Clinical Elective in Dermatology in India, Part 1

Cristina Thomas, MD

Resident in the Harvard Combined Internal Medicine-Dermatology Residency Program

PGY-5

02/25/2020 

Hello from Kerala, India! I have now been working at Amrita Hospital in Kerala, India for the past two weeks and have learned so much over that time. I’ve been to India a number of times for global health work, but this elective has been very different from my prior work because I have had the opportunity to delve into clinical care rather than focus on research endeavors.

Amrita Institute of Medical Sciences

Amrita Hospital is a 1450-bed hospital that treats around 3000 outpatients daily. Within the dermatology department, a broad range of skin conditions are seen, ranging from common diseases that we see in the US like psoriasis to neglected tropical diseases like lymphatic filariasis. Despite the range of diseases seen, I have been struck by the department’s ability to practice cost-effective care. Although Amrita Hospital has the ability to perform many complex lab tests including dermatopathology (which is a key component of dermatology), the dermatologists at Amrita only order these tests if they are absolutely necessary. This is because, in general, patients are paying for their care out of pocket. This includes the physician visit, any lab testing, and any prescriptions. Without a reliance on ancillary testing, the dermatologists at Amrita have outstanding physical exam skills. They are able to distinguish between bullous pemphigoid and pemphigus vulgaris with the Asboe-Hansen sign, identify leprosy with palpation of a slightly thickened ulnar nerve, and diagnose oral lichen planus by picking up on fine white reticulations in the mouth of a patient with oral burning. Along with these excellent physical exam skills comes a true focus on the patient. The physicians spend time gathering a history to narrow their differential diagnosis and carefully examine each patient looking for any clues to point to a specific disease. This is in stark contrast to many of our patient encounters in the US where we have a short 15 minutes with the patient to develop our assessment and plan and thus, relay on testing to expedite the process. I have found it refreshing to reflect on my approach to clinical care through the lens of the health care infrastructure in India and am excited to continue this over the rest of my rotation.