be lethal, even when the patient receives proper treatment. I have also seen a lot of tuberculosis, but the cases are much more advanced beyond pulmonary TB. On the ward, I have seen both disseminated tuberculosis and TB meningitis. These patients with extra-pulmonary TB manifestations are often quite sick and having the opportunity to see such advanced cases is very interesting and a unique privilege. However, the most beneficial part of my medicine week was probably observing the outpatient clinic yesterday, primarily because I had a chance to discuss the methods of payment and reimbusment with my resident. I have sort of been wondering about cost and how people here are able to afford such expensive procedures such as MRIs and angiograms given that most people here live in poverty. As it turns out, emergency treatment is not all that different from the US. If someone walks in to the ER with a massive myocardial infarction, for example, they will be admitted and taken care of. However, the doctors will only perform tests and procedures that are directly related to initial stabilization. So in the case of a heart attack, the patient would be admitted and stabilized, but further diagnositic work up to determine the cause of the MI, such as an angiogram, will not be performed unless the patient can pay for it. Acute emergency treatment is similar in the US, in that, regardless insurance status or ability to pay, patients will be acutely cared for. However, CMC has also set up a system to take care of patient's less acute problems. When patients come to the clinic at CMC, the doctor is supposed to assess their financial status, both by asking questions and by judging their physical appearance. If it is determined that the patient cannot pay, the medicine department will pay for most any test the patient requires, even if it is something very expensive such as a CT or MRI and they will cover doctors visits etc as well. And if the patient falls into a category where they have some money but are unable to afford an expensive test, they are encouraged to go to the Government hospitals located in the larger Indian cities, where I was told any test that is required will be covered by the government (although the waiting period may be extensive). Apparently, there are also companies that provide medical insurance, but only very wealthy people are able to afford this insurance. So for the most part, the people here get taken care of, even when they have very limited resources.