I cannot think of a better way to learn

By Alex Barash

(Observer at LVPEI in July – August 2011)

For over three years, I had been researching 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 LCSD 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, 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. Dr. Sangwan warmly told me, “Sure, come to India and see how we do it”' when I asked about a potential visit.

I returned home to read about LVPEI. What I thought was a hospital center turned out to be much more. Top surgeons and clinicians in ophthalmology were concentrated in one place, all working towards the goal “So that all may see.” I had been actively working within the local East Harlem community to treat and prevent blindness in a population that did not have health insurance, so I became even more interested.

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 be 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, a little jetlagged but running on adrenaline from the excitement from 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 text 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.

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. I will absolutely be returning to LVPEI, especially once I have more experience working in the field of ophthalmology, as the experience will be invaluable to my education.

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. One morning during a case presentation, Dr. Sangwan asked a fellow where in the hospital his patient picked up his medicine. The resident did not know, so he was asked to look into the matter. This was done so that he could better understand and counsel his patients. Similarly, fellows observed and participated in tasks such as scrubbing in as nurses and taking one day to follow the surgical supply carts and patient transporters. Attenders frequently asked residents to go to the microbiology lab to read each smear and test.

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 pthisis 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.

As I expected, I saw patients from all walks of life. I was especially interested in the fact that over half of the patients seen at the institute are non-paying. These patients are subsidized by those that are able to pay more, as well as with donations and an in-house artist who sells his work. It was fascinating to see such a sustainable model of treating all citizens, as it is incredibly difficult to find anything similar in the US.

The experience that gave me the most 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 Vision Centre. There, techs 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 has seen 1100 patients in the clinic and performs 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 hope to return again soon. I would like to thank Dr. Sangwan and the other doctors, residents, and staff for welcoming and hosting me.

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