Letter One

Hi! My name is Angeli Sharma and I am a rising sophomore from New Jersey. At Duke, I want to study public policy focusing on health care disparities and neuroscience as a pre-medical student.

My interest in medicine began at a young age. My mother has always been my role model and I always saw her on call, doing research, and overall just being excited about being a physician. Her passion for her career intrigued me. I slowly learned that I too was interested in medicine; it was the perfect intersection of science and altruism. In high school I wanted to explore all aspects of medicine. Instead of going to my regular public school, I attended a magnet school that focused on health sciences.

My parents emigrated from India and I am a first generation American. I feel that this has enabled me to keep a foot in both worlds. I volunteered at our local hospital here in the United States and shadowed a bariatric surgeon in India. Through a variety of such experiences, from planning blood drives at my high school and serving as a State and National Officer for an international health career organization called HOSA, my curiosity on the many divides in healthcare grew.

Out of all these experiences, one stood out to me the most. My family has always been very involved in community service and a big part of my time in high school was spent volunteering with an organization called Ekal Vidyalaya. Ekal Vidyalaya is a nonprofit that focuses on providing education to children to rural and tribal parts of India. In addition, to their main focus of eradicating illiteracy they also run health clinics and medical projects to better the health of these villages. One summer, I volunteered in these health clinics and schools. At these health clinics, physicians would work pro bono to provide medical treatment to common illnesses like malaria, TB, and anemia that would go untreated until these health clinics would arrive in these villages.

All of these experiences lead me to develop the ideas for my project. My project for the KSF focuses on medical ethics. I want to study how physicians treat low-income patients and make decisions regarding resource allocation. I hope to accomplish this by shadowing physicians and then conducting a formal interview where I ask them specific questions regarding both topics. From my high school experiences, I have seen how drastically resource allocation varies in resource-rich and resource-scarce countries. I hope to explore this aspect of medical ethics by shadowing physicians in both the U.S. and India.

I hope that with the conclusions that I draw and the observations I make will help me make similar decisions when it is time for me to be a physician. Additionally, I hope that with the report or paper that I write after my experience, other physicians can assess themselves and the way they practice medicine.

Getting my research approved was a complicated procedure because there are patients and protection of their privacy is of the utmost importance. But, now that is finally has been approved, I am trying to contact physicians who I can shadow in both countries.

This week, I have started with shadowing a physician in New Jersey and had my first day yesterday! I am very excited to see what I learn about ethics, medicine, and myself through this project.

Letter Two

This was my second week of my research. And it has been an interesting experience.

When I set out to do this project, I never realized my biggest obstacle would be to find physicians who are willing to participate in my research. I called over 35 different hospitals, health clinics, and private practices. I only was able to get 2 physicians in the United States to agree to let me shadow them so far. So the search is ongoing for the rest of my physicians for the study.

Last week, I shadowed an internist and was able to really learn a lot. After the first day, the whole process became very natural and routine. The physician would ask each patient if it was okay if I was in the room and if they said yes, I would enter the room and introduce myself while explaining my project.

The physician would ask questions to try and diagnose the patients. I recorded things like how much eye contact they maintained with the patient, if they used their personal phone during the appointment and the different ways that they showed respect.

I also recorded things like the amount of time that the physician spent with each patient. I noticed that the more time that a physician spent with a patient, the higher the quality of care was and the more respect they showed their patients throughout the appointment. Some indicators of respect that my mentor and I mapped out are introducing themselves, if they apologize anytime they cause pain by touching an injury, for pediatricians, do they talk to the child as well or just the parents, do they respect the patients privacy, etc. However, I was curious on how the physicians managed the business aspect of their private practices (where seeing a higher quantity of patients would be in their best interest) and the medical aspect (where seeing a patient for more time would be in their best interest.) This is something that will definitely be addressed in my interviews with the physicians.

I shadowed a pediatrician this week. Seeing the different physicians and their very different styles of medicine made me think critically about the medical ethical dilemmas that each of them faced.

One particularly interesting incident occurred that really helped see the stark contrast that exists in this sphere. When a patient, complained to one of the physicians I shadowed that the medication they prescribed the last time was very expensive. The physician completely ignored the comment and made no efforts to assuage the patients financial concerns. A similar situation occurred with the other physician. However, this physician suggested alternatives that may not be as effective but were substantially cheaper and let the patient decide which medication they would like to fill.

I haven’t had a chance to interview either of the physicians yet. I look forward to learning more about the physicians through the interview process and discussing my observations with them.

Letter Four

Interview week has finally arrived! I am excited to see how the observations I made about physicians differ or are similar to their own assessments of their ethics through the formal interviews.

I am also shadowing a physician this week who works in family practice medicine. In this type of medicine, the physician sees patients of all ages from children to the elderly. I think it is a great way to conclude the project. It enables me to bring all the different medical experiences considering that the physician has to relate to patients of all different ages.

The one thing that I am disappointed with in my research project is my inability to shadow physicians who are working in health clinics and health care settings. All major health clinics, hospitals, and charity care centers refused to be a part of the project. Although their concerns regarding patient privacy and having an additional liability are valid to an extent, this was extremely frustrating because the project would have had better data gathered from these larger institutions. This may lead to some difficulties especially with the interviews that I am conducting since half the questions focused on resource allocation in such health clinic settings. Since all the physicians are in private practices, which gave them the flexibility to allow me to shadow them, the questions will focus on time as a resource instead of material goods and finances.

Through this project, I learned some valuable lessons regarding research and the importance of documentation, patient privacy, and the layers of rules in healthcare. Realizing the importance of patient privacy, my own protocol was changed several times to ensure that no data regarding patients was collected including their health insurance status or ability to pay. This made me rely on more subtle cues and interactions that helped me see when a patient was part of a lower income group or was having difficulty paying for healthcare.

Although initially, a little frustrating, it enabled me to operate off of similar information as the physicians. Through the interviews, I learned that oftentimes, physicians are unaware when their patients have Medicare/Medicaid insurance or no insurance. Until the patient tells them during their appointment or if the prescription is rejected at the pharmacy, that is when the physicians decide to change the course of treatment based on ability to pay.

As I was interviewing physicians, only one of them consented to being filmed while the interview was taking place. The other two that I have interviewed so far, said they felt uncomfortable being filmed so I took notes by hand on their answers and recorded observations that I made on their body language.

Through my last semester at Duke, I had began to question on whether a career in medicine is what I wanted to pursue or a career in healthcare policy is something I was better suited for. I felt that through the shadowing aspect, my research would enable me to have a unique perspective on medicine, which would help me make this decision.

This summer has shown me that medicine is not as standardized as I originally believed. Through the physicians’ subtle difference in practicing medicine, they became more personable or more efficient. Medical school curriculum is standardized in the United States and even doctors who studied medicine in other countries must take the same exams as American medical students to prove their competency. Despite this, physicians end up still having their own unique styles of medicine. One physician saw 4 patients during her clinic hours and another saw 30. Both had a great rapport with their patients, but one physician was clearly more effective in the balance between running a business and providing quality patient care. She had mastered the art of resource allocation; in this case, the resource being her time.

It is interesting that although medical knowledge is tested in various ways through a physician’s career and even during their time as a student, many important lessons in running a private practice are learned through trial and error. To gain more knowledge and expertise in the balancing act, physicians need to go on and get an MBA. I am intrigued as to why a course in managing the balance between having a lucrative career and providing the best patient care is not mandatory in medical schools too.

This concludes the U.S. part of my project. In a few weeks, I will be traveling to India where I see how medical ethics plays out in a developing country. I will resume my letters when I reach India!