1. How are you today?

Good, Thank you. How are you?

2. Did you have any trouble finding us?

No. I was well prepared to get into here.

3. Do you have any questions?

I can understand the enormous effort that you have put in this rigorous process of
selecting the candidates. I am really interested to know how the committee selects
them for the interview and the residency match ?

I had the pleasure of reading on your website that the residents are given an
opportunity to participate in the researches as well. I was really wondering to know
what kind of research the residents’ currently are involved in.

4. How much do you know about our program?

5. Tell me about yourself. Personal qualities….

I am a recent medical graduate from Nepal, a small Himalayan country in Asia. I

received my medical education from one of the pioneer medical school in my
country. During my medical school, I was actively involved in social activities,
research activities and also got a chance to present my paper in national and
international conferences. For my academic excellence, I was awarded Linneus
Palme Scholarship Program for an exchange internship by University of
Gothenburg, Sweden. After my graduation, I worked as a medical officer which
has provided me tremendous hands on clinical experience. Now I am ECFMG
certified and trying to pursue my career in Internal Medicine. As an observer, I
worked in the department of Internal Medicine of The Reading Hospital and
Medical Center, Pennsylvania. I have a passion and dedication to offer. Given the
chances, I strongly believe I can meet the expectations to the best of my ability.

6. What are the three things that you are proud of?

a) Being a doctor.
I love my profession. The art that lies with the medicine and the satisfaction I get
from my profession is extremely rewarding. Like it says in a movie, with great
power comes great responsibility. People put their lives in our hands. That’s an
immense responsibility, and I am dedicated to fulfill that responsibility to the best
of my abilities.

b) Participation in world congress of IPPNW

I was privileged to participate as a volunteer member of PSRN, in the 17th world

congress of IPPNW that was held in Helsinki, Finland. I presented a paper entitled-
one bullet story in the student seminar of the conference. This has motivated me
for further social works.

c) Getting Linneus Palme Scholarship Award:

For my outstanding academic performance in the medical school, I was offered

this scholarship for exchange internship in the Sahlgrenska Academy hospital,
University of Gothenburg, Sweden.

7. How have you changed since high school?

I have not only matured professionally but also personally. I have understood the
value of teamwork, cooperation and how everybody is important for the overall
functioning of the team. I have become more flexible, adaptable and more
tolerant. 

Earlier I used to study everything, I had a good knowledge base but of very less
practical use. Later I realized education is not only about knowledge and started
studying according to the cases I encountered.

I travelled around, mixed with people; I slowly explored the world around me
trying to understand cultural values and technologies.

8. What has shaped you the most and got you where you are at today?

My hard work, strong determination and enthusiasm along with my family’s’ and
friends’ constant encouragements and support have brought me to this stage.

9. What were the most difficult and trying time in your life? How did you handle
it?
During my final year of medical education, I had to undergo five months long
exhausting exams. At the same time, there was so much pressure to excel that I
almost had a breakdown. But I kept on persevering, and finally got through. My
family and friends were a great deal of support in those difficult times.

10. Tell me about your medical school.

Well, I graduated from Tribhuvan University which is a pioneer medical school of Nepal. We
have community oriented integrated MBBS program of 5 and half yrs. Unique to our medical
school is residential field trips in differernt parts of the country to provide sociocultural exposure
as well as research and health management skills. We have clinical rotation in Tertiary hospital
serving around 3,00,000 out patients and 20, 000 inpatients a year. Our medical school runs 26
post graduate programs including internal medicine. So we have plenty of didactic teaching
learning activities and wide variety of clinical exposure. During 1 year of internship we get
adequate hands on clinical experience under supervision.

My days in Medical School were much of fun along with didactic teaching learning activities
throughout the basic medical and clinical sciences. I graduated from Tribhuvan University which
was established in 1972 A.D. Our medical school runs 26 post graduate programs including
internal medicine. Our curriculum is focused on problem based learning and evidence based
medicine to provide better patient care. We have clinical rotations in Tertiary hospital serving
around 3,00,000 out patients and 20, 000 inpatients a year. This wide range of patients provided
ample hands-on-experiences under supervision during my clinical rotations and compulsory
internship. One of the unique features of our medical school is the residential field trips in
different parts of the country to provide sociocultural exposure as well as research and health
management skills. I take pride in being a graduate from this institute as there are so many of my
seniors pursuing their career here in the US. And, they are doing their best. And, I believe that I
can make significant contributions, if given an opportunity in your program.

Tell me something about your book.

Getting into the medical school in our part is really tough as we have to appear in
the objective based tests. Finding the appropriate material for the entrance
examination was not so easy. So a thought came into my mind to present the
required information in a comprehensive way and so that it will be extremely
useful for the medical aspirants. I finally came up with first edition of Quick
Review of Health Science while I was in third year of medical school. It was
overwhelmingly popular and that gave me an immense satisfaction to come up
with subsequent three editions within a period of 4 years. Now I am very happy as
it is heading towards its 5th edition. I have authored two other books related to
Health Education which are designed for the high school students. I would like to
continue my experience of medical writing in the future as well.

Tell me about a case that involves clinical judgment.

Well, I remember 26 year old male patient who presented ENT outpatient
department when I was doing a clinical rotation there during my internship. He had
repeated episodes of Upper Respiratory Tract Infection for the last 3 years. He had
been to many physicians and was prescribed some antibiotics that helped him just
for few weeks. When I asked him in detail, he told me that he had on and off joint
pain and fatigue, as well. I thought that some systemic conditions might be
causing his recurrent problems and sent all the routine tests. Urine examination
revealed proteins and RBCs. This made me suspect Wegener's Granulomatosis on
his case and I referred him to Nephrologist. And, the biopsy confirmed it. During
the follow up, the patient was very happy to inform me about his final diagnosis.
And, it made me realize that we should always think medicine in a more holistic
approach, during the presentation itself.

Tell me about your country.

Nepal is a small landlocked Himalayan country located in between China and India
in south East Asia. Politically our country is federal democratic republic with a
presidential system. Hinduism is practiced by larger majority of people in Nepal.
This is rich culturally and geographically with exquisite natural beauty and
astonishing landscape. Eight of the 10 highest mountains are situated in northern
aspect of Nepal. Our country is famous for mountainering, trekking, paragliding,
rafting and so many adventures.

Agriculture is major occupation but tourism has a good scope in Nepal. It has area
of around 56000 square miles and population of 27 millions. 40% of the people
live below the international line of poverty and stands on 138th position on human
development index. Some of the major health indicators like infant mortality rate
of 47 compared to 9 per 1000 in the USA. The maternal mortality of Nepal is still
241 and is slowly improving in the health care services. Nepal is struggling to
move ahead despite of limited resources.

Tell me about your teaching experience.

I am a recent medical graduate from Nepal, a small Himalayan country in Asia. I
graduated from Tribhuvan University, one of the pioneer medical school in my
country. During my medical school, I was actively involved in social activities,
sports, research activities, teaching and medical writing. After graduation, I
worked as a medical officer which has given me tremendous hands on clinical
experience. This has helped me to become proactive and responsive to the health
care needs of my patients. I had an opportunity to teach and guide aspirants for
medical education. This has helped me to develop interpersonal skills as well as
teaching experiences. Now I am ECFMG certified and trying to pursue my career
in Internal Medicine. Recently I have finished my rotation in the internal medicine
department of The Reading Hospital and Medical Center, Pennsylvania. I love
working in a team, working with my patients and interacting with people of diverse
background. I have plenty of experiences of team work. I am hard working which
has been reflected by my consistent performance in my medical school and in
USMLE steps. As a person, my friends find me very optimistic, intellectually
honest, flexible and open-minded. I have a passion and dedication to offer. Given
the chances, I strongly believe I can meet the expectations to the best of my ability.

Take me to your PS.

Be very short and include important points. Work on…eg YRB

I was born and brought up in a farming community in Nepal. Due to my passion

for learning, my teachers and my family members encouraged me to be a good
physician. Since then I had envisioned becoming a physician to help humanity for
a long time. Finally I was selected to receive medical education with a merit based
scholarship in the pioneer medical school of Nepal. During third year of my
medical school, we had family health exercise. It instilled in me a desire to serve
the underserved and to positively affect patient’s lives. I eventually set my sights
on Family Medicine which is the best choice for me. Opportunity to provide
comprehensive medical care, encounter with diversity of cases, direct interaction
with patients and good scope for academic teaching are some of the factors which
fascinate me about family medicine.

After graduation I worked as a medical officer independently in rural setting for

about one and half year and then I had privileged to work as teaching assistant in
reputed Taishan medical university of china. Then I joined a tertiary care center in
Kathmandu for about 5 months. Added on that, I did one month observer ship in
Rhode Island Hospital of Brown University. This observership has helped me
transition into the American system. I strongly believe that my accumulated
experiences perfectly fit to this program.

The numerous research opportunities, strong academic foundation, advanced

technology and evidence based medical practice have dragged me all the way to
this place. Training in USA is focused not only in the patient care but also in all the
components of a competent physician as defined by ACGME. So I decided to
pursue my career in the place where emphasis is given on state of the art
technology.

Tell me about an ethically difficult case.

Well, it was a cold winter night and I was working as an intern. A 40 year old
homeless lady presented with suggestive symptoms of common cold. Further work
up revealed no acute illness. When I was planning to discharge her with some
medications and counseling, she said that she might have severe pneumonia and
requested hospital admission. She told me that she does not have any place to stay
that night. She was too ill to recover on the streets and too well for a hospital
admission. At that time I found myself in ethical dilemma. I then talked to a
welfare organization but I could not arrange the bed for her. After discussing with
my attending I kept her in the hospital wheel chair for the whole night so that she
could make her way the next day when it will be warm and bright.

What is your experience about third year field?

The notion of viewing health in holistic approach One of the unique features of our
medical school is the residential field trip to explore socio cultural aspects and
family dynamism. In third year, we conducted a comprehensive study on five
cases, analyse the impact of illness in the patient and family along with gender
issues. Those cases were selected from the hospital, and we usually used to follow
them in their families. we interviewed to the family members, discussed the role of
family in causation and outcome of the disease. We have prepared the report and
submitted to the department of Family Health of Institute Of Medicine.

What was the most important event in your life?

Being born in a country where doctors are highly regarded and are seen next to
god, it was my dream to become a doctor. My medical school is one of the best in
our country and the admission is very competitive with less than 1 in 200
applicants getting selected into the medical school. When I got in, I was very
happy. That was the turning point in my life. All in all, I am proud I chose this
path.

11. How does your roommate describe you?

As a friendly, helpful, hardworking person.

12. What are your strength and weaknesses? How well do you take criticism? If
you could change one thing about your personality, what would it be?

I believe that the passion for my profession is my real strength and along with my
dedication, enthusiasm, and motivation, I will be able to excel in my profession.

Talking about my weakness, previously I had a hard time dealing with criticism.
Now I have learned that this can be constructive when taken positively.

I used to be uncomfortable with patients who don’t comply with the treatment. But
lately I have realized that there is always a reason behind their noncompliance. I
have always motivated them to share it with me so that we can work on some
practical suggestions. It is as much my responsibility to ensure compliance as is
theirs, perhaps even more on my part.

In fact I get along with all sorts of people regardless of ethnic, cultural and
socioeconomic status. I love people who are open minded, respectful and who have
consideration for others.

Like it says in a movie with power comes the great responsibility. People put their
lives in our hands and that is an immense responsibility. This always drives me to
work hard to provide best care to my patients.

If you could be any cell in the human body, which would it be?

I would like to be a neuron- With this I can communicate all other cells and
coordinate their activities.

What is more important, knowledge or imagination? Are you organized and

structured or flexible? Are you serious and dedicated or relaxed?

I consider knowledge more important, especially in our field. I am organized and

serious. I cannot be casual and relaxed on my job. I feel like I have a lot of
responsibilities on my hand.
If your house was burning, what are the three objects you would save?

People, nothing else usually- this is the national recommendation; my certificates

and my laptop.

 What differences do you see in the health care system between your and this
country?

GLEW IDEA

Important invs like ctscan ,mri , usg are not widely available in our country. Many
instances, we have to rely on clinical judgement.

In our part, the motto is doing the greatest good to the greatest number of
people. Hospitals and ER are very crowded and stressful, so are the floors. Patients
rarely get individual attention from the doctors. Here, patients are cared for
individually by doctors, which is nice.

We are definitely low tech in our part of the world. We have no interventional
radiology, no fancy drugs like imatinib and rituximab. Only drugs which are being
used for a long time are available, and we have to make do with them. No new
investigative technologies like MUGA or PET scanning that is no any
radionuclide imaging.

We don’t have electronic record keeping system, and no way of coordinating

care between 2 centers.

The doctor to patient ratio is very low, workload is high.

There is mostly no concept of healthcare insurance, so patients all pay their own
bills, but the good part is that the cost of treatment, at least in public hospitals, are
very low and significantly subsidized by the government.

We have less fear of litigation in our part, so doctors don’t practice defensive
medicine like here. In our part, whatever doctors say is the ultimate, patients don’t
question that.
The education level of general public is also not enough for patients to be
proactive for themselves, so doctors have to decide on the best course of
treatment most of the time.

Even those treatment and investigations available cannot be afforded by many,

so we have to rely on our clinical judgment more than anything.

What are your three wishes? If you have unlimited money, what would you do?
What is the most important thing in your life? If you are deserted on an island,
what would you take with you?

Wishes: To enjoy whatever I am doing. To be engaged in an intellectual job;

have a loving family and dear friends close to me. If I had money, I would start a
network of nice hospitals in my country. I would also try to improve the health
system of the US.

Family is the most important thing in my life; after that my friends.

My girlfriend, my parents, my laptop (else it would be incredibly boring, though I

do not know how long the battery will last)

What kind of people do you get along with? Describe your best friend. Who are
your heroes?

Open minded, understanding and respecting others from any culture, religion or
nationality; in fact I get along well with people from a wide range of background.

Best friend- friendly, hardworking, helpful and honest.

What is the last book you read?

Alchemist

How do you define success?

For me, success is to be good in whatever I do, to get whatever I deserve, to be

happy with whatever I have, and to have a stable loving family.

If you could accomplish only one thing in your life, what would it be?

Improve the health system of my country at par with the States.

What physician characteristics do you admire the most?

Intellect, compassion, and hard work with thoroughness, high level of stamina and
energy.

In your med school, whose work do you admire the most and why?

A Nephrologist. First of all he was very dedicated and meticulous at his work.
His compassion towards patients was impressive. He used to explain everything to
the patient. He was always eager to teach us and ready to help in every aspect.

What do you do in your spare time? If you had a free day, what would you do?

Go for a trekking. Study novels. Stay home with family, meet friends.

Have you done any volunteer work?

I volunteered in many organizations including PSRN and NMSS which is affiliated

to international organizations. I have also worked as a general secretary of Kavre
Health Society, which organizes health education and free health camps in rural
setting of Nepal. These organizations work to bridge social inequalities in different
sectors of the society.

What is the most bizarre thing you have ever done?

I went alone for a trekking in the foothills of the Himalayas.

Where have you travelled?

Almost every part of my country, including India, Finland, Denmark and Sweden.
Nepalese are very hospitable. Finnish and Swedish people are very helpful. Nepal
is the place if you want exotic natural beauty. India is very rich culturally and there
are so many places of historic importance.

Tell me about the research on CVA management protocol.

During our rotation in emergency department, we saw a lot of stroke patients but
there was no fixed protocol being followed there. I went back and studied standard
books and came up with an idea to conduct a study to find out how stroke is being
managed in our emergency in comparison to the standard treatment.
We analyzed 82 case records of stroke patients. We found that in case of
hemorrhagic stroke, all patients with indication were given antihypertensive
treatment. However in case of ischemic stroke, blood pressure treatment was
given only in 72 percent of patients with the indication.

At the same time, only 9 percent of the cases who had indication for blood sugar
control, received insulin.

Regarding Antithrombotic treatment, only 52 percent of the cases with ischemic

stroke got treatment with aspirin. Only few cases were due to contraindication, no
causes were mentioned in others. I have a strong conviction that this findings
would give some feedback to the emergency department.

What medical journals do you study?

Well, I study journal of institute of medicine published from my medical school. I

also study BMJ, JAMA and NEJM.

Do have experience of presentation?

There was a flood disaster in august of 2008 in the eastern part Nepal. We, team of
five interns, went there as a health support team.

Yes, I presented a report on the topic “intern doctors’ health support team to flood
victims of Koshi.” it was about our trip to the flood affected area where we carried
out a descriptive epidemiological study of the diseases after the disaster. Besides
providing medical support in the health camps, we also conducted a micro health
project on sanitation and chlorinated water supply. We taught them about the safe
drinking water and methods of chlorinating water.

What nonmedical magazines do you regularly read?

Times and local magazines published back in my country.

What would you do if you found out one of your colleague is using drugs/ alcohol?

According to an article in JAMA, confronting the colleague is useless, as they are

usually in a state of denial, and he might take it as an insult. So anonymously
informing the physician health service (PHS) is the best idea, which will then try
to provide help to the physician. Reporting to state medical board is also too
extreme, because physicians are also human and their problem have to solved,
rather than revoking their license.

Residency in this hospital is quite busy and tough. How do you convince us?

Well I am well aware of this fact. But I believe residency is a tough training
everywhere. Back in my medical school also we used to work with residents
sharing their responsibilities like admitting cases, doing work up of the cases ,
performing the procedures,( writing the progress notes ,discharging the patients
etc). we also used to have 1 to 2 night night duties in a week I have the experience
of working in busy emergency room where around 12- 14 doctors had to handle
around 100 emergency patients per day. Being tertiary level and less expensive
hospital , we used to have overwhelming patient flow in outpatient clinic as well as
inpatients wards. With this entire set of experiences and motivation to face the
challenges I am confident that I can meet the expectations of your program.

In which situation are you most efficient?

Based on the experiences I have so far, I think I can give my best when there
is moderate level of stress to accomplish my work. The motivation from my
teammates also enhances my performances. I am quite goal oriented and I have
always been able to finish my things before the given deadlines.

To which organization do you belong?

PSRN- daughter organization of IPPNW, with mainly social goals of bridging the
social inequalities in the country with the help of physicians.

Kavre Health Society- free health camps, , school health education and blood
donation camps. I write health realated articles to help create awareness among
people from various cultural backgrounds.

Shashi…I have always been involved in various social and medical associations
since my highschool. In my medical school, i was elected as secretary for NMSS,
an affliate for Imternational Federation for Medical Students Association. When i
worked as a National Officer for HIV / AIDS and Reproductive Health, i had the
opprtunity to plan school health programs and conduct various seminars. I worked
as an active member for PSRN, an affliate of International Physicians for the
Prevention of Nuclear War, a recipent of Nobel Peace Prize. I had an opportunity
to present my paper titled " Children Amidst Maoist Conflict". I coordinated
various workshops, raised fundings and conducted several health camps during
epidemics.

Would you have any trouble working in this predominantly catholic hospital?

No, I respect every person’s right to religion and faith. I have worked with people
of different faiths, from Muslims to Catholic to Hindu to Atheists. I have always
mixed with them very well. Taking care of their health is a different issue and I
always try to deal with them professionally.

How important is family for you?

Having a loving and caring family helps to relieve our stress and the hardships of
daily life. If we have somebody to love and care our life and work becomes easier.
Family gives purpose to my life.

If you could no longer be a physician, what career would you choose?

My passion and attachment in science and discovery of knowledge would have

driven me to become a researcher. By this I would have contributed to develop
new understanding in the field of medicine.

How do you deal with nurses?

I beleive that nursing staff are key component of health care delivery team. I will
try to maintain professional and harmonious relationship with them and I will try to
deal with every criticism positively. All in all this is our combimed effort to meet
the best interest of the patient.

What do you think about the evaluation system used by USMLE Step II CS
Exams?

USMLE CS exam intends to assess the art of patient interaction and clinical
evaluation to arrive at a clinical diagnosis in a limited time and efficient manner.
At the same time, it also evaluates the effectiveness of Interpersonal and
Communication Skills and mastery over the Spoken English Performance. This set
up is a reflection of the exact clinical settings we practice here in the States. I
highly appreciate the way this exam tests our knowledge and skills in a succinct
manner in a variety of common cases we encounter professionally.
Why did you choose to be a physician?

Well, I had been a very good student throughout my childhood. I thought

medicine would be intellectually challenging. At the same time, I have witnessed
my father’s suffering, long months of hospital stay, radiotherapy and how the
doctors helped to alleviate his pain. This has inspired me to become a doctor and
treat people’s illness.

How will you incorporate your research interest into your residency and future
career?

I have a keen interest in the clinical research and would like to carry some research
apart from my job so that I can take care of my patients better. This will add to the
growth of evidence based medicine.

What do you think are the most important traits in a clinician?

Knowledge, dedication and compassion are most important. It is very true

that our eyes don’t see what our mind doesn’t know. So we go to have
knowledge. Knowledge without an attitude to work and help others is however
useless. We cannot help others unless we have compassion towards them in our
heart.

In what sub specialty would you like to go?

I am interested in Cardiology as I really like the wonder outcome of intervention

cardiology and treating all the cardiac conditions like MI, Heart Failure and many
others.

How do you make decisions? Are you a risk taker? What was the most difficult
decision you had to take in your life?

I take very calculated decisions. I m not much of a risk taker.  Probably the most
difficult decision was whether to stay in my country or come to US for my
further studies. My own country, is afterall, my own. But there were so less
opportunities for further studies, and no any opportunity for sub specialization that
I decided to come here.

What are the major deficiencies in your medical school training? How do you plan
to get over those? What medical school course or class interested you the most?
Probably the pathophysiology classes were the most interesting classes, especially
because we had a very charming professor- whose anecdotes were so full of life,
we didn’t feel like we are sitting in a class. He used to talk beyond the books, about
life, and research and those things, he always kept us interested. I really liked him.
His classes also helped me after I started working as a clinician, and also while I
taught the same topic later I graduated.

Probably biostatistics is my weak part. I am trying to improve it, but it is so

complex. I am planning to take a SPSS software course after I match into a
residency. Apart from that, I think our medical school training was at par with
anywhere else in the world. We really used to study hard. I don’t feel deficient as
far as my clinical education is concerned.

What motivates you to study?

A patient puts his/her life at our hands and I believe that is an immense
responsibility. This sense of responsibility motivates me so that I can give the best
possible treatment available to help my patient. Helping someone feel better is
itself a reward to keep moving.

What have been the biggest failures in your life? What have you done to ensure
they don’t happen again?

I really have never experienced what I would call the biggest failure. I am sure I
have had minor failures at times, like not being able to prepare very well for my
exams during my first year of Medical School. But like Sir William Osler used to
say let the failure not define you but teach you. I try to focus on doing my best
each day and to me it is the effort which counts. I try to deal with mistakes as
learning experiences.

What kind of patient you find difficult to work with?

I used to be bit intolerant with patients who don’t comply with the treatment. But
lately I have realized that there is always a reason behind their noncompliance,
and that it is as much my responsibility to ensure compliance as is theirs, perhaps
even more on my part.

How do you handle conflict?

Many a time’s conflict and criticism can be constructive. Taking this in mind I take
time to analyze what exactly is going on. I consult with my colleagues, mentors
and professors to come to the final conclusion.

What subject or rotation did you have the most difficulty?

I probably had hard times going through my orthopedics rotation. The short
postings in fourth year did not equip me with much knowledge. There were so
many technicalities I had never heard or seen and it was very difficult to get what
they were exactly doing in the operation theatre and the wards.

What has been greatest challenge?

To excel in the field of medicine is the biggest challenge for me. I believe hard
work, compassion and ever growing enthusiasm will help me acquire my set goals.

Why do you want to go into this specialty? Why did you choose internal medicine?

The combination of clinical evaluation, logical thinking and diagnostic modalities

makes internal medicine extremely appealing to me. The wide range of
subspecialties that it offers further inspires me in this field.

Though I decided about choosing Internal Medicine after I started working as a

medical officer in different remote settings, it had always fascinated me.  It
embodied the core value that inspired me to choose this great calling in the first
place.  I love medicine for how, the art of patient interaction and clinical evaluation
are integrated to the science of deductive reasoning to arrive at a diagnosis and
formulate a plan of care.  I have been very impressed with the wide scope of
medicine and the choices it offers, from primary care to many different sub-
specialties.  Internal medicine has appealed me in every settings and
circumstances, from outpatient clinics to the long nights in the wards.  

 Although I saw all ages of patients during my tenure, especially pediatric

population fascinated me the most. The multitude of presentations ranging from
simple viral infections to severe congenital heart diseases always inspired me to go
to this field. More importantly, I find children having an honesty, ignorance and
interest for life that adults somehow loose along the way. I have seen pediatric
population of all age groups ranging from neonate to teen age. From neonatal
resuscitation to teenage contraception, I always find my time best spent with them.
An equally rewarding aspect of pediatrics is preventive medicine ranging from
immunization to nutrition care. It is simply a rewarding fact to work with young
people because of the chance to be involved in a growing relationship as they
mature and learn.  I want to feel delighted that what I do improves the lives of
children in big or small ways. This field holds my interest, and I believe my
abilities will best be used. Training in this field will enable me to become a
knowledgeable pediatrician with refined skills, and increase the ability to evaluate
my patients and set-up their care.

The multitude of presentations from all age groups and its wide scope makes
family medicine extremely appealing to me. The pivotal role played by family
physician in connecting different fields of medicine has enhanced my interest
further. It has a unique combination of intellectual reasoning, clinical evaluations
and unique diagnostic opportunity. This field holds my interest, and I believe my
abilities will best be used. Training in this field will enable me to become a
knowledgeable physician with refined skills, and increase the ability to evaluate
my patients and set-up their care.  

What sacrifice are you willing to make to become a specialist?

I have left my country, family and friends to get the best training here. I have
significantly cut down my hobbies like sports and travelling. While working as a
medical officer back in my country I had many sleepless nights. When it comes to
education and patient care I am motivated and willing to offer my sacrifice to the
fullest integrity possible.

Tell me an interesting case that you have seen.

a. A case of Dieulafoy’s Disease.

A 42 year old man presented with massive hematemesis. He was non-alcoholic but a chronic
smoker with the history of 20 pack per year. He had experienced numerous similar episodes of
hematemesis for the last 2 years. He mentioned that he had completed a course of
antituberculosis therapy after the episode of hemoptysis 10 years ago. When he was hospitalized
at our center with this episode, massive hematemesis was the only abnormal finding on initial
clinical examination. Blood biochemistry parameters were within normal limits initially but
patient became hemodynamically unstable after some time. His hemoglobin dropped to 8 mg%
and his systolic blood pressure went to 86 mm of Hg. He was resuscitated with NS and blood
transfusion. Upper gastrointestinal endoscopy revealed no abnormalities. After 8 hours the
patient again started to vomit blood. With ongoing resuscitation, a senior gastroenterologist was
consulted and on UGI endoscopy, he noted around 5mm mucosal defect with a protruding vessel,
located on the lesser curvature of the stomach. A diagnosis of Dieulafoy’s disease was made and
endoscopic injection sclerotherapy was performed. There was no recurrence of bleeding in the
first year of follow up.

b. A case of Myocardial Infarction .

A 44year old woman presented to the emergency department of the Hospital with a continuous
epigastric pain of four hours duration and intermittent vomiting. She was also having diarrhea
since the morning and Her medical history included hypercholesterolemia and type 1diabetes for
25 years treated with insulin injections twice daily. She was a smoker of more than two packs of
cigarettes daily. On initial assessment she was drowsy with pulse rate of 110 bpm, respiratory
rate of 26 per minute and blood presuure of 106 by 74 mm of Mercury. A physical examination
of her abdomen had normal results. Her initial EKG revealed sinus tachycardia.

With a presumptive diagnosis of Diabetic ketoacidosis, a urine dipstick test was ordered but
surprisingly that was negative. His systolic blood pressure suddenly decreased to 90mm of Hg.
With ongoing resuscitation, bllod glucose and ABG were ordered. Findings were consistent with
slight metabolic acidosis.. We immediately suspected an acute myocardial infarction. A repeat
EKG showed ST segment elevation in anteroseptal leads. And cardiac enzymes proved our
diagnosis. The patient was managed accordingly.

This case has taught me to explore for every possible cause of the patient’s problem.

Tell me one joke.

1. A guy walks into the doctor's office and says, "Doc, I haven't had a bowel movement in a week!"
The doctor gives him a prescription for a mild laxative and tells him, "If it doesn't work, let me
know." A week later the guy is back: "Doc, still no movement!" The doctor says, "Hmm, guess
you need something stronger," and prescribes a powerful laxative. Still another week later the
poor guy is back: "Doc, STILL nothing!" The doctor, worried, says, "We'd better get some more
information about you to try to figure out what's the problem is. What do you do for a living?"
"I'm a musician." The doctor looks up and says, "Well, that's it! Here's $10.00. Go get something
to eat!
 2. It was the day of the big sale. Rumours of the sale (and some advertising in the local paper) were
the main reason for the long line that formed by 8:30, the store's opening time, in front of the
store.

A small man pushed his way to the front of the line, only to be pushed back, amid loud and
colourful curses. On the man's second attempt, he was punched square in the jaw, and knocked
around a bit, and then thrown to the end of the line again. As he got up the second time, he said
to the person at the end of the line...

"That does it! If they hit me one more time, I won't open the store!"

Are you interested in teaching?

Teaching and learning activities always fascinate me.What is the use to the society if the doctor
doesn’t transfer his knowledge to the next generation? Then the insights gained in decades of
work will become of no use. Teaching his medical insights should be the major component of the
doctor’s ideal. This transfer of the intellect can be in a variety of settings from teaching medical
students, nursing students, junior colleagues to writing books and participating in the internet
forums. The other important aspect of teaching could be educating the patients and the society.
Who to teach the society better than a doctor, that the HIV patients should not be discriminated?

Are you interested in research?

The present highly advanced medicine is due to the collective effort of thousands upon thousands
researchers to find better solution to medical problems, to find novel mechanisms and therapies.
The only way to keep the flow is by discovering new and better things, though we may not
benefit from all that we do, the next generation will surely benefit. I want to make my
contribution in the field of evidence based medicine by doing some clinical researches.
Do you have any question for me?

I went through the program website and also had discussion with the residents here. I was able to
get all the info that I needed. I do have one question. Could you describe how the residents are
evaluated during the residency training? Is there a periodic evaluation of the performance? Will I
be having a mentor to advise me during my training?

How do you spend your free time?

Ever since I left my medical school, I have very less free time (smiling). I do have a variety of
interests outside medical field. I love travelling and trekking. I also watch movies and study
novels. I am a very outgoing person and I enjoy hanging around with my friends

Have you applied to another specialty?

No, I have applied only to internal medicine residency programs. Internal Medicine has always appealed
me in every setting and had always been my passion since medical school. I like the diversity of cases
that this specialty manages and the art of clinical evaluation and deductive reasoning to come to an
accurate diagnosis and formulate plan of care.

Tell me something about the place that you have visited.

I have visited Sweden, a Nordic country, situated on the Scandinavian Peninsula in

Northern Europe.Sweden is home to a large number of World Heritage Sites and also
boats of mesmerizing natural beauty. Sweden is second most technologically advanced
country in Europe.I have visited the largest shopping mall of Europe is ‘Nordstan’ in
Gothenburg. I have visited Nobel Prize distribution center in the Stockholm. Alfred
Nobel, a Swede who invented dynamite in 1866.Sweden is popularly known as ‘The Land
of the Midnight Sun’ and ‘The Land of the Vikings’. Sweden is set to become the first country in
the world to phase out petrol for biofuel. Sweden has an excellent reputation as a car maker with Volvo
and Saab. Swedish men are very tall. There are largest number of McDonalds in Sweden. For every one
Ikea in Sweden there are 39 McDonalds. Instead it is perfect for those who love nature, space, clean air,
beautiful landscapes and outdoor activities.
How much of lifestyle considerations fit into your choice?

A moderate level of stress and workload is what works best for me. Getting to
enjoy with friends and families definitely helps me recharge though. When it
comes to education and patient care I think I am motivated and willing to offer my
sacrifice to the fullest integrity possible.

Why did you apply to this program?

I have been lot of forum discussion. This program offers highly organized and
closely supervised broad clinical training and is linked to community rich in ethnic
and socio- economic diversity (HOCS BCT). This is the program where I
encounter the widest possible spectrum of medical problems.

These assets, combined with pleasant friendly and supportive working

environment produce a high quality training experience.

Talk about size of program, faculty, patient volume, elective opportunities,

population mix, foreign medical graduates and research

Well, this seems to be a resident friendly community program, where there is

real interaction between the attending and the residents. There seems to
be enough didactic sessions going on. The stress and workload seems to be just
right, not too much, not too less. I think I will be very comfortable here.
Plus one of my senior is already doing residency over here, and I have heard good
things about your programs from her. I can see that she is really satisfied with your
program.

What qualities are you looking for in a program?

I am looking for a program where I can get highly organized and closely
supervised broad clinical training in a friendly environment so that I will have
opportunity to learn and practice evidence based medicine and grow as a whole.

Good teaching learning activity and moderate workload.

I am looking for Moderate level of stress, helpful ancillary staff, close contact
and supervision from the attending that is supervised autonomy.

I am looking for an opportunity for direct patient care, supervised autonomy,

self directed learning and friendly working atmosphere.

What do you think you will contribute to our specialty/ program?

My devotion to patient care, my interest in academic activities, my friendly

nature and my ability to get along with patients from diverse cultures will add
to the efficiency of your program. (DIFA)

I am interested in clinical research so that we can improve our patient care and

make it more evidence based. I plan to not only work as a clinician, but also
conduct some research in different aspects of medicine, so that I can bolster the
practice of EBM.

What will be the toughest aspect of this specialty for you? Can you stand for a long
time? Are you willing to do graveyard shifts and all weekends for a month?

Toughest aspect will probably be keeping abreast of all the developments in the
EBM that is changing day by day. Keeping track of new recommendations, like
PPI improving COPD patients, is quite a challenge for a clinician.

I might have some difficulties in the beginning in understanding socio cultural and
ethnic factors. For example: When I will be working as a resident I need to counsel
my patients regarding diabetic and renal diet.

I came to know that there are more than 21 main languages spoken in this country. 
For example, more than 10% of the people speak Spanish. So, I think, at times, it
would be difficult for me to communicate with patients speaking Spanish or other
languages.  Even though there are translators in hospitals who are providing great
help, I would be able to work more efficiently if I can speak Spanish at least.
Therefore, I am planning to take a Spanish language course before my residency
which would definitely make me faster and more efficient.

Why should we take you in preference to other candidates? What makes you
unique?

I am not in a position to make that decision. I appreciate that there are many
qualifiedcandidates applying to this program, but I think, my devotion to patient
care, my interest in academic activities, my friendly nature and my ability to get
along with patients from diverse cultures will add to the efficiency of your
program.

What is your energy level like?

When I was in medical school, due to shortage of attending, I had to see almost 30-
40 patients in a single shift. I had to stand for 3 hours in the round, and another 4-5
hours taking care of inpatients, which was followed by night floats starting from
6PM and ending at 5 PM, the next day. I have an experience of going through all
these and I think I have good energy level to work as an efficient resident here.

How well do you function under pressure? How well do you function under
pressure. How well do you handle death?

I enjoy working under pressure because I believe it helps me grow. In my previous

experience I always worked well during deadlines and I always learned how to
work more efficiently afterwards. I have worked for one and a half month in the
Emergency room in my final medical year. It was one of the most crowded and
most stressful ER I have ever seen. Lack of adequate ancillary staffs
compounded the problem even more. We had to handle multiple patients at once,
send the blood works our self, insert Foleys and NG and do blind LP. I guess it was
pretty stressful. I had to witness many deaths in my ER postings. Initially it made
me feel sad, but I got used to it later on. Later I realized that there is no point to
worry when we have done the best we can. The more difficult part is to make
the patient accept the reality.

Present an interesting case. What errors have you made in your patient care? What
was the most memorable experience in your school?

It was a hectic morning in the emergency room when 71 year old patient came with
leg swelling for 3 months and shortness of breath for 4 hours. When I examined
him, he had a moderate swelling of his left leg, with ecchymotic changes on the
skin surface. Apart from that, there was no other positive finding. He was
tachypneic, but his breath sounds were normal. His chest x ray and ECG was
normal. His pulse oximetry showed 90% on room air, so he was put on oxygen. I
strongly suspected DVT with PE, since this is commonly missed diagnosis in our
part of the world. We don’t routinely give heparin prophylaxis for bedridden
patients, and we usually under diagnose DVT. Although I consulted with the
medicine resident on call that day, he was a bit hesitant about using heparin. His
suspect was cellulitis. Being a holiday, I couldn’t send for CT. As I had started
him on antibiotics, and thought of sending him to USG Doppler, he started
desaturating. Interventional radiologists for embolectomy, or cardiothoracic
surgeon were not available. He went on desaturating further and within minutes,
he was unresponsive. When we started CPR, black infracted lung tissue started
coming out of his mouth. We couldn’t save him. It was one of the most horrific
experiences in my life. I felt I was helpless.

Tell me about the patient from whom you learned the most.

The other case I witnessed was 12 year old girl with rash on her face, presenting
with mild edema of the feet. She was admitted and investigated for SLE, which
came out to be positive. She developed ARF and deteriorated very fast. She died of
pulmonary edema in few days time. It also made me realize the need for proactive
measures and incessant vigilance in patient care, and the importance of
effective communication and team work (PIECT). May be if we had been more
vigilant and more proactive in her treatment, we might have saved her.

Tell me about the novel that you have read recently.

It was Alchemist.

With this symbolic masterpiece Coelho states that we should not avoid our
destinies, and urges people to follow their dreams, because to find our
"Personal Myth" and our mission on Earth is the way to find "God", meaning
happiness, fulfillment, and the ultimate purpose of creation.

   The novel tells the tale of Santiago, a boy who has a dream and the courage
to follow it. After listening to "the signs" the boy ventures in his personal,
Ulysses-like journey of exploration and self-discovery, symbolically searching
for a hidden treasure located near the pyramids in Egypt.

   When he decides to go, his father's only advice is "Travel the world until you
see that our castle is the greatest and our women the most beautiful". In his
journey, Santiago sees the greatness of the world, and meets all kinds of
exciting people like kings and alchemists. However, by the end of the novel,
he discovers that "treasure lies where your heart belongs", and that the
treasure was the journey itself, the discoveries he made, and the wisdom he
acquired.

   "The Alchemist", is an exciting novel that bursts with optimism; it is the kind
of novel that tells you that everything is possible as long as you really want it
to happen. That may sound like an oversimplified version of new-age
philosophy and mysticism, but as Coelho states "simple things are the most
valuable and only wise people appreciate them".

   As the alchemist himself says, when he appears to Santiago in the form of

an old king "when you really want something to happen, the whole universe
conspires so that your wish comes true". This is the core of the novel's
philosophy and a motif that echoes behind Coelho's writing all through "The
Alchemist". And isn't it true that the whole of humankind desperately wants to
believe the old king when he says that the greatest lie in the world is that at
some point we lose the ability to control our lives, and become the pawns of
fate. Perhaps this is the secret of Coelho's success: that he tells people what
they want to hear, or rather that he tells them that what they wish for but never
thought possible could even be probable.

Tell me about movie that you have recently watched?

1. It was Cinderella Man

James J. Braddock is a hard-nosed, Irish-American boxer from New Jersy, formerly a light

heavyweight contender, who is forced to give up boxing after breaking his hand in the ring. This is a relief
and an upset to his wife, Mae, who cannot bring herself to watch the violence of his chosen profession,
and yet knows without him boxing they'll have no good income.

As the United States enters the Great depression, Braddock does manual labor  to support his family,
even after badly breaking his hand. Unfortunately, he cannot get work every day. Thanks to a last-minute
cancellation by another boxer, Braddock's longtime manager, Joe Gould, offers him a chance to fill in for
just this one night and make a little money
The film spends nearly two and half hours establishing Braddock's credentials as a true
American hero, a man with unyielding integrity, humility and courage who is devoted to
his wife and family. What it fails to address is any hint of the weakness or failing that,
unless he's a divine spirit or fictional character, he surely possessed. Even in the midst of
his darkest times, he is a model of virtue. This image appears at odds with the primitive
and brutish nature of a boxer nicknamed 'The Bulldog of Bergen'. 

Cinderella Man focuses on the period from 1928 to 1935, beginning with Braddock as a
successful fighter living in a nice house and blissfully married to Mae (Renee
Zellweger). After breaking his hand, his fortunes, like those of his country, spiral
downhill rapidly. The next we see of him, it's 1933 and he's living in a slum with Mae
and their three young kids. He's reduced to casual work at the docks and the occasional
fight until finally his boxing license is revoked following a pitiful performance. When
their electricity is cut off, Mae turns to God but Braddock has lost faith. "I'm all prayed
out," he admits before swallowing his pride and turning to welfare for subsistence. 

The good thing about hitting rock bottom is there's only one place to go. For Braddock
the ascent begins when his longtime manager Joe Gould (the always excellent Paul
Giamatti) gets him a fight against an upcoming prospect, Corn Griffin, for whom the
ageing Braddock is supposed to be but a stepping-stone to success. But Braddock, who
has never been stopped, hasn't read the script and duly defeats Griffin, thus launching a
comeback that leads him on a path to a title shot against the overwhelming favourite, the
lethal Max Baer (Craig Bierko). 

Bathed in the warm, muted tones of the thirties, Cinderella Man possesses a lush, rich
look, one that is in stark contrast with the times it's depicting. The bloody, punishing
realism of the fight sequences are effective in conveying Braddock's grim determination
and certainly didn't the flashbacks to echo the point. The ring is the one place where is
able to truly vent his frustration with a world that has been so cruel to him and, more
importantly, his family. 

There are few actors who immerse themselves so completely in their roles as Crowe. He
is the raw, visceral embodiment of Braddock. His authenticity only serves to illuminate
Zellweger's faux emotions which, when uttering lines like "You are the champion of my
heart" are plastered all over her squinty face. 

Cinderella Man is precisely the kind of slick, well made film whose overwrought
integrity and luminous pedigree will have its name uttered during Oscar conversations,
but while Crowe is worthy of such plaudits, the film itself lacks sufficient punch to truly
make it a contender. 
 2. It was Inception.

Which is to say that the time — nearly two and a half hours — passes quickly and for the most part
pleasantly, and that you see some things that are pretty amazing, and amazingly pretty: cities that
fold in on themselves like pulsing, three-dimensional maps; chases and fights that defy the laws that
usually govern space, time and motion

ities that fold in on themselves like pulsing, three-dimensional maps; chases and fights that defy the
laws that usually govern space, time and motion

What's new here is how writer-director Christopher Nolan repackages all this with a science-fiction concept that
allows his characters to chase and shoot across multiple levels of reality. 

In "Inception," Nolan imagines a new kind of corporate espionage wherein a thief enters a person's brain during the
dream state to steal ideas. This is done by an entire team of "extractors" who design the architecture of the dreams,
forge identities within the dream and even pharmacologically help several people to share these dreams.

This is especially true when the hectic action in one dream, a van rolling down a hill with its dreamers aboard, causes
a hotel corridor to roll in another, producing a weightless state in the characters. Even Fred Astaire didn't dance on
the ceiling as much as these guys do.

What strategies do you suggest to prevent obesity?

Obesity has reached epidemic proportions globally, with more than 1 billion adults overweight - at least
300 million of them clinically obese. To prevent this, we need long term plans for effective weight
management like encouraging healthy fiber rich diet, regular physical activities, and a faithful
compliance to medical advice for obesity related conditions.

According to a recent data published by CDC P, 17% of children between ages 2 to 19 were suffering
from severe overweight. A cohesive effort from every member of the family to improve diet and
exercise is key to prevent childhood obesity. At the meantime, rewarding children for cutting down the
length of watching television and encouraging sports activities would help to a great deal.
Where do you see yourself in ten years from now? As an academician or as a
community physician?

I see myself working as a primary care physician (PCP) in rural setting, may be in
mountains somewhere in US and hopefully also get done with MPH degree.

 In ten years time, after a few years of working as PCP, I will get enrolled in
Hematology fellowship. I see myself working as an attending in very academic
program, also doing some social works in my country and enjoying a lot working
with my colleagues. But my orientation might change with the experiences I
gain during my residency.

How do you see the delivery of health care evolving/redesigning into the 21st
century?

Numerous changes are inevitable, not only on how it is practice, but also the way it
is paid for. Newer discoveries, newer drugs, and radical changes in treatment
protocol as a result of EBM are inevitable.

 Immunopharmacology including monoclonal antibodies are the hot topics of the

new era of medicine. 

Gene Therapy might be the next hot topic as a solution for many diseases.

In US, healthcare will become more affordable with the health reform that is

being pushed with so much energy. We might see major changes in the role players
in the commercial healthcare market, with more autonomy to individuals as to
which healthcare plan to endorse. I hope the no of uninsured population will go
down, and everybody realizes that health is a basic human right. But this will put
a lot of strain on the existing hospitals and physicians in the country.

We will probably see more focus on preventive medicine. (IGAP)

There are many reasons which compel us to redesign health care system.

Continued rise in hospital costs can be solved by bringing a functional socialistic

health care system. If health insurance coverage was made compulsory, private
health insurance was dissolved and the government covered everyone through
taxes, this would bring down premium rates and make health care cheaper. We
could put a check on exploitation of concept of defensive medicine by ordering and
subjecting patients to unnecessary investigations and medications.
There might be primary care shortages. Health professionals like nurse
practitioners and physician assistants can help bridge the gap between the supply
and demand for primary care by improving access to those who need it.

Patient dissatisfaction- by decreasing enormous redundancies in care delivery

processes and enhancing the range and quality of services offered.

How do you think socialized healthcare will affect medical progress?

It will definitely ensure basic health service to all regardless of their ability to

pay, but I think it will slow down medical progress, because it removes the profit
incentive for people to come up with better technology. I think if we can strike a
balance between the capitalist and the socialist approach to health care that might
be good.

How would you change the health care delivery system of the country?

Well it’s a huge subject, and I am not qualified enough to actually try and change
it. But according to my limited opinion, universal healthcare covering basic
services to all people regardless of their ability to pay should be implemented,
something like the NHS of UK.

There should be an attempt to decrease the rising healthcare cost, which is

almost 3-4 times more than in other countries. For that we should cut down
on unnecessary investigations, which in turn can only be brought about if we can
decrease the physician’s risk of litigation. Defensive medicine that we practice in
the US is quite costly. We should be more focused on providing efficient and
affordable healthcare to all, rather than trying to defend our self with unnecessary
investigations.

Medicines are also very costly due to patent rights and monopoly on market.
This should be taken care of, and government should place a limit to the price hike
in the pharmaceutical industry. Continued rise in hospital costs can be solved by
bringing a functional socialistic health care system. If health insurance coverage
was made compulsory, private health insurance was dissolved and the government
covered everyone through taxes, this would bring down premium rates and make
health care cheaper. We could put a check on exploitation of concept of defensive
medicine by ordering and subjecting patients to unnecessary investigations and
medications.
There might be primary care shortages. Health professionals like nurse
practitioners and physician assistants can help bridge the gap between the supply
and demand for primary care by improving access to those who need it.

Patient dissatisfaction- by decreasing enormous redundancies in care delivery

processes and enhancing the range and quality of services offered.

What is the biggest challenge facing health care delivery?

The steeply increasing cost is the biggest challenge facing the health care delivery
system. Health care has become more and more profit oriented.

Physicians are practicing more and more defensive medicine, sending unnecessary

investigations. This has made health care in the US 4 times as costly as in other
developed nations of the world.

Plus the gargantuan overhead/administrative cost related to the hundreds of

insurance companies and HMOs is causing less money to actually go into the
health care of the people. US spends almost 15% of its GDP on health care,
highest among all developed nation, and 30% of that goes to overhead cost. Due to
this, the health outcome of the population is far worse compared to other countries,
with IMR comparable to Middle Eastern and African countries.

Pharmaceutical companies are gaining a huge and ugly profit by selling

medicines invented 50 years ago, on the name of patent rights.

To control this, government should set a limit on the profit margin that

pharmaceutical and insurance companies can achieve.

Single payer health system, like the universal health care talked of so often by
President Obama, and like NHS of the Great Britain, might decrease the overhead
costs associated with management.

Tort reform to curb litigation on physicians would also decrease the unnecessary
investigations that doctors do to defend themselves against any lawsuit.

What does a cross cultural approach to healing mean?

Giving importance to cultural feelings and rituals, and combining traditional

medicine like acupuncture and naturopathy with our modern medicine has
shown to be beneficial than just practicing allopathy as we normally do.
How will you as a physician try to curb the rising cost of health care?

Send fewer investigations; use my clinical judgment instead.

Try to cut down the days and patient stay in the hospital; many patients stay in
hospital for investigations that can be done on an outpatient basis. This costs
thousands of dollars each day. I will try to make sure that patients stay in the
hospital only for the minimum days required.

Also I will focus more on preventive medicine, like patient education,

vaccination, early diagnosis and treatment of chronic diseases like cancer, heart
diseases, HTN and DM. If pts comes with complications, it takes far more
resources to take care for them.

What recent newsworthy medical event would you like to discuss?

Obama’s speech on health care reform one month ago- his main points were

Making a public insurance option for those who cannot afford private
insurance.

Prohibiting insurance companies to deny insurance on the basis of preexisting

medical condition.

Making every individual buy some kind of health insurance and excising a tax
if they don’t.

What problems will our specialty face in the next 10 years?

With government pushing universal health care, and Medicare already going
into bankruptcy, with the elderly population growing day by day, especially due
to the baby boom generation, I think we will face a major lack of fund in treating
elderly population in the days to come. It will be tough for hospitals to get
reimbursement for their services from the Medicare, so that they might have
to drop physicians, or the services they provide, and this might also hamper the
amount of innovations and research that is going on in geriatric medicine.

What do you think is the number one issue facing our specialty now?

a) Rising health cost b) Medicare going into bankruptcy c) Rising geriatric

population.
If a patient just stabbed your best friend, what would you do?

I would restrain the patient, get medical attention for the friend, and continue to
care for the patient. I will try to understand his concerns, his reasons for doing so,
and try to work an agreement with him.

What would you do if the house staff has a job action, also known as a strike?

Depends on if the issue directly concerns me or not- if it does, then I would have to
show solidarity/unity by joining the job action; if it doesn’t then I wouldn’t waste
my time, I will just go on working.

What do you think about using animals in medical research and teaching?

Well, on one hand animals are also living beings, and using them for research
sounds cruel. On the other hand, many scientific discoveries have been made by
researching on them, which have greatly helped the mankind. So it’s the question
of mankind versus the animals. Both have the same capacity to feel pain, so I have
no easy answer to this.

Should physicians be involved in active euthanasia?

Types of euthanasia

a) Active

b) Passive that is withholding treatment,

c) Assisted suicide

d) Voluntary Refusal of food and fluids.

There is no easy answer to this either. Since the decision of one’s health care
rests with oneself. If a person with MND and persistent vegetative state, or
locked in syndrome with no hope to recover any function decides to die, maybe we
should respect the decision. But on the other hand, assisting in suicide does sound
very unethical. I guess the best way out is to define some criteria to fulfill before
the patient is approved for euthanasia, so that it is not indiscriminately overused.
Some forms of euthanasia, like assisted suicide (but not active euthanasia) are
legal in Oregon and Washington, and European countries like Luxemburg,
Belgium, Netherland, Switzerland and also Thailand. Passive euthanasia that is
withholding treatment for patients who have little hope of recovery, is already
practiced everywhere. Voluntary refusal of food and fluids (VRFF) or Patient
Refusal of Nutrition and Hydration (PRNH) is practiced in states prohibiting active
euthanasia.

Is health care rationing ethical?

Well rationing occurs in a number of ways. Health care rationing according to

necessity, with sicker people getting better treatment, what we call triage, and less
sick people getting less intense treatment, is plausible. While on the other hand if
health care rationing occurs according to the patient’s ability to pay, or race, then
it is definitely unethical. For example, studies have shown that physicians
preferentially treat white population better than black, with more
investigations, and more use of drugs. This is unethical. Having said that,
certain procedures for cosmetic purpose, or treatments in trial which have not
yet been proved effective, and are very expensive, might well be rationed for
those who can pay, so as not to overburden the system

What would u do if a colleague wanted to keep a therapeutic error secret from the
patient?

First I would talk to the colleague about the ethics of doing that. I would advise
him to talk to the patient and apologize. If he doesn’t, then I would have to talk to
his senior and finally to the head of the staff about it. I would give an opportunity
to him to correct his mistake before I talk to other people though.

What do you think of hospitals that refuse admission to patients without insurance?

This is a very difficult question to answer. The EMTALA act requires hospital to

provide emergency treatment including active labor management to all people,
regardless of their insurance coverage. But after emergency management is done,
many hospitals try to dump those patients to other safety net hospitals. Though
this sounds unethical, the hospitals are compelled to do that because the health
care costs incurred that way will not be reimbursed by either the insurance
companies or the government; while many safety net hospitals are subsidized by
the government. But these hospitals, like the Cook County hospital of Chicago,
are so overburdened due to uninsured patient population, that it has a
significant effect on their quality of care. So I think the government should either
find a way to insure those people who cannot afford insurance, for example
by publicly mandated health insurance system, or provide more funding for
safety net hospitals all over the country. Many states don’t have such hospitals, so
the patient might have to wait a long time or travel to get treatment, which is not
ethical at all. So government should open more public hospitals. This way both
private and public health system can survive side by side in a healthy
environment.

Tell me a case that reflects compassion.

There was a 40 year female patient who has presented with a chief complaint of
chronic pain in her neck and back. She was seen by many physicians including
orthopedic surgeon and finally she was diagnosed with cervical rib. She was
advised to go for surgery but because she could not afford this, she was just using
medications worsening her condition and dragging herself to depression. I was
touched emotionally and tried to help her. I talked with some representatives from
Drug Company, social welfare organization and finally assisted her for surgery and
she is always grateful to me for the help. The virtue of compassion has always
given me rewarding satisfaction in my practice of medicine. I believe that
compassion is the most important thing for the doctor patient relationship. It is
difficult to be great without being compassionate in the artful practice of medicine.

OR

This was a case that I encountered while working as an intern in ER. As always,
there a rush. Suddenly a 32 yo woman came with severe pain in her belly and
bleeding per vagina. With further inquiry,it was found that she had missed her
lmp. Her pregancy was confirmed by upt. routine investigation n usg was done n
the case was disgnosed as Ectopic pregnancy. but to her dismsay, as all these
investigations were done, she had no money left with her for emergency surgery.
She was cry with agony, she was crying for life.... I was touched emotionally and
tried to help her. I finally convinced a social welfare org's representative to help
her.I personally talked to attending gynecologist and to my relef I was able to
collect blood, after requesting my.social welfare organization and finally assisted
her for surgery and she is always grateful to me for the help, moreover my
compassion for my patient was able to save her life . The virtue of compassion has
always given me rewarding satisfaction in my medical prctice. I believe
compassion is the most important thing for the doctor patient relationship. It is
difficult to be great without being compassionate in the artful practice of medicine
OR

This was a case I remember as this helped me realize that a physician should be as
compassionate as he is competent. This was a case that I encountered while
working as an intern in the Emergency Department. The ER in our part of the
world is always stressful. And there was this 34 year old lady who presented with
severe pain in her belly and bleeding per vagina for the last 10 hours. She had
missed her periods, as well. So, her pregnancy was confirmed by an UPT. The
routine tests were sent and he USG showed it to be an ectopic pregnancy. When I
went to inform that she needs an emergency surgery, she told me that she had no
money. She was accompanied by her 10 year old daughter. She was in tears due to
the pain and she couldn’t make for surgery in that state of no-money.

Her state made me feel very sad and I wished that I could do something to save her
life. I personally talked to my attending Gynecologist and we were able to arrange
a free bed. I personally talked to a social organization and pleaded them to support
her. I was able to arrange blood with the help of my friends. And, finally we were
able to take her to the Operation Room. I was glad that she recovered well
postoperatively. She was very grateful to the whole health care team. I believe that
the virtue of compassion is the most important thing in doctor-patient relationship.
And, it has always motivated me to become more competent and compassionate, in
my practice.

Why is medicine called an art, or a practice?

Medicine is a science, but there is more to it than that. Unlike other sciences,

where the subject under study always behaves the same under similar
circumstances, humans don’t. Patients with same disease can have such different
presentation and natural course of illness that nothing can be predicted in
medicine. A single presentation can be a result of many diseases, and vice
versa. So the clinical judgment of a physician is very important. No matter how
sound our knowledge is, humans can not be tested in a lab, or be expected to
operate along certain principles. That’s why it needs a human to fix a human,
and that’s why medicine is an art rather than science. Physicians practice this art,
that’s why it’s a practice.

What clinical experience have you had in this specialty?

I have worked for 4 months in medicine during my third year of medical schooling,
one month during my sub internship, and 3 months again during my internship,
which was the final year at my medical school. I worked in different remote
settings for almost one year as a medical officer where I encountered all types of
patients further enhancing my clinical skills.

What do you think of physician advertising?

On one hand, advertising increases the patient’s awareness about the treatment

options available, while on the other, physician advertising is a conflict of interest
on the part of physician. He is trying to do the best for the patient, but is also
enticing patients to come to him, when that might not be the best option.

Why are beer cans tapered at the top and the bottom?

This is to save aluminum and to help stack, as the flip flop won’t work without
thick cover.

Why are manhole covers round and not square?

Easier to dig, doesn’t fall down, can be rolled.

How do you weigh a jet plane without dismembering it?

Archimedes principle- Put the plane in a barge, then draw the line of the water
level. Then take it out and put other things with known weight till the same line is
reached.

Tell me a joke.

Doctors at a hospital in Brooklyn, New York have gone on strike. Hospital

officials say they will find out what the Doctors' demands are as soon as they can
get a pharmacist over there to read the picket signs

A man goes to the doctor and says to the doctor: 

"It hurts when I press here" (pressing his side) 
"And when I press here" (pressing the other side) 
"And here" (his leg) 
"And here, here and here" (his other leg, and both arms)

Doctor says- well you have a broken finger. 

How well do you see yourself adapting to the American Health System?

I like orderly workplace in the US hospitals, the nice electronic record keeping

system which gives access to every information about the patient at the click of the
mouse, the capping system on the number of patients any particular house staff
has to handle, the ACGME rules/ RRC (Residency Review Committee) on the
hours on duty that are usually followed around the US, so that the staffs aren’t
overburdened. I like the sharply defined roles between different specialties and
ancillary staff, so that I don’t have to run around doing everything for the patient
like I had to back home, from drawing blood to transporting patients or doing bone
marrow aspiration. Of course I can handle a little bit of everything, but in our part
of the world, it was so overwhelming that it resulted in too much chaos, and caused
poor patient care. Considering these facts, I think I will actually enjoy working
in US healthcare system. One thing I have to adapt to, however, is not making the
decision for the patient, and giving him complete autonomy over his body.

What do you consider the positive and negative aspects of this specialty?

The positive point, especially of primary care, is that we can manage the patient
as a whole, with help from other specialties. We are in charge of everything that is
going on in our patient, and we have to coordinate with different specialties. This
is a very appealing prospect of medicine. Plus if we ever decide to specialize, there
are a vast majority of subjects we can choose from, from interventional
cardiology to interventional nephrology. We get to sit down and think and not
rush around all the time like in Emergency medicine or surgery, which is why this
specialty interests me so much.

The negative aspect is probably the multiple subspecialties that this specialty is

divided into. It makes us into mechanistic beings who are taking care of one aspect
of the patient or the other, without any regard for the total well being of the patient.
But I guess that is what the primary care physicians are there for.

We have a busy and stressful life, with limited time for personal and family
life, but I guess if we can manage our time well, we can have a pretty decent
personal life.

What are your expectations regarding this program?

i. friendly working environment

ii. good learning opportunity with supervised autonomy
and direct patient care
 iii. enough didactic activities
iv. good contact and helpful relationship with the
attending staff,
v. helpful ancillary staffs
vi. enough time for rest and personal study.

What is your stand on abortion and cloning?

Well on one hand a woman should have complete authority over her body and
what to do with it, and should be able to discontinue her pregnancy if she so
wishes. On the other hand terminating a perfectly viable and normal pregnancy
sounds unethical. There’s no easy answer and abortion due to personal choice is
quite controversial. All unanimously agree that if the baby is deformed or if the
abortion is for medical reasons there is no problem. Still I think the mother
should be given complete authority to make the decision about her fetus.

Cloning has a very huge potential for treating different diseases and research. The
ethics associated with manipulating cells, and wasting different cells in the process
is controversial, but I guess many cells are getting wasted even in the nature, for
example during the fertilization process, as the majority of embryos self abort, and
only a few survive. So I think cloning holds more promises for future for any
ethics consideration to stop it.

There are different kinds of cloning. Horticultural cloning in agriculture and

therapeutic cloning in stem cell research by way of somatic cell nucleus transfer
(SCNT) are well accepted, and shouldn’t be opposed by anybody, as stem cell
research holds great promise in treating diseases as far and wide as DM to MS to
phenylketonuria. Reproductive cloning, on the other hand, is again successfully
done for sheep to camel to Labradors and particular breeds of horse, and I don’t
see any reason to object on that. Cloning extinct and endangered species might be
a good idea too. But cloning human beings is probably too dangerous, as it
raises a question on the genetic identity of the individual itself.

How do you see the health care delivery system of the country evolving?

With the universal health care pushed by President Obama, I think we will see
radical changes in the way we provide health care, and the way it is funded. There
is a huge impetus for making a public health insurance mandate, which will
increase the insurance coverage to all citizens. That way the workload of the
hospitals is going to increase, and we might have to shift our focus towards
greater good for greater no of people. We might have to prioritize our resources,
and use them efficiently. Defensive medicine might have taken a downturn and
we might be able to practice more efficient healthcare without worrying about
litigations. Next big issue is how to curb the rising health care cost. Again if
physicians don’t have to worry about litigations, and if government puts a limit on
the profit margin that any pharmaceutical company or insurance company can
accrue, I think that will at least halt the growing healthcare cost.

What if you don’t match?

I won’t give up. I will still try for same specialty next year. I will do some
volunteering, externship and research in the meantime. Medicine is the
dream of my life, and I wouldn’t leave that for anything.

Anything else you would like to add?

Well, I would just like to take this opportunity to say that I will do the best I can to
meet your expectations during my residency. With my hard work and dedication, I
will do my best to contribute to the program.

If you were offered a position today, would you accept?

Considering the good reputation of your program and the opportunity for direct
patient care and for fellowship, I would definitely accept the pre match.

What would you do after your residency? Will you go back to your country?

I plan to get into a cardiology fellowship after I finish my residency. I intend to do

some work to improve the healthcare system of my country, but I think I will
keep on practicing in the States also. I will probably join a hospital which
provides direct inpatient patient care and also academic activities since I like
teaching learning process very much.

HEALTH CARE DELIVERY SYSTEM IN THE STATES:

Highlights
 The most money spent on biotechnologies, with 80 % spent by private
sector in R&D
 NIH funds basic research only
 Highest health care spending per GDP, yet highest infant mortality
 30% goes to hospital, 20% to physicans, 23% to diagnostics, 10% to
pharmaceuticals.
 In 2007, the U.S. spent $2.26 trillion on health care, or $7,439 per person
 The highest-spending 5% of the population accounted for more than half of
all spending
 Acute hospital care accounts for over half (55%) of the spending
for Medicare beneficiaries in the last two years of life, though it was
found that this doesn’t improve life expectancy.
 Prevention does not produce significant long-term costs
savings. Preventive care is typically provided to many people who would
never become ill, and for those who would have become ill is partially
offset by the health care costs during additional years of life.
 Without health insurance coverage at some time during 2007 totaled
about 15.3% of the population, or 45.7 million
 Almost 82% have insurance, 56% provided by employer, and 8% bought
individually, rest by government institutions.
 Dental and vision care are bought separately and not covered
 COBRA (consolidated omnibus budget reconciliation act) and HIPAA, Health
Insurance Portability and Accountability Act (HIPAA) regulate insurance
companies; allows employees to have health care even after they leave
the employment. Same for Health insurance portability and accountability
act.
 Providers (hospitals and doctors) can refuse to accept a given type of
insurance, including Medicare and Medicaid. Low reimbursement rates
have generated complaints from providers, and many hospitals have
stopped taking Medicare patients.
 MA,NJ and SF have charity care to those who cannot afford.
 EMTALA: Emergency medical treatment and active labor act: cannot refuse
emergency treatment, but ER treatment is costly than urgent clinic care
 Most employee health is covered today by managed care organization, like
HMO or PPO; also known as Health Maintenance Organization and
Preferred Provider Organization respectively, which negotiate with care
providers and pay low prices than out of pocket prices. There
 is copayment or deductible involved. Capitation is the amount paid to
provider every time the patient uses his care, no matter how much. This is
the incentive system to persuade the provider to give less care. Primary
care provider acts as a gatekeeper to decide if specialist is required.
Likewise, any costly procedures usually need a second opinion before
being approved. Patients going out of the network are charged extremely
high.
 PPOs have edged out HMOs. It is common today for a physician or hospital
to have contracts with a dozen or more health plans, each with different
referral networks, contracts with different diagnostic facilities, and
different practice guidelines.
 The first HMOs in the U.S., such as Kaiser Permanente in Oakland,
California, and the Health Insurance Plan (HIP) in New York, were "staff-
model" HMOs, which owned their own health care facilities and employed
the doctors. They focus more on preventive aspect.
 Government run community clinics and certain county hospitals provide
free care. Child health insurance program for those who earn too much
to qualify for Medicaid, but too less to buy insurance themselves.
 There is no taxation on employee health service, which distorts the whole
system, because people who buy their own care have to do so after tax cut
from their income
 Medicare enrollment is increasing due to baby boomers
 Health savings account is also tax exempt, but it benefits rich more than
the poor
 15% of 300 million populations are without care of any kind. Some say
30%. They usurp 30 billion of uncompensated care
 Massachusetts has adopted a universal health care system through
the Massachusetts 2006 Health Reform Statute, Health Safety Net Fund
for those who cannot afford insurance
 In July 2009, Connecticut passed into law a plan called SustiNet, with the
goal of achieving health-care coverage of 98% of its residents by 2014
 Federal Medicare and Medicaid rules forbid private healthcare providers
from setting their own rates for these programs. physicians are not
allowed to "opt-out" if they provide services at any healthcare facility that
accepts these programs
 McCarran Ferguson act allows states to control insurance policies without
interference from federal government.
 survival rates in the U.S. for a broad range of cancer types are the
highest in the world,
 the proportion of low birth weight babies may be affected by factors other
than health care like Teen motherhood
 mortality gap between the well-educated and the poorly educated
widened significantly between 1993 and 2001 for adults
 1% increase in the unemployment rate would increase Medicaid and SCHIP
enrollment by 1 million, and increase the number uninsured by 1.1 million
 Many primary care physicians no longer see their patients while they are in
the hospital. Instead, hospitalists are used. This fragments care.
 There are hundreds, if not thousands, of insurance companies in the U.S.
This system has considerable administrative overhead, far greater than in
nationalized, single-payer systems, such as Canada's
 numerous causes of increased utilization, including rising consumer
demand, new treatments, more intensive diagnostic testing, lifestyle
factors, the movement to broader-access plans, and higher-priced
technologies
 cost shifting- due to low embursement  by medicare, hospitals charge
higher to private insurance companies, thus increasing the overall cost.
 37% reported that they had foregone needed medical care in the previous
year because of cost
 A lack of mental health coverage for Americans bears significant
ramifications; The Paul Wellstone Mental Health and Addiction Equity
Act of 2008 mandates that group health plans provide mental health and
substance-related disorder benefits
 An estimated 5 million of those without health insurance are
considered "uninsurable" because of pre-existing conditions; people
seeking to purchase health insurance directly must undergo medical
underwriting. Insurance companies seeking to mitigate the problem
of adverse selection;
 minority groups have higher incidence of chronic diseases, higher mortality,
cancer incidence rate among African Americans, which is 25% higher than
among whites, DM, HIV, IMR, and cardiovascular disease
 black Americans received less health care than white Americans —
particularly when the care involved expensive new technology.
 EMTALA is the key element in the safety net for the uninsured, but the cost
is never fully reimbursed by the federal or state government to the
 hospitals. EMTALA is an unfunded mandate that has contributed to
financial pressures on hospitals in the last 20 years, causing them to
consolidate and close facilities. Emergency room visits in the U.S. grew by
26 percent, while in the same period, the number of emergency
departments declined by 425. Some hospitals make pt pay by fee per
service system, but many cannot pay, and go into bankruptcy when
hospital sues them.
 The majority of the cost differential arises from medical malpractice, U.S.
Food and Drug Administration (FDA) regulations
 An FDA ruling went into effect extending protection from lawsuits to
pharmaceutical manufacturers, even if it was found that they submitted
fraudulent clinical trial data to the FDA
 Many other countries use their bulk-purchasing power to aggressively
negotiate drug prices, governments of such countries are free riding on
the backs of U.S. consumers. US consumers are thus effectively
subsidizing cost for other nation’s consumers, so the lobbyists of the
pharmaceutical companies say.
 Bush passed an act to prohibit drug price negotiation for Medicare, thus
giving power to companies to profit off the Medicare.
 Democrats prefer universal health care, while Republicans don’t.
 The lack of health insurance among the self-employed does not affect their
health, a study has shown
 Advocates for single-payer health care often point to other countries,
where national government-funded systems produce better health
outcomes at lower cost. Opponents deride this type of system as
"socialized medicine"
 In 1973, the federal government passed the Health Maintenance
Organization Act, which heavily subsidized the HMO business model. The
law was intended to create market incentives that would lower health
care costs, but HMOs have never achieved their cost-reduction potential.
 Around 7500 per head per annum is spent on health care.
 High drug cost in the states is due to lack of government price control, and
implementation of intellectual property right.
 Health care cost of Medicare are rising steeply.
 Uninsured are unfairly billed for services at rates far higher—305% in
some areas of California—than are the insured; USA Today concluded that
"millions of [uninsured patients] are forced to subsidize insured patients
 44,800 excess deaths annually in the United States due to Americans
lacking health insurance; and almost 100,000 due to lack of medical care
 Clinton signed Medicare Prescription Drug, Improvement, and
Modernization Act which included a prescription drug plan
for elderly and disabled Americans. Before that, medicare didn’t cover
prescription drugs.
 Barack Obama called for universal health care. His health care plan called
for the creation of a National Health Insurance Exchange that would
include both private insurance plans and a Medicare-like government run
option. Coverage would be guaranteed regardless of health status,
and premiums would not vary based on health status either. It would
have required parents to cover their children, but did not require adults to
buy insurance.
 HIPAA includes electronic data interchange schemes like EDI Health Care
Claim Transaction set, EDI Retail Pharmacy Claim Transaction (NCPDP
national council for prescription drug programs)
 Health Information Technology for Economic and Clinical Health Act
(HITECH Act),
 HIPAA has affected research adversely.
 Proponents of health care reform argue that moving to a single-payer
system would reallocate the money currently spent on the administrative
overhead required to run insurance companies in the U.S. to provide
universal care
 Malpractice liability has resulted in defensive medicine. Tort reform act are
suggested as a way out.
 Massachusetts' law forcing everyone to buy insurance caused costs there
to increase faster than in the rest of the country
 Eliminating the profit motive will decrease the rate of medical innovation
and inhibit new technologies from being developed.
 Healthcare rationing- acc to age by medicare, acc to economic status by
Medicaid, acc to employee status by EHS, acc to preexisting illness. And
acc to how much you can pay. Other countries, by contrast, ration
healthcare acc to need. In America, this rationing means there is no triage
by need. Physician gatekeepers are also key in rationing.
I had the pleasure to read on your website that your program has highly

1. w is the faculty resident relationships

2. Are there non clinical responsibilities like research, projects, writing and
administration ??
3. Is this program particularly well known in any special areas ??
4. What are the types of clinical sites used? VA, public, private,,
5. What kind of patient population will I encounter ?
6. Are there elective opportunities- I was wanting to know if there were any elective
opportunities?
7. Are there research opportunities ? what research projects are the department’s faculty
and residents working on currently? Are there facilities, funding, time and support staff
and statisticians for the job? Can we take time off? Can we take time for speciality’s
national meetings ?
8. Are administrative, bioethics and legal training available ?
9. Is there any mentor/advisor system ?
10. What types of resident evaluations system are used. How often.
11. There is no problem with the program’s accreditation, is there?
12. Have any housestaff left the program without graduating, or have transferred to
another hospital? Why?
13. Where are your graduates currently working? Fellowships? Academic centers, private
practice, group practice, research or in administration ?

ASK THE RESIDENTS

1. WOULD YOU CHOOSE THIS PROGRAM AGAIN? WHY

2. What contact will I have with the faculty?
3. What has changed since you came to the program? An y change in the curriculum,
rotations, electives, major faculty changes, patient mix, or resident responsibilities,
4. Any system to evaluate faculty, and any changes recently made thereof
 5. How much teaching learning/ didactic activities occur? Is the current month’s schedule
available
6. What types of clinical experiences will I have. What kind of patient’s population will I
encounter?
7. What is the relationship of this program with other specialities
8. Tell me about the on call rooms, meal plan, café, library, parking, computer and
database access.
9. Will I have time to read
10. Are the support staff available as per need and are they helpful? Is there a lot of scut
work to be done by the residents?
11. What is the call schedule like. Can I see this month’s schedule? Who makes the
schedule? The chief resident or the faculty or the residents themselves? How hectic is
it?
12. Do you have a plan for sick days?
13. Are there any medical students on the service.
14. Do the residents socialize as a group?

Ask about PD’s latest research article.

With the release of the World Alzheimer's Report 2010, Alzheimer's Disease

International (ADI),  is trying to raise awareness about the global financial burden
caused by dementia. The United States ranks highest when comes to the cost of
caring for a person with dementia, which comes to more than $48,000 according to
the report. What is your view regarding the raising awareness to the Alzheimer’s
population and how can this be done?