Day 16: Separation Sunday

August 17, 2014

Our third Medtronic engineer, Adam, joined us early on Sunday in Hyderabad. The morning was filled with breakfast, conversation, and bringing Adam up to speed. After official planning in the morning, the team split up to have a relaxing Sunday. Shruthi and Dhananjay visited family while Erin, Maddie, Kesevan, and Adam left to visit a famous museum.

Shruthi visited her aunt and uncle in Hyderabad and Jay went home to Indore where he also met with Atul Sethi, the Managing Director of Shree Pacetronix Pvt Ltd. Mr. Sethi shared some great insights about the Indian healthcare system and the medtech industry in general, apart from the pacemakers space. Shree Pacetronix is one among a handful of medtech companies in India that are doing well. Mr. Sethi’s father is a cardiologist in the US and they, together 20 years ago, decided to enter this industry and make pacemakers available to the middle class Indian at an affordable cost and yet good quality.

Erin, Maddie, Kesavan and Adam spent their day looking at artwork in the Salarjung museum and doing some shopping. Kesavan, in particular, was very interested in Raja Ravi Verma’s paintings since he himself was an artist. You can check out Kesavan’s work here: http://www.kesavanpotti.com/

  

Sign for the Salarjung Museum

Outside of the Salarjung Museum

Excited to get some Indian clothes, the girls steered the group to MG Road to buy authentic Indian clothes but unfortunately, most of the shops were closed because of the festival of ‘Janmasthmi’ (Lord Krishna’s birthday). Overall, Sunday was relaxing and helped the team recover from the hectic week.

Pretty fabrics found when shopping!

Reflections on the Indian Medical Education System

16th August 2014

"Today I made a new friend that I hope to keep for a long time coming. For now, I'll call her Priya. Priya is an intern at Osmania General Hospital, a government hospital in the heart of Hyderabad, and she is in the process of completing her fifth and final year of her MBBS degree (Bachelor of Medicine, Bachelor of Surgery). A very intelligent young woman, her angst and emotion towards the Indian healthcare system are such that she no longer wants to work here, nor does she feel prepared to start practicing as a GP if she doesn't pursue her MD next year. [To provide some context, an MBBS degree in India is the first level of training required to become a licensed general physician, and the MD program provides the next level of specialization in Internal Medicine].

Priya dreams of doing her MD residency in a place like the US. She has a passion for oncology - pancreatic cancer in particular - but over coffee today she explained that the chances available for distinction students like her to make it to specialist level are slim when they have to compete against a large population, with limited infrastructure, and politics disrupting the system. She attributes this solely to the way medical education programs are structured in India, and this was with her background of studying at a private facility. For me this conversation exemplified why education and healthcare now go hand-in-hand as two of India's highest focus areas for development. It spoke to me about the underlying systemic changes that need to be achieved in order to increase awareness about bradycardia and its symptoms, amongst patients and the general physician population. This is especially true in areas where there may be limited contact with practitioners, or in facilities where there may not be the infrastructure to allow for accurate differential diagnosis.

For GPs, training and education can become limiting factors for two reasons. Firstly, the immense competition faced by thousands of students for admission into MD programs after completing their MBBS degree means that many GPs are practicing straight after their MBBS final year internship, with a breadth of knowledge but not much depth into the area of cardiology. Priya explained that her only experience in cardiology throughout her MBBS degree was in her fourth year, where her class studied one chapter of a textbook on cardiac conditions. She is highly motivated, so a lot of her extra knowledge about bradycardia diagnosis and treatment methods came from self-learning, but for those who may not be as inquisitive as her, the same knowledge may not be reached, or could be misinterpreted. She learned how to read an ECG under senior guidance during her internship, but this wasn't taught to her; she had to seek this knowledge by driving her own interests.

Secondly, there are few programs in place to maintain up-to-date dissemination of medical knowledge at the MBBS level, at least in the parts of Hyderabad that we spoke about (there are various programs around the country that are available in some areas but not others). This means outdated practices are commonly used and diagnosis is often based on clinical symptoms, or it is assisted with suboptimal tools. This has been confirmed by a variety of healthcare professionals, and seems to be one of the contributing factors towards unwell but asymptomatic patients being missed or misdiagnosed. However, GP awareness is not the only reason for this; accessing adequate care also relies on the patient being aware of their health and choosing to seek treatment in the first place. A sense of complacency is often seen due to age, financial constraints or both, which means the importance of regular check-ups for screening is undermined.

After two hours of eye-opening and humbling conversation, I left the café feeling very grateful to have met Priya and heard her story. It is connections like this that I feel can make a difference, whether it be on a personal level or on a larger scale, and I look forward to being a part of that change."

- Maddie.

Patients and families at the entrance of the OGH Outpatient Center

 

Driving in India

After ten days in Hyderabad, India, I have started to gain a grasp on the culture and lifestyle of this city and country. While understanding the hospitals and care pathway for patients has been eye opening, the most shocking thing for me has been  learning and understanding driving in India.

Before I start on my insights into how people drive in India, I have to give a bit of a background to an incident that happened a few days before we left Baltimore...

Our group had been working on some research before the trip at our (Maddie, Erin, and Shruthi's) house. When we finished working, Dhananjay asked if I would drive him back to his place. For the last two months Jay had been trying to convince me to let him drive my car and for some reason on this day I decided I would let him drive my car the five blocks down the street to his apartment. After settling into the car Jay turned to me and said just tell me the rules. Being the naive American I am, I simply said, "stay on the right side of the road, follow the street signs, and follow the speed limit." Simple enough instructions and ones that I thought would get us from point A to point B without any issues. Unfortunately I was incorrect. Jay was also not privy to staying in one lane when driving, he sped up randomly and wanted to go around cars, and was generally not too aware of the speed limits, street lights, or street signs. Luckily it was a quick two minute drive and when we pulled up to his apartment, I told Jay that this may be the only time I let him do that.

Now fast forward three weeks, and I have quickly learned why Jay drove the way that he did. In India driving is a combination of chaos, skill, and luck. It is an experience that I don't think can be properly explained through words and one that has been extremely difficult to capture in pictures and videos (although I have tried).

An atempt to capture what driving and traffic is like here in India

The first thing you will realize when riding in a car in India is that everyone, and I mean EVERYONE, uses their horn all the time. As I sit in the hotel in the middle of the night, 8 floors up, and a good quarter mile away from the road, I can still hear the horns beeping away. Speaking with people who learned to drive in India we have come to understand that teaching people how to honk is part of leaning how to drive in India; which from my experiences definitely seems to make sense. Fortunately, Jay is not much of a casual honker so when driving in Baltimore, this was not an issue.

This was one of the most congested roads we have seen so far in India.

However the next thing I noticed riding in cars, and something that Jay did do in Baltimore, was disregard lanes. Here a two lane road becomes a four lane road and a 4 lane road somehow leads it's way to 16 rows of staggered cars, bikes, buses, motorcycles, fruit carts, and auto-rickshaws. At any given time a new lane of traffic can appear and people here will drive wherever they can to get by other people.

Another attempt at trying to capture traffic from inside the car

This leads me to the next point of Jay trying to drive around cars. In India, you drive looking out for yourself and hope that people move out of your way. What this means is that while in a car, it is not unusual for cars to speed up quickly and narrow in around you or for motorcycles to swerve in and out of tiny narrow gaps. When you think about 16 rows  of traffic on a 4 lane road there is not much room for anything else. Yet in India, somehow people seem to still get by and within those 16 rows of traffic you find people knocking on the window begging for money or trying to sell things to your car.

Cars closing in around the autorickshaw during our first ride.

Another interesting thing to note is that very few people here wear seatbelts and even less of the people on bikes and motorcycles wear helmets. I have not quite figured out how people are okay with this but, considering most cars have over 6 people in them, motorcylces have anywhere from 1 to 4 people on them, and autorickshaws can have up to 8 people in them, logistically, their really is no way for everyone to wear a seatbelt.

This is a typical auto-rickshaw packed with lots of people

All of the motorcycles without their helmets piled onto the bikes.

Aside from the sheer shock of actual driving, the way people get around is almost as mind boggling. Imagine being dropped in the center of New York, along with a few hundred thousand extra people that don't live there, and there are no street signs or general indicators of where you are. Now add into that the poverty of India, the winded and crisscrossed roads, and the fact that they drive on the left hand side of the road, and that is a bit of a better picture of what I feel like driving in India is. In our entire time here I have seen one green street sign hanging on a bridge over what appeared to be a major road. The sign itself appeared to be a good 30 years old and it was hidden behind a billboard that made it pretty difficult to see from the street. It seems that people here just know where to go. Thankfully we have a driver and some guidance from people who know where they are going because, even if I could have access to google maps (which apparently works pretty well here), I would have no idea what I was doing. Although I did not realize at the time, the fact that Jay was not sure what street we were on or the names of the streets he walked on everyday, makes sense. He has never really needed to know the names so it is just something that he has not paid attention to.

A deceptively calm picture of Dr. Yazdi crossing the street.

Another driving/ traffic related experience in India is crossing the street. In America we take for granted cross-walks and the fact that when we press a button a little light up man will show up to indicate that we can cross the street. In India, this is definitely not the case and in fact, it was not until our fifth day here that I even realized they had crosswalks. To cross the street in India you have to commit. As soon as you get in front of the line of traffic you have to be prepared for cars to keep going, horns to beep, and your life to be in danger. There is no second guessing your decision and definitely no place you can stop in the lane. This is another phenomenon I have tried to capture with pictures, but unfortunately I think a GoPro may be the only thing that could do it any justice.

Another attempt of capturing a video of the honking and busy streets

In a country with so many people and so much congestion, it is no wonder that this is the way driving and traffic is. And although I could probably go on for another three pages about the shock of driving here and how somehow when Jay drove the car here in Hyderabad I felt safe, I should probably stop. However, reflecting on this aspect of Indian culture and society it is difficult to imagine that this world, which seems so complacent with the  way traffic is, would be willing to implement change elsewhere; especially in the healthcare sector. But I guess that is the reason we are here in India and hopefully, understanding this and other aspects of life will help us find a meaningful niche for our project.

Day 15: Information Overload

August 16, 2014

This morning we decided to separate in a few different directions so that we could maximize the number of people we spoke to, as our final few days in Hyderabad are approaching. Erin and Jay went off with Raju to search for more GPs around the area whilst Maddie, Anant, and Kesavan went to Osmania General Hospital (OGH) to watch a procedure and speak with patients, doctors, and students.

Erin and Jay tried their luck following up with a few of the GPs the group had met on Thursday and attempted to search for a few of their own. Unfortunately, most of the GP offices did not open up until 9:30 or 10am. Luckily Raju, who saw how much trouble they were having, suggested that they go talk to one of his friends that he knew had previously had a cardiac surgery. Suprisingly, Raju's friends welcomed us into his home and willingly spoke with us about his medical history and knowledge about insurance and cardiac issues. The two of them then made their way back to one of the GP houses they had found on Thursday. When the the doctor came to the door he immediately seemed taken aback that they were asking to speak with him. He quickly shooed them away from the house, but not before telling them to go visit Dr. Salman at his clinic down the road. After some help from people on the street, Erin and Jay made their way to Dr. Salman's office. Inside the office they found a busy waiting room with about 12 chairs, a consult room, and a pharmacy room. Dr. Salman was busy attending to his patients, so they patiently took seats in the waiting room. Jay used this opportunity to speak with a number of the patients about their conditions, how they got to the clinic, why they were there, and what their normal pathway was while Erin did her best to pick up on the few words that are the same in English and Hindi. When it was finally their turn to go into the consult room, Dr. Salman was more than happy to share his thoughts on the Indian medical system and provided some helpful insights into the role of general practioners in the care pathway.

Following the talk with Dr. Salman, Erin, Jay and Shruthi headed to Global Hospital to speak with Dr. Naveen, a neurologist. Becuase of the lack of awareness and knowledge surrounding bradycardia and arrhythmias in India, a number of patients who faint from cardiogenic syncopes end up at a neurologist office instead of a cardiologist. Although Global Hospital is a private hospital and one of the most prestigious and structured hospitals we have seen in India, Dr. Naveen acknowledged that this can still be an issue and shed some light onto his thoughts regarding patient awareness and healthcare in India.

Meanwhile at Osmania, Maddie, Anant and Kesavan were kindly accommodated again by Dr Imamuddin, who invited them to watch a pacemaker revision procedure and talk to the patient afterwards. During the procedure they spoke to Martin, a technician who had been practising for 33 years, who provided some valuable insights on how age is a strong influencing factor on the adoption of implantable devices. He also explained why some patients abscond from treatment at OGH at the last minute. The majority of patients who come to this government hospital are below the poverty line, which means that under the Aarogyasri Insurance scheme for Andhra Pradesh, they are also eligible for treatment at corporate private hospitals, which are required to allocate 30% of their beds to the scheme. When these patients are given a definite recommendation for a medical device at OGH, they are sometimes found to be swayed by the advertising provided by corporate hospitals and will go to these institutions for treatment instead due to perceived superiority in facilities and care. The reality is, the OGH cath lab is just as adequate as some of the other private facilities. This was an interesting perspective to hear, as it uncovered some underlying insights about the power of money in societies such as India where there are significant discrepancies in knowledge and resources.

After speaking to a few patients and their families, plus pharmaceutical representatives in the outpatient center, Anant, Kesavan and Maddie had gathered a substantial amount of information on the experiences and concerns patients have, as well as the decision processes GPs go through in distinguishing bradycardia from hypertension and diabetes (now the two most prevalent medical conditions in India). They moved on next to a meeting with a medical student about her experiences working in the OGH system. Her personal insights spoke very strongly to the team and will be shared in a subsequent post.

After a long and information-packed day for everyone, the team regrouped in the afternoon to discuss what they learned and to plan out the next few days.

Day 14: Independence Day and Hyderabad's Famous Byriani

August 15, 2014

August 15th was India's Independence day. So, just like in America, this meant that most things would be shut down for the day and we would have a "day off" of interviews and hospital visits. We decided to take advantage of this by sleeping in a little later than usual and taking some time to mind map and debreif all of our information for the week. It was a nice change of pace from our busy week!

In the evening we had all planned to go out to dinner to a famous Hyderabad restaurant, Paradise. Paradise is known for there biryani. It is a dish of rice and chicken (for the non-vegetarians) or vegetables cooked in a closed pot, or Dum, and filled with lots of delicious spices. The biryani is served with a yogurt sauce and a chili paste sauce that are mixed in with the rice for additional flavors. We all thourougly enjoyed our meal and the biryani definitely did not disappoint!

 The group eating dinner at Paradise

Satisfied from our dinner, we left the restaurant and headed back towards the hotel. Some of us had considered going to see a movie following dinner, but with our full stomachs, we figured it would be better to get up and walk around then sit in a movie theater for three hours. We asked Raju to drop us off on the side of the road and we spent some time walking down the street along the water and enjoying some fresh air. A great end to our Independence Day holiday!

The Brady Bunch by the lake

Day 13: GPs and Healthy Heart for All

August 14, 2014

During the morning our group set out to find general practioners (GP) in the community. Raju was kind enough to drive us around us to some of the GP homes and buildings in the local neighbourhood and we tested our luck on getting inside to see them. One of our contacts was a medical practitioner at the Shruthi Clinic, Banjara Hills. He provided us some valuable insights on his practice in treating general ailments with medication and first aid, plus the way he detects patients with obvious cardiac symptoms and refers them onto cardiologists for more specialized care. Another contact we made was a GP at the Familia Hospital and Diagnostic Centre nursing home. She explained how they do not have the facilities here to perform definitive diagnostic tests for bradycardia, so they will prescribe immediate pain relief drugs, take blood pressure and oxygen saturation tests, administer an IV line to rehydrate the patients, and will then refer patients onto CARE Hospital for further care. She spoke to us about her medical training and her approach to patients experiencing syncope, which strengthened some of the insights we had already been receiving from other stakeholders. Overall a productive morning that kept adding to our story!

After plenty of running and driving around, we all got back together at the hotel to prepare for a skype meeting with the director of Medtronic's Healthy Heart for All (HHFA) program. We had a very insightful conversation and we all felt like we developed a much better picture of the goals of the initiative, its various components and its success so far. When this interview ended, we all had a long discussion and brain dump with our thoughts on the HHFA initiative and our project as a whole, which helped us once again refocus and organize our strategy for the next few days.

Team brain dump in the hotel

Team brain dump in the hotel

Following this, we decided to clear our exhausted minds, so the boys took some down time whilst the girls took a trip to the nearby mall to buy some Indian clothes! Maddie and Erin had their first experience riding in an auto-rickshaw, which gave a completely different perspective on the traffic surrounding them. Shruthi describes it as 'peace among the chaos.' All three of them ended up having a successful shopping trip and made it back a few bags heavier.

Erin and Maddie in the auto-rickshaw

The boys had gone out to dinner in the meantime, so when they arrived back we met up at the hotel to hang out together and enjoy a nice relaxing evening.

'Day 12: The Rat that Scrubbed in and the "Raja" CEO

August 13, 2014

Before we begin talking about today, let us introduce Kesavan. Kesavan is the second member of the Medtronic team to come join the Brady Bunch in India. He arrived early yesterday morning, after about two days of travelling, exhausted and jet lagged. He took the afternoon to rest up yesterday in preparation for a busy week ahead.

Kesavan waiting in the OR

Now on to the story about the rat...

This morning started early for Erin and Kesavan as they were supposed to be watching an ICD implant procedure at 7:00 am. After arriving at the hospital at 6:45 and convincing someone to show them where to get scrubs, they made their way down to the Cath Lab. They soon learned that the 7:00 am procedure was on Indian Standard Time (IST) and it did not actually start until 8:45. Quickly after entering into the OR, Erin and Kesavan witnessed a rat run by them in the corner of the room. Kesavan said it looked like the rat was scrubbed in, so he thought that everything was okay. Suprisingly, no one else in the room seemed to notice the rat or pay much attention to the three times the power went out. Apparently, these are pretty common occurences within these settings.

While Erin and Kesavan were off watching the procedure, the rest of the team was having a slightly different experience over at the Osmania government hospital.

 At Osmania, they met Dr. Syed who was a senior cardiologist there. This was the first visit to a government hospital and everyone was shocked to see the state of affairs there:;physicians were overworked, patients were restless, many slept in the corridor and were tired of waiting. Dr. Syed shed light on the concerns patients have regarding device implantations. We also had the chance to talk to patients in the OPD (Outpatient Department) which helped us understand their experiences and perspectives, plus some staring loopholes in the Indian healthcare system. 

Shruthi and Anant talking with a patients family in the OPD

After meeting with the patients and Dr. Syed, Erin and Kesavan rejoined the team at Osmania. While waiting outside, we managed to catch up with a medical student who was heading to the outpatient diagnostic clinic. We followed her up to the clinic and sat down to discuss her training, responsibilities, and feelings on the Indian Healthcare system. She provided our team with a lot of information about government hospitals and their lack of funding and resources, as well as gaps in the Indian MBBS program. It was an extremely valuable interview from another new perspective.

Interviewing the medical student in the OPD clinic at Osmania

Our next stop for the day was the Aarogyasri Health Care Trust building to meet with Sri K. Dhananjaya Reddy, the CEO of Aarogyasri. We were fortunate enough to be able to get an interview with Mr Reddy through Aditya's connections with the Andrah Pradesh government. During this interview Mr Reddy walked us through the Aarogyasri insurance scheme, including how and why it was developed and the future directions for the scheme and the country. The whole team found this interview to be eye-opening to the benefits that the government run insurance scheme has provided to the state of Andrah Pradesh and the potential future opportunities for continued expansion among other states. Our whole group felt humbled to be in the CEO's presence as he was an extremely high up officer and even had a bell to ring for his personal assistant. We felt like we were in the presence of a king or "Raja".

Aarogyasri Healthcare trust building

Plaque inside of the Aarogyasri building

We left the Aarogyasri meeting and said our goodbyes to Val as he was heading back home to Minneapolis later in the evening.

Kesavan, Shruthi, Anant, Val, Maddie, Jay, Erin, Aditya, and Naresh before saying bye to Val

We then decided to head to Birla Mandhir, a Hindu temple made completely out of marble. It was a nice change of pace and time for us to reflect on what had been a very busy and heavy day. Unfortunately, we were not able to bring our cameras our phones into the temple to capture the incredible marble sculpting and architecture or amazing views of the city, but we did pick up some trinkets and manage to capture a few pictures outside the gate.

Marble statue outside at Birla Mandhir

Team Brady Bunch outside of the temple

So at the end of the day we saw a scrubbed in rat, a king-like CEO, and the serenity of a Hindu temple.

Until next time, Namaste!

Day 11: The Patient Perspective

August 12th, 2014

We had a very busy and fruitful day gathering information from the two different CARE hospital branches in Hyderabad. The morning was spent refining interview questions for providers and patients. After interviewing 3-4 cardiologists in the past three days we changed our flow of questions to have a better focus for needs assessment. We started our day at CARE Banjara, interviewing Dr. Narasimhan, the most well-known and established EP in India. Surprisingly, he has also treated Shruthi's grandma (what a small world)! This was one of the most interesting and exclusive interviews our group has had yet. We were excited to hear Dr. Narasimhan's thoughts on the barriers for pacemakers and bradycardia treatments in India. The interview exposed us to certain key needs which we are in the process of analyzing for potential project areas. After the interview, we had an American lunch at Pizza Hut (a nice change from all the Indian food) and headed to CARE Nampalli, where Dr. Narsimhan conducts his cardiac clinics. Here we split into groups and covered device implant surgeries, clinical evaluations, and patient interviews. This was the first interaction our group had with directly talking to patients and we found that it was a humbling experience. We are looking forward to more patient interviews in the future and hope to understand the referral pathway for cardiac patients even further. The rest of the night was spent working on mind maps and initial hypotheses while some of the group members spent time analyzing more implant surgeries. Tiring, but a very great day!!!

Please keep reading!

The Bradys 

Day 10: Healthy Heart For All?

August 11, 2014

After a 2 hour delay of Jay's flight, he finally arrived in Hyderabad by 12.30 am and checked into his room by 1.15 am and crashed into his bed straight away. After a really Graduation weekend, Jay was looking forward to his first day in Hyderabad. We had meetings scheduled with Dr. Krishnamohan (senior cardiologist, CARE hostpital), Mr. Thiyagarajan, the Sales Manager South of Medtronic India for South India and Dr. Ramesh, Head of Cardiology, STAR Hospital.  Dr. Ksrishnamohan and Mr. Thiyagarajan helped us identify the key barriers in the carepathway of bradycardia patients receiving pacemakers. It was really interesting to know about Medtronic’s Healthy Heart for All Campaign and how it was an attempt to help the less affluent patients, financially and increase patient awareness. Another barrier was less number of cardiologists and EP’s. We would love to but can’t share the details of those issues here due to confidentiality clauses.

Meeting at CARE Hospital with Dr. Krishnamahon

Meeting at Medtronic

Group outside of the Medtronic building

After our first two meetings, we had lunch at Chutney’s and everybody seemed to thoroughly enjoy the South Indian food!

South Indian Thali

Puris for the thali

 We met with Dr. Ramesh (HOD, STAR Hospital) after lunch and he helped us dig deeper into the financial barriers that deter patients getting pacemaker implantations. After a long day of work, we ended up having American food for dinner ironically. We relaxed and crashed into our beds right away. We had plans to observe a pacemaker implantation procedure in the afternoon and had some rest to finally recover from our jet lag and sleepless nights in Norway.

Day 9: Hyderabad is Garamm!

August 10, 2014

Today we woke up ready to head out and explore Hyderabad! We began our day with a late breakfast and some catch-up mind mapping from yesterday. After finishing our mind-maps, we packed our bags for the day and headed downstairs to meet the car. Since Aditya knew how to get where we were going, he sat in the front to lead our trusty driver Raju to our destination. The rest of us enjoyed our time in the back of the car listening and dancing to the collection of Hindi music on Shruthi and Anant's iPods.

Our first stop on our Sunday journey was McDonalds. Dr. Yazdi had been told about the McPaneer sandwich and wanted to make sure he got one before he left India. Raju dropped us off across the street and we navigated our way through the traffic to get to the little shopping center with McDonalds (AKA Maccas in Australia). After a quick and somewhat American lunch, we headed back to the car for our drive to Golkanda Fort.

Shopping center with McDonalds

Group eating our McDonalds lunch

When we arrived to Golkanda Fort, we were instantly awed by the fort and busy streets around us. We were immediately approached by a tour guide asking us for money to buy tickets. Shruthi, Anant, and Aditya (the Hindi speakers) handled the haggling and the tour guide brought us our tickets. We all found it interesting that a foreigner ticket (that is what the ticket was called) was 100 Rupees (Rs), but a ticket for everyone else was only 5 Rs. Nevertheless, we headed into the fort with our camera's ready to go. Our tour guide, Muhammed was very enthusiastic and made sure to keep us involved during our trek through the fort.

Muhammed pointing out something interesting to the group

Golkanda Fort, which was built in the 1500s, was used by the king and had all kinds of cool acoustic features that could help with warnings for attacks. At the bottom part of the fort you could stand in the middle of a room with diamond shaped cutouts along the cieling and walls, clap your hands, and it could be heard by someone standing near a ledge on the very top of the fort (It was pretty cool!). We made our way up to the top, making sure to stop for water breaks and to hide in the shade, as it was very hot in the Indian sun! Despite the heat, we saw some pretty cool views of the city and some awesome architecture.

After making our way back down the fort and out into the street, Shruthi and Anant stopped to get some sugar cane juice. Unfortunately, the rest of us were warned against trying the street food, so we all stuck with water bottles.

Little boy making Shruthi and Anant's sugar cane juice drink

Raju came to pick us up and we packed back into the car, put the Hindi music back on, and headed to Charminar Bazaar. The Charminar is a monument located in Hyderabad and one of the most recognized structures of Hyderabad. Surrounding the Charminar our busy, crowded, and colorful streets filled with vendors, traffic, and lots of people. We got dropped off about a block away from the Charminar, but ended up spending over an hour weaving our way through people and in and out of shops. Sadly, by the time we got up to the Charminar, we learned that it was closed and we would not be able to go inside. We stopped for a few more group pictures, and a few pictures with some of the locals who wanted to take pictures with Maddie, Val, and Erin, and we made our way back to the car.

Charminar Bazaar with the Charminar monument at the end of the road

The Charminar monument

When we got back to the hotel we all took a little time to shower, change, and cool off before we headed across the street to dinner. We decided to try our luck at the lower part of Bikeranwala (the restaurant we ate at on Monday night). This part of the restaurant was self-service so after reading over the menu, and consulting with Anant on our decisions, we placed our orders. After finishing our food we decided to head next store to the Kirachi Bakery for some sweets. Definitely a good ending to a fun and busy day!

Day 8: NIMS, Balaji Temple, and Speaking Hindi with Raju

August 9, 2014

Today started with an authentic Indian breakfast at the hotel, a group meeting to collect our findings from yesterday, and a discussion about focus areas for our next meetings. The hospital we visited today was Nizam’s Institute of Medical Science (NIMS). We waited in the NIMS Cardiology Outpatient Center before meeting Dr Sai Satish, a highly recognised EP and Senior Cardiologist who performs the whole range of available cardiac device implantations.

Maddie, Shruthi, and Erin on the way to the hospital

In the waiting room, Shruthi had the opportunity to chat to some of the nearby patients about their experiences surrounding their health care. We gained some important insights through their eyes, and were very excited to begin piecing together parts of our puzzle. Dr Satish continued in providing us with valuable information about the diagnosis, referral and treatment pathway for patients with AV block, sinus node dysfunction and other cardiac conditions, plus the reimbursement options available to different populations. Today’s conversation raised a few common points that had been mentioned in previous meetings, which helped in starting to substantiate our hypotheses. His key messages involved the state-wide Aarogyasri health care reimbursement program for below-poverty-line (BPL) families in Andhra Pradesh and 5 other states, and the nation-wide Rashtriya Swasthya Bima Yojana (RSBY) Scheme for below-poverty-line (BPL) families across India. There was also discussion about the existence of other state-government subsidies plus corporate reimbursement programs for middle-income families. However, each program has its limitations in terms of reach, awareness and availability.

After thanking Dr Satish for so much of his valuable time and gathering our thoughts, we broke for the evening to go on a great drive through High-Tech City. The most incredible part of this drive was where we ended up for dinner. After walking around the grounds of Apollo Hospital, we crossed the road to take photos of a beautiful temple we saw through the trees.

Our group outside of the temple

Balaji temple

It turns out we had made it in time to participate in the prayer ceremony for the famous god Balaji. Here we were given bindhis to wear, blessed with Holy water and generously given three tasters of food – Chundal, Puliyogare and Kesari – delicious! We were so grateful to be welcomed here, and found it very calming and humbling to be a part of.

Maddie with the food they gave us taking part in the ceremony

Maddie and Erin with their Bindhi's in the temple

On the way home Maddie had a conversation with Raju using the words Shruthi and Anant had taught her today. It went something like this…

M: “Aap kiase ho, Raju?” … How are you, Raju?

R: “Accha!” … Good!

M: “Dhanyavad!” …Thank you!

Obviously, a little laughter ensued.

Day 7: Arrival in Hyderabad

August 8, 2014

Brady's First Day on the Job 
After Erin, Jay, Maddie, and Aditya arrived in Hyderabad they soon said goodbye to Jay so he could attend his graduation ceremony at ITT Mumbai. 

CONGRATS DJ!!

Shruthi came in just an hour later to join the group! So glad she didn't miss out on much! 

Our first day on the Medtronic project was a major struggle. All three of us were quite tired and jet-lagged. So we quickly had breakfast and short naps before our initial team meeting at 12.30pm. 

We were finally able to gather our whole Medtronic team together (minus Jay) for our kick-off meeting. Naresh (our project coordinator in India and close assistant to Dr. Narsiman) , Dr. Yazdi, Aditya, Val (Medtronic Engineer) , Anant (CBID alumni/current Clinvue representative), Erin, Maddie, and Shruthi discussed project goals, target areas, and itineraries for the 3-week trip. 

We started the day by walking to Care Hospital (our main clinical center for this trip) and met with Dr. Sridevi, a senior cardiologist. We interviewed her for about an hour where she answered various questions about the cardiology pathway, pace-making, and the Indian healthcare structure. Her insights were very interesting and she clearly, was a established and caring physician. During the interview we also had a short talk with Subrat, a Medtronic-India technological rep. We set up a meeting with him for next week to talk in detail about his role.

The Aarogyasri scheme in Andhra Pradesh is a governmental insurance scheme that reimburses patients below the poverty line for medical emergencies and treatments. We were lucky enough to be able to talk to an Aarogyasri "Mithra" (friend/representative) who informed us about the procedures for signing up for the scheme and the procedures the patients had to go to when they came to the hospital (Thanks Shruthi for that idea). The Mithra only spoke in Hindi so Shruthi and Anant spoke and translated for Maddie and Erin throughout the conversation. We thought this was a valuable interview to better understand the insurance scheme and the difficulties poor patients have to endure to receive proper treatments.

After our talk with the Mithra we left for the Care Out-Patient Clinic. At the clinic the whole group was able to observe EKGs, Echos, and stress/treadmill tests. We interviewed cardiologists and patients within the various rooms that we got to visit and were able to get some additional information about how diagnostic tests are run in the outpatient center. The main take away message from this visit was the differences between the roles of the cardiologists and EPs.

At around 5:30pm, exhausted from our very long first day, we left the outpatient center and headed to dinner at Bikeranwala a chat place in Hyderabad. We had a delicious meal topped off with even more delicious butterscotch ice cream. Unfortunately, our jet-lag kicked in so we went to sleep early and prepared to power-up for the next day!