Rohan Shankarghatta
As a final-year medical student keen on pursuing a career in Ophthalmology, I spent my elective at Sankara Eye Hospital, a large speciality eye hospital in Bangalore, India. It was an exciting opportunity to spend time in a healthcare system facing challenges with the ever-growing demand of a 1.4 billion population. I hope to share my thoughts on how Indian healthcare systems have adapted to the ever-growing demands and what we could learn as the demand for NHS services grows. In this piece, I will aim to reflect on my elective experience abroad using the Gibbs Reflective Cycle (1).
Like the UK, there are both private and government health sectors in India which provide an excellent elective experience. Government hospitals are state-funded and are often busier, catering for patients who can’t afford private healthcare. However, compared to the UK where we spend around 11% of our GDP on healthcare, India spends only 1.9% (2,3). As such, the government healthcare sector in India is often unable to meet healthcare demands leading to many patients to going private (4). This is reflected in the difference in healthcare delivery between the two nations with the NHS delivering 87% of healthcare in the UK compared to the Indian government delivering 18% of outpatient care and 44% of inpatient care (5,6).
In large metropolitan cities, patients may travel long distances from surrounding villages to receive specialised care only available in larger institutions. The Sankara Eye Foundation is one of the largest non-profit eye foundations in India offering eye care for underserved rural communities (80%) and paying private patients (20%) with a network of 13 eye hospitals distributed across India (7). The hospitals are run as nonprofit entities where any profit generated from private patients is invested back into services to fund eye care for rural communities (7).
During a routine day in the clinic, my consultant reviewed between 50-60 patients. While this was busier than the ophthalmology clinics I experienced in medical school, I found that my consultant was very well supported with a dedicated admin and support team to help each patient with booking follow-up appointments and organising any further tests. This freed up my consultants’ time to focus purely on medicine. I was impressed at the rate of patient turnover and the efficiency of the system but thought that the significant time pressure detracted from building a doctor-patient relationship. However, I realised that this was the reality of working in an extremely busy eye centre with an insufficient number of consultants to deal with the huge patient load. I wondered how sustainable this practice would be for clinicians long-term and how this could precipitate physician burnout – a growing prevalence in India. A study in 2019 explored the burnout levels in 300 doctors in Mumbai and found that 57% of doctors had work-related burnout due to extensive working hours and pressures (8).
Interesting strategies to increase capacity were employed in theatre to optimise the patient journey. Patients who had been screened for cataracts in their communities from rural areas would travel to the hospital on the day of surgery. Upon arrival, patients would first have an amplitude scan and keratometry performed. The anaesthetic team would then review the patient before listing them for the day. Soon after, patients were moved to a pre-op waiting area to be readied for theatre. When the time arrived, the team of porters would then take the patients into the theatre where the surgical site would be cleaned and draped by the theatre nurse. I found that the hospital used smaller theatres designed for cataract surgery to make the best use of space available. While one patient was operated on, the next was prepared in the adjacent theatre, minimising downtime between surgeries. After the ophthalmologist completed the operation, they were able to dictate to admin staff who wrote up the operation note. As the patient was being moved to recovery, the surgeon would move to the adjacent theatre and scrub, ready to operate again.
I felt there was a clear delegation of roles amongst staff where everyone had an important role to play. Furthermore, compared to the UK, I felt that the hospital was able to employ much more staff, including admin staff, porters and nurses, who played a vital role in maintaining patient turnover.
Due to the number of patients, the Indian healthcare system also offers its own training benefits where doctors may be expected to take on more responsibility and gain more exposure earlier in their training. The registrars I shadowed on my elective routinely completed more than 15 cataract operations independently by midday. In contrast, there is an increasing number of UK trainees who haven’t completed more than 50 cataract operations by the end of ST2 (9). However, as mentioned previously, doctors in India are expected to work significantly longer hours and don’t have the same working hours protections as UK doctors like as the European Working Time Directive (10,11).
In the UK, Ophthalmology is the busiest outpatient speciality, with 7.5 million outpatient appointments and 500,000 surgeries performed (12). However, with ever-growing demand, further efficiencies made within the system can enable us to increase output and reduce waiting lists. The administrative burden for physicians has continued to rise and is a factor driving physician burnout (13). Strategies to reduce this administrative burden could include employing extra staff and delegating admin tasks allowing doctors to focus on seeing and reviewing patients. However, it may be difficult to rapidly increase the number of support staff required in the NHS when the UK struggles with an ongoing workforce shortage, unlike India (14). When employing additional staff may be difficult due to workforce or budgetary reasons, we could look at ironing out systemic inefficiencies to improve patient flow.
Organising an Elective in India
An international medical elective can be hugely valuable, enabling students to experience a different healthcare system and get more hands-on experience before starting work as a doctor. As a medical student, you can expect to gain a lot of hands-on clinical experience and see cases of advanced disease progression amongst patients who may not have access to routine medical care. India has 28 states with 121 languages. However, most patients will speak English (more so in larger cities), and quite often local doctors will happily translate when you are shadowing.
India is very diverse with people from various backgrounds and religions. With a large number of festivals celebrated in the country, you can likely expect to experience at least a couple during your elective experience! Healthcare tourism is a growing phenomenon in India as patients around the world are drawn to the high quality and relatively affordable private care available which you may also come across should you undertake an elective in a private institution. You may come across patients who may have travelled from sub-Saharan Africa and the Middle East to see specialty doctors in India. Private hospitals are often modelled on the American healthcare system where patients often pay through insurance or out of pocket. Private hospitals may also offer better amenities for students with lockers, canteens etc. While India certainly boasts a different culture to the UK, students will still learn from a diverse range of patients.
Organising international electives can be a challenge as a medical student. I reached out to various Ophthalmology departments across Bangalore to enquire about elective opportunities 8 months in advance to allow time for any unforeseen delays. Personally, as an overseas citizen of India, I was fortunate to enjoy a relatively straightforward experience in terms of travel arrangements. At the time of writing, the cost of a visitor visa to India valid for 6 months is £115. I’d recommend getting this process started well in advance prior to organising travel arrangements. Compared to the UK, the cost of living is relatively low in Southeast Asia and in my experience, flights and travel arrangements can form the largest part of the expense. You can expect to live comfortably on the equivalent of less than £10 a day. There are various bursaries and grants available both through the NHS student bursary and charitable organisations which can allow you to enjoy your time while alleviating some financial pressure (15,16).
My elective was a fantastic experience in learning how different healthcare systems operate, and I would thoroughly recommend the next generation of doctors to experience healthcare systems abroad where possible. No healthcare system is perfect, and the Indian healthcare system faces its own challenges of ever-growing demand and continued challenges of accessible healthcare however, there’s a lot we can learn from other healthcare systems as we strive to improve the NHS.
References
1. Gibbs G. A guide to teaching and learning methods. Learning by Doing. 1988;129. [accessed 27 Nov 2024] Available from: https://books.google.com/books/about/Learning_by_Doing.html?id=z2CxAAAACAAJ
2. Healthcare expenditure, UK Health Accounts – Office for National Statistics. [accessed 28 Nov 2024] Available from: https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthcaresystem/bulletins/ukhealthaccounts/2022and2023
3. Government Health Expenditure Rises to 1.9% of GDP in 2023-24: Economic Survey. [accessed 28 Nov 2024] Available from: https://www.downtoearth.org.in/governance/as-told-to-parliament-august-9-2024-government-health-expenditure-stood-at-19-of-gdp-in-2023-24
4. Right to Health: The fight over who’ll pay hospital bills of India’s poor – BBC News. [accessed 28 Nov 2024] Available from: https://www.bbc.co.uk/news/world-asia-india-65159986
5. How much planned care in England is delivered and funded privately? | Nuffield Trust. [accessed 28 Nov 2024] Available from: https://www.nuffieldtrust.org.uk/resource/how-much-planned-care-in-england-is-delivered-and-funded-privately
6. Idhrees M, Padmanabhan C, Jagadeesan K, Velayudhan B. An Indian study: impact of COVID-19 on clinical decision-making and consensus in cardiac surgery practice across the country. Indian J Thorac Cardiovasc Surg. 2020 Sep 1;36(5):451–63. doi: 10.1007/S12055-020-01022-Y
7. Best Eye Hospital in Bangalore | For All Eye Problems. [accessed 8 Oct 2024] Available from: https://sankaraeye.com/
8. Dhusia A, Dhaimade P, Jain A, Shemna S, Dubey P. Prevalence of Occupational Burnout among Resident Doctors Working in Public Sector Hospitals in Mumbai. Indian J Community Med. 2019 Oct 1;44(4):352. [accessed 28 Nov 2024] Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC6881898/
9. RCOphth publishes blueprint for delivering cataract training in independent sector | The Royal College of Ophthalmologists. [accessed 8 Oct 2024] Available from: https://www.rcophth.ac.uk/news-views/rcophth-publishes-blueprint-for-delivering-cataract-training-in-independent-sector/
10. India’s Doctors Are Overworked and Feeling Unsafe – The New York Times. [accessed 28 Nov 2024] Available from: https://www.nytimes.com/2024/09/01/world/asia/india-doctors-safety.html
11. Female doctors safety: 35% of doctors, mostly women, feel unsafe at night shifts, says IMA survey | India News – Business Standard. [accessed 28 Nov 2024] Available from: https://www.business-standard.com/india-news/35-of-doctors-mostly-women-feel-unsafe-at-night-shifts-says-ima-survey-124083000644_1.html
12. RCOphth & BEECS develop emergency eye care commissioning guidance – The Royal College of Ophthalmologists. [accessed 8 Oct 2024] Available from: https://curriculum.rcophth.ac.uk/2020/04/rcophth-beecs-develop-emergency-eye-care-commissioning-guidance/
13. Administrative burden is driving physician burnout, and puts access to care at risk | CMA. [accessed 8 Oct 2024] Available from: https://www.cma.ca/our-focus/administrative-burden/facts
14. Staff Shortages | The King’s Fund. [accessed 8 Oct 2024] Available from: https://www.kingsfund.org.uk/insight-and-analysis/data-and-charts/staff-shortages
15. Elective bursaries | Medical Schools Council. [accessed 29 Nov 2024] Available from: https://www.medschools.ac.uk/studying-medicine/current-medical-students/elective-bursaries
16. Student Services | NHSBSA. [accessed 28 Nov 2024] Available from: https://www.nhsbsa.nhs.uk/nhs-bursary