Can Nepalese doctors practice in India

Experience report about PJ-Tertial in surgery in the Tribhuvan University Teaching Hospital in Kathmandu / Nepal from March 31, 2008 to July 20, 2008

From Barbara F├╝rbeck



1. Motivation
2. Application and preparation
3. Tribhuvan University Teaching Hospital
4. Daily routine in surgery
5. Country and people
6. Conclusion



1. Motivation
I wanted to spend the surgical tertial of the PFY in a developing country to learn how medicine can be practiced with limited resources and to see under what circumstances doctors work in these countries. I was also interested in what diseases are prevalent in a developing country. Since I've always been enthusiastic about Nepal, its culture, its peoples and its landscapes, I decided to do a PJ tertial in this country.

2. Application and preparation
First, I looked for a university hospital in Nepal, which was listed in the PJ foreign catalog of the state examination office. There, in addition to the Bir Hospital, the National Academy of Medical Science, Kathmandu, the Tribhuvan University Teaching Hospital (TUTH), the Tribhuvan University, Kathmandu was given. The TUTH has a very well designed homepage (www.teachinghospital.org.np), on which all necessary information and application forms for exchange students can be found. The application can be made very easily via email. I personally sent all my documents by post and there were no problems with that either. Shortly after my application arrived at TUTH, I received the confirmation by email. Miss Urmila Lama, the person responsible for foreign students, usually answered quickly and reliably to further questions. Tuition fees are $ 500 for a 16-week PJ term. The first 4 weeks cost $ 200, each additional 2 weeks cost $ 50.
A visa is required to enter Nepal. This can be issued at the airport in Kathmandu or it can be obtained in advance from one of the Nepalese consulates in Germany. You generally only get a visa for 60 days (40?), Which can then be extended by another 30 days at the Immigration Office in Kathmandu ($ 30 per extension). The maximum annual stay in Nepal is 150 days.
Before traveling to Nepal, you should check your polio, diphtheria, tetanus and hepatitis A and B vaccination protection. Since Kathmandu is over 1500 m, malaria prophylaxis is not required. According to the Hygiene Institute, vaccination against Japanese encephalitis should only be considered if you stay in very humid, rural regions where rice is grown for a longer period of time.
For the period of my full year term I had taken out additional private health insurance abroad.

3. Tribhuvan University Teaching Hospital (TUTH)
The Teaching Hospital of Tribhuvan University is an academic teaching hospital and one of the largest and best equipped hospitals in Nepal.
The TUTH has 430 beds, in surgery a total of 170, 700 outpatients daily, approx. 60 emergency patients. About 130 fully trained doctors work at the teaching hospital, with? Interns? and? residents? significantly more and more than 300 nurses. The TUTH has the following departments: surgery, anesthesia, internal medicine, emergency medicine, orthopedics, gynecology, dermatology, ENT and psychiatry. Ophthalmology and paediatrics are also represented in other clinics on the same site.
The TUTH is semi-public, which means that patients have to bear a large part of the costs themselves. There is almost no insurance system in Nepal. The financial contribution to the teaching hospital is one of the reasons for the better hygienic situation than in purely state hospitals, such as the Bir Hospital. In addition to a cross-section of patients and their illnesses that is unimaginably large for German PJ conditions, it offers considerable equipment for diagnostics and therapeutic intervention options for Nepalese conditions, as well as reasonably acceptable hygienic conditions. CT, MRI, immunological tests, open heart operations, neurosurgical, laparoscopic and arthroscopic interventions, etc. are standard. In addition, you get to see a variety of creative surgical techniques, especially in plastic surgery, which you would most likely not see during a PJ tertial in Germany.
Unfortunately, some necessary technical devices are in short supply. For example, there are only 6 ventilators. If more patients require ventilation, the relatives must ventilate the patients day and night using an Ambu bag. This is possible because in almost all cases at least one relative is permanently on site (the relatives sleep and eat in the hospital corridors) to look after the sick person and take on a large part of the care work.
However, the material equipment is noticeably different where single-use items are usually used in German hospitals and medical practices. Sterile gloves are cleaned and autoclaved to be used in ward work. Dressing material is not packed individually, but in large autoclave containers. Unfortunately, the number of post-operative wound infections and the pre- and post-operative use of antibiotics is high.
Prescribed medication, but also single-use catheters, syringes, cannulas, etc. are not provided by the hospital. These must be bought by the patients themselves or their relatives in the hospital pharmacy. As long as the material is not available, venipuncture cannot be performed, for example (these items are of course provided in the emergency room if quick action is required.

4. Daily routine in surgery
According to a personal rotation plan, I went through the following surgical departments: visceral, thoracic and breast, neuro and plastic surgery, which gave me an insight into a variety of different clinical pictures and surgical techniques.
The day began - depending on the department? between 7.30 a.m. and 8.00 a.m. with the rounds. This was followed by the? Morning Conference? instead, in which the new arrivals and incidents were handed over to the night. Every morning a different student had to introduce one of the new patients. Each of these cases was discussed in great detail. The patient presentations of the students were mainly used for learning purposes, with the head of the department, senior physicians and experienced ward physicians explaining and explaining a great deal. There was so much to learn in this meeting. Each department had surgery appointments on different days. On these days you were present in the operating room, could assist with operations or, if no assistance was required, follow the operation. Since the Nepalese are rather small in stature, they usually had a very good view of the surgical area. On the days when no operations were planned you were assigned to the outpatient department, where you had the opportunity to see a wide range of different diseases. Unfortunately, many of the patients only presented in the advanced stages of their disease (e.g. palpable rectal carcinoma or pronounced abdominal tumors, hepatosplenomegaly, etc.), because they wait until they can no longer endure their suffering for financial reasons or further away from Kathmandu. There was also the possibility to carry out small, outpatient operations (e.g. abscess splitting or removal of warts) in the aseptic operating room or to assist with hernia and hydrocele operations.
Seminars, case presentations and conferences were also held regularly. In the late afternoon, when the surgery or outpatient clinic program was over, there was another final visit together with the respective senior physicians.
Doctors and nurses all speak English, which is the official language in hospital and university education. Early meetings, rounds, seminars, conferences, etc. are also held in English. The patients often speak no or only broken English. So you should at least know enough Nepali that you can say that you want to auscultate them now. In all other cases a local student or a doctor can be used as an interpreter.
The training of Nepalese doctors is based on the English system (M.B.B.S). Much importance is attached to anamnesis and physical examination, which in my opinion is neglected in the German training.
I was particularly fascinated by plastic surgery. Most of all, burn victims are cared for there, since numerous accidents with kerosene stoves repeatedly cause severe burn injuries, which require skin grafts, the removal of scar contractures or cosmetic operations. It is also highly recommended to take part in night shifts. You not only assist more often in the operating room, but also have the chance to attend or assist in medical activities such as pleural puncture, chest drainage and, unfortunately, resuscitation in the emergency room.

5. Country and people
Nepal is a beautiful country with diverse landscapes and ethnic groups. Kathmandu is the capital of the predominantly Hindu country (approx. 80% Hindu, approx. 20% Buddhists, tiny minorities of Christians and Muslims). The hill country adjoins the Terai (the subtropical flat land in the south of the country). The conclusion in the north is the high mountains of the Himalayas, which are home to some of the highest mountains on earth.
Nepali is the national language, but almost each of the approximately 60 ethnic groups has its own language, so that not everyone speaks Nepali. Understanding is usually always possible somehow.
The Nepalese are a very friendly, peaceful and honest people. They are especially courteous and helpful towards strangers.
In terms of landscape, the Terai in the south and of course the Himalayas in the north are fascinating areas. The Kathmandu valley is home to the three ancient kingdoms? Kathmandu ?,? Patan? and? Bakhtapur? and is therefore very attractive to foreign tourists from a cultural and historical point of view.
Until the April 2008 constitutional assembly elections, in which the Maoists obtained a majority, Nepal was a constitutional monarchy. On May 28, 2008 the decision was made to abolish the monarchy and to establish a federal, democratic republic. There is great hope among ordinary Nepalese that the establishment of a republic will bring peace and prosperity. However, it is very uncertain whether the new government will fulfill these hopes. The political situation is unstable. The Communist Party has been tasked with forming the next government, but it needs the support of other parties in order to have a majority in the assembly. Until recently, a coalition had yet to be formed, and key ministries were still vacant.
How things will go in Nepal is in the stars and time will tell whether the hopes of the Nepalese will be fulfilled.

6. Conclusion
A PY tertial in Nepal is highly recommended, despite the somewhat uncertain political situation. I myself have never felt threatened or insecure: I learned and saw a lot in practical terms during my PJ in the teaching hospital: rare clinical pictures, poor conditions and social injustices that are not as obvious in Germany as in a country like Nepal. The prosperity and (social) political security in the western world became clear to me in many situations. Since then, I have valued the good medical care and security in Germany much more and will no longer take this for granted.
The stay in Nepal showed me my own limits again and again. In situations of foreignness, distance and homesickness you get to know yourself better and grow with all the new and unknown and the challenges that come with them. .
Last but not least, Nepal is a beautiful, impressive, diverse and contrasting country that is always worth a trip. I saw and experienced a lot there and got to know many interesting ones. Nepal is worth a trip in every way!

Munich, October 16, 2008

Looking back over a year, the following should be added:
Unfortunately, you couldn't do that much in a practical way at TUTH. Often you just stood by, or you had to show a lot of initiative to be able to do practical things. Language barriers should not be underestimated either. You have to get used to Nepali English before you can reasonably follow. In addition, the doctors often switched between English and Nepali, so that unfortunately a lot of valuable information was lost. Still, I think I learned a lot. As I said, you see a wide range of diseases and really more emphasis is placed on anamnesis and clinical examination. All in all, I can only recommend it.
By the way, the tertial was recognized at the LMU Munich (and they are rather strict)! I'll see if I can find a few photos (only had an analog camera with me).
8. 2.2010