Through the looking-glass

Vinod E Nambudiri

 Department of Medicine Clinical Fellow in Medicine, Harvard Medical School Resident, Harvard Combined Dermatology Residency Program and Brigham and Women's Hospital, Longwood Medical Area, Mission Hill, Boston, Massachusetts, USA

Correspondence Address:
Vinod E Nambudiri
Massachusetts General Hospital, 55 Fruit Street, Bartlett Hall 6th Floor, Boston, MA 02114
USA

My arrival in Mumbai was marked - as is that of many a visitor to the giant metropolis - by a rapid wave of awe for the sheer human density and vibrancy that emanated from every corner. Having taken a month of my current dermatology residency training program in the United States to design a clinical and research elective experience in India, I was eager to gain exposure to the practise of dermatology in a setting much different from the familiar clinics and hospitals where I had begun to hone my clinical skills. The fantastic intensity with which the city instantly greeted me was a harbinger of the incredible clinical insights, patient interactions, and professional growth I would experience during my elective time in Mumbai.

Dermatology as a field presents a unique opportunity for international training experiences. The highly visual nature of the specialty and the heavy reliance upon image-based diagnosis (one may look to the tremendous power of teledermatology over the last few decades in revolutionising clinical care delivery) at first glance seem to obviate the need for clinicians to be at the point of care. However, the presence of face-to-face interaction with patients and being directly involved in their management, particularly with an understanding of the varying diagnostic and therapeutic resources available, provides a powerful learning experience that may not be conveyed or fully understood by the inspection of a digital photo or studying a series of Kodachrome slides.

Global experience during residency training has been promoted by a number of professional dermatology societies, including the American Academy of Dermatology (AAD) through its Resident International Grant. ^[1],[2] The AAD has supported work at the Princess Marina Hospital in Botswana, affording residents from around the United States to experience dermatologic care delivery from diagnosis through treatment and follow-up in a clinically-rich yet resource-limited environment. Participants in such endeavours have recounted the strong value of their training in fostering their future clinical directions and enhancing their dermatologic knowledge at a critical point in their career development. ^[2] Several other organizations and societies provide additional channels for students and residents and faculty to gain international experience through sponsored grant programs affording selected members the opportunity to travel to international dermatology meetings of partner organisations around the globe, spend time working with expert faculty clinicians, or engage in research under the guidance of a mentor abroad. ^[3],[4] By stimulating a bidirectional exchange of ideas, grantees have the chance to dialogue with physicians and researchers from across the world, learn about new basic science and translational developments, and forge relationships for future collaboration to push forward the field of dermatology as a whole.

My clinical work in Mumbai, supported by Partners Harvard Medical International, ^[5] took place at KJ Somaiya Hospital and Medical Research Centre located in Sion, Mumbai. The hospital has 550 inpatient beds and an active Dermatology department, which sees patients daily in the outpatient clinic and also maintains beds on the inpatient wards for complex medical dermatology patients requiring admission. The hospital serves an urban population from predominantly low- and middle-tier socioeconomic strata, reflecting the immediate surrounding areas of Mumbai.

On my first day in the dermatology outpatient clinic, I was immediately struck by both the daunting differences and striking similarities between the practise of dermatology in India and my own dermatologic training in the United States. What the clinical infrastructure lacked in space and technology was more than compensated by the complexity of patients and diagnostic acumen of the faculty. As I sat with the hospital faculty and saw new patients presenting to the clinic for the first time, the epiluminescence dermatoscope I carried - a constantly relied-upon technology in my Boston clinics where pigmented lesions and melanoma are always top-of-mind - seemed out-of-place against the sober, simple, and somehow elegant hand-held magnifying glass in the hands of the senior clinicians, lending their diagnoses a weight of erudition. When the post-graduate trainees would present their new patients to the faculty physicians, carefully reviewing the clinical history and cutaneous examination and proffering a thoroughly considered list of differential diagnoses, echoes of my own clinical training resounded.

Clinically, the range of diagnoses encountered each day served as a constant reminder of the enormous breadth of dermatology and the protean manifestations of disease within the human skin. Patients with common dermatologic diseases - atopic dermatitis, psoriasis, acne, vitiligo, alopecia - provided me with an opportunity to gain insights into local therapeutic management strategies and engage in discussions about alternative approaches I would use on patients of my own. When a 40-year-old woman with advanced systemic sclerosis entered the clinic - her face marked by patchy salt-and-pepper pigmentation, her digits deformed by years of ulcerations and contractures, her mouth stretched tight, her hair thinning away - I wondered, ephemerally, about suggesting the use of immunomodulatory or biologic therapies for halting the progression of her disease before quickly realizing the fiscal and logistic impracticality of such a regimen.

Given the location of the hospital and the demographics of the population it serves, the burden of infectious diseases and their associated dermatoses was striking. Diagnoses that were more familiar to me from textbooks than from actual patients - Hansen′s disease, lupus vulgaris, primary varicella (as most children in the United States are now vaccinated), and the myriad manifestations of HIV - came to life in the patients I saw each day. My interactions helped reinforce the common treatment regimens that I had merely committed to rote memory without having had the chance to actually prescribe or administer. The challenges of managing such conditions also became immediately tangible. Seeing a 22 year old pregnant woman receive a new diagnosis of Hansen′s disease or a 10 year old boy with a new diagnosis of HIV presenting with immune reconstitution inflammatory syndrome after starting antiretrovirals are the kind of clinical encounters I had that are sure to leave an indelible impact on the complexities of practising dermatology in the Indian context.

As I left Mumbai and returned to the United States, I paused momentarily to reflect on how I had changed through my elective experience there. The short but intense exposure gained over four weeks provided much more than a series of interesting diagnoses. The camaraderie and fellowship I developed working with peers in-training in dermatology - sharing experiences about memorising esoteric eponyms and eagerly recollecting our most challenging, complex patients - were highlights of the time I spent in Mumbai. The clinical diagnostic pearls acquired from the seasoned faculty are nuggets of knowledge I will cherish and look forward to incorporating into my own differential-building approach.

Perhaps most importantly, though, I will hold on forever to the true spirit and humanity of the patients I met, who serve as the greatest teachers for fostering my understanding of the dermatologic diseases they suffer from. The experience provided me with so much more than any amount of reading or reviewing the highest-resolution images could have offered. I began to plan a presentation for my residency colleagues back in Boston, with the goal of not only showcasing my own learning encounters but also encouraging them to pursue their own opportunities for international clinical exposure. Taking off from the ground on my return flight, I pressed my forehead against the plane′s thick window glass and looked out over the fastly-shrinking slums down below, gazing in eager anticipation of my next chance to return.

Acknowledgments

The author would like to thank Partners Harvard Medical International and the faculty and administration of KJ Somaiya Hospital for their support.

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