Student Trip to India Yields Lessons, New Perspectives, and Areas Where U.S. Healthcare Can Improve
Nursing students spend 26 days in Manipal; trip is return to South Asia after pandemic interruption.
International experiences in India made a triumphant return as a contingent of MGH Institute nursing students and faculty spent nearly a month in Manipal as part of an immersion experience at Kasturba Hospital and the surrounding community where they shadowed students from the Manipal College of Nursing.
The group left New Year’s Eve and returned in late January; the trip came on the tenth anniversary of the Institute’s first nursing trip to India.
Making the 8,000-mile trek were Master of Science in Nursing students Leah Rothchild, Kyle Fletcher, Disha Patel, Sonal Bhatt, Nikita Desai, and Ilan Millstrom, who were accompanied by Professor Elissa Ladd and Assistant Professor Kaveri Roy.
“It was such a privilege,” said second year student Desai. “We had so much access.”
“The experience was great,” said second-year student Bhatt. “I would definitely recommend it to students. It was a really wonderful way to learn about a different healthcare system.”
“They were so welcoming to us, from the top of the nursing school administration to the students and staff that we worked with,” said Fletcher, a third-year student who’s in the acute care nurse practitioner track. “I had an open invitation whenever I had time to participate in rounds and to ask questions. I never felt stifled and felt very nourished from a learning standpoint.”
“I had a really amazing experience in India and I'm so grateful I had the opportunity to go on this trip,” said Millstrom, a second-year student.
Ladd spearheaded the first trip in 2014 after returning from a six-month placement as a Fulbright Scholar at Manipal University.
“When I was there, I remember thinking, ‘Wow! This is this is such a wonderful, rich place to bring students,’” remembered Dr. Ladd. “You have the setting in South India, a wealth of cultural activities as well as healthcare services that are being provided in the context of a low-middle income country.”
The global immersion program was suspended during the pandemic and returned this year.
For Bhatt, Desai, and Patel, it was a return to roots of sorts. While none have ever lived in Manipal, all have family in India, and all spoke one of the country’s many dialects. Only Desai’s family was from Karnataka, the state Manipal sits in, so she knew how to speak the Kannada dialect used there, which came in handy.
“It was a little bit of pressure at first to make sure I was translating everything correctly,” said Desai. “But I was happy to help. It was a very meaningful experience to go there and have all the staff, faculty and students say, ‘Oh, my gosh. Wow! That's so cool that you're here and so cool that you know the language.’ Bridging that gap of living in the U.S. but being able to show them my interest in coming back and learning from them was extremely exciting.”
Added Patel, who is from Northern India, about the culture: “There’s definitely a way of doing things there and a culture to understand. It’s important to respect and at least understand. They say very few words, but they mean a lot. And so, it’s a lot of looking at expression, recognizing somebody's body language and tone. Basic mannerisms and respect are vastly different there than it is in the United States. Being able to share that with my classmates was really great.”
Unlike many of the international trips MGH Institute students take, where hands-on experiences lend themselves to learning, this was an immersion trip with observerships.
“Their focus is to look at the Indian healthcare system and how it compares with ours,” said Dr. Roy. “And so, it's really to observe a different health care system, how people are being treated, and look at it systematically. We tried to structure the experience this time. They had readings and reflection papers. One of the important things that we did is we debriefed every week and we talked about issues and the things that they were seeing.”
The IHP students saw quite a bit because they participated in rounds and kept the same routines as the Indian nursing students.
“We followed the same schedule as their nursing students followed,” said Bhatt. “So, we came in with them, we'd leave with them, and then we take our breaks with them. We got to talk to the students, which was a really big, eye-opening thing for us. It really helped us understand the system better.”
A student’s specialty dictated where in Kasturba Hospital they would spend the day. For Patel, who’s in pediatric care track, what she could do depended on which ward she was in.
“When we were in the general wards, it was a lot more lenient than what we would have expected,” said Patel. “We were allowed to do assessments and things like that, but we didn’t give medicine because we're not authorized over there but whenever we were in the NICU, it was all hands off - we were just observing.”
Along with full workdays, there were case studies, workshops, and presentations to take part in too. Ladd called it a bilateral peer mentorship.
“The students were mentoring each other,” said Ladd. “They were sharing their own experiences and their own context in terms of you how they do things, where they work, what are the challenges.”
For Rothchild, a third-year student and veteran of IHP service trips to Malawi and Uganda, the hands-off experience was very different than providing direct patient care or administering education.
“It was actually really fun in a way because it took all the pressure out of this situation and it really allowed me to take everything in with no obligation to intervene or even offer advice or an opinion on anything,” she said. “So, I had the opportunity through questions to share what we do differently.”
Because Desai and Bhatt are specializing in women’s health, they were stationed throughout various floors - antenatal, postnatal, labor, and operating theater, high dependency unit, and a fertility clinic.
“We definitely got to see a lot there,” said Bhatt. “And they did a good job of rotating us through and making sure that we saw a little bit of everything.”
“Everybody was just so excited to have us there,” said Desai, “and so excited to share education and how they do things there.”
Differences in Healthcare
As one would expect, the approach to healthcare half a world away will be different. Community health, the influence of nurses, expertise in critical reasoning, and resources were what the IHP students noticed the most.
In the area of community health, people were met where they’re at, thanks to primary health centers in rural outposts where people receive free healthcare. Screenings for pregnant women, tests, and vaccinations are no cost because they’re provided by the government. More complicated, higher-risk procedures are done in a private facility at an out-of-pocket cost.
“The way that they do community health there is light years ahead of how we do community health here,” said Bhatt. “Their outreach is absolutely amazing. The way they go into communities and provide care for people and make sure that everybody has a basic level of care is amazing. Same with prenatal care - they do the best that they can to make sure that everybody gets prenatal care, no matter how rural the location is of the patient. It's unlike anything I've seen here.”
“Just the idea of bringing healthcare to people and meeting them where they're at was really impressive,” said Desai. “I think a lot about how in the U.S., access to OGBYN care in rural places is really limited. You have people having to drive hours and hours just to get basic prenatal care. To see the easy access in India where people don’t really have to worry about it is something I’ll be thinking about in my career.”
Critical reasoning was another significant difference, especially when it came to how many tests were ordered.
“A lot of times they are only ordering one or two tests.,” said Patel. “They're able to look at a patient or perform such a thorough assessment that they're able to tell us, ‘We actually don't need to do all of these tests - just these two will give us the answer, and in the off chance that it doesn't, we will go back and perform something.’ I would say almost every time, they were correct in what they were doing.”
Rothchild shared a similar observation.
“It highlights the flaws of the U.S. system, where we have so much at our disposal that when a patient comes in with a vague complaint, we'll just run every test available. There may be situations where that's beneficial, but a lot of times it's really a misuse and a waste of the resources. They use these critical thinking skills and their diagnostic reasoning and think which tests will offer the most valuable information. I think this experience will contribute to my being a more thoughtful and calculated and less wasteful provider here. I can adopt some of that practice and not just order every test here, simply because I can.”
While nurses are heavily relied upon in the U.S. for a patient’s care, that wasn’t the case in Manipal.
“The scope of practice is much more limited there,” said Patel. “The nurses are educated enough to do assessments and have a nursing care plan, but there is a lot of medical hierarchy there. So, there is a lot of nurses doing their assessments, and they do the vitals, but the doctors do their own assessments and their own vitals, and they base their patient care plan on what the doctor's findings are, not in collaboration with what the nurse's findings are.”
Resources were another glaring difference.
“When I go to clinicals here in the U.S., I don't have to think twice about, ‘Am I going to have a fresh pair of gloves? Am I going to have all of my surgical attire?’” said Patel. “But for them, all they've ever known is being a little bit resource poor. Gloves are one example, and air conditioning is another. They have a huge ward style, pediatric floor - it's one spacious room. There's no curtains, there's about 30 beds, and there's no air conditioning. And so, all these patients are extremely uncomfortable. Their families are extremely uncomfortable.”
With an interdisciplinary approach a central tenet of the IHP education, the lack of it in India was glaring.
“In the U.S., we’ll have interdisciplinary rounds that includes the whole care team with nurses being at the table and developing the plan of care,” said Fletcher, a third-year student specializing in acute care. “In India, there wasn't a dedicated time for all the different disciplines – medicine, nursing occupational therapy, physical therapy, or speech-language pathology.”
Rothchild addressed the differences in approach through questions.
“They had all of the patients in the pediatric ward on a very powerful antibiotic that we really don't use here,” recalled Rothchild “Rather than coming in and saying, ‘You shouldn't have them on that’ and ‘Why are you using this?’ I said, ‘Oh, can you tell me why this is the selection?’ and then using that opportunity to say, ‘Oh, that's so interesting. In the U.S, we really don't use this one for this reason. So, I'm curious about why it's different here.’ And so, through those opportunities, I was able to learn but also able to say, ‘This is why we're doing practice differently.’ And our practices may apply, or they may not, depending on the situation.”
While the line of questioning was well-received by the students, hospital leaders seemed threatened and territorial about their decisions.
For example, children were being admitted to the pediatric ward and given IVs for conditions, such as tonsillar pharyngitis, which would be treated as an outpatient in the U.S. In a question addressed to the students, Rothchild asked why and whether these children had access to primary care.
“But before they could answer, one of the faculty intervened and said if they were admitted, then there must have been a reason – maybe they had a high fever for four days or their oxygen saturation was too low,” recalled Rothchild. “But having gone through the chart, I knew that that wasn't the case. I thought it was really interesting because my question really wasn’t intended to be a critique, but rather, ‘Is there primary care and is that something that people aren't able to access?’ I think that some of the men in particular reacted to those questions as, ‘We know why we admitted people and there was definitely a reason.’”
Sights to Behold
The trip wasn’t all work and education – there was fun to be had. The group went to beaches, hiked a mountain, saw temples and museums, traveled to nearby cities on the weekend, took boat tours on rivers, and even bathed an elephant.
“We got to see a lot of cultural things while we were there,” said Bhatt. “So, it was a nice way of kind of like learning more about the area, the religion, and the culture that's there.”
“My favorite part was actually visiting the Krishna Temple on our last day,” said Fletcher, “and getting that immersion into the spiritual culture.”
“There were a lot of beaches where we were,” said Patel. “So, there was quite a few days that we went after clinical to see the sunset. One of the students and I went to Mangaluru to go shopping, so that was great.”
Leveraging the Learning
The 26-day trip led to considerable lessons and learning to be leveraged.
“By being immersed into another healthcare system, the students really saw how challenging it is to provide care in resource-poor settings,” said Ladd. “Reflecting on where they come from, they felt very fortunate, but I also think it's going to give them a level of empathy that certainly will be translated here with people of different cultures, people that do not have the resources that a lot of people have. I really believe that this global immersion rounds out their educational experience and prepares them to think critically about healthcare delivery in both high income and low-middle income settings.”
Added Roy: “It helps them realize, ‘OK we are good at some things, and they are good at some things. It may affect how they see other countries that they go to as well. In the U.S., we have this habit of saying, ‘We're going to go and save these people, or we're going to provide these services that they don't have.’ We really need to start looking at what can we provide and what can they provide. There needs to be reciprocity. And I think that's what they learned.”
For some, the trip helped form a new perspective on healthcare.
“We sometimes get this attitude of, ‘We’re the best and we need to teach other people how to do things,’” said Desai. “But I think one of our big takeaways from this trip was, ‘There's a lot of things that even with less resources that India is doing so well.’”
“We need to work on our community health outreach, the way that we educate the public, and the way that we include families into healthcare decisions,” said Bhatt. “One of the bigger things that I took away is the importance of piloting community health programs here in the States and doing more outreach when it comes to women's health care.”
Millstrom, who is on the psychiatric/mental health nurse practitioner track, enjoyed the clinical placement at the Hombelaku psychiatric rehabilitation facility and Kasturba Hospital psychiatric ward, and says seeing firsthand the care there was invaluable.
“Actually getting to experience and interact with how culture influences the manifestation of and interpretation of psychiatric symptoms and conditions I felt was really valuable for not just understanding Indian culture, but also for building my empathy and understanding of psychiatry,” said Millstrom. “For example, many of the patients with severe depression or schizophrenia were much more socially engaged and active than I expected based on my prior learning and experience with patients in the United States. I can think of a few reasons why this might be, but it has made me rethink my idea of these diagnoses and what patients might be capable of.”
Trip Takeaways
For Desai, the experience opened her eyes to working around the world.
“It definitely made me feel more interested in pursuing opportunities of working globally,” said Desai. “I had never really thought about it before. It was not only like a really amazing experience to see things I wouldn't normally be able to see in the U.S. Professionally, but it was also a really valuable experience for making connections and establishing ties with people that are effectively either my colleagues or going to be my colleagues. Having that sort of like international collaboration, I think, was really worth it.”
Patriotic pride was what Patel took away.
“It was honestly very heart warming,” said Patel. “I've seen the healthcare system very surface level in North India, but I I've never gotten to see exactly how government hospitals run because we don't really have that here in the States. It was very heartwarming to see how forward they are in India.”
For Fletcher, the takeaway was a confirmation on his career track.
“It helped me solidify that I could see myself working in the ICU,” said Fletcher. “I went into it without much exposure in that specific setting, so I have only really played with the idea of pursuing that specialization in the future. The experience really solidified that it's a fun environment for me to practice in.”
This trip was Fletcher’s second in as many months. From November to December, he was at the Rosebud Indian Health Service in South Dakota, another learning opportunity offered by the IHP, thanks to its affiliation with the Indian Health Service (IHS).
“Coming to it from that perspective, it was very enriching,” said Fletcher. “One of my big passions for nursing is to do global health work. This experience was highly informative and reassuring. India is a place with lots of possibilities, especially with the affiliation the IHP has there.”
Rothchild feels the same way.
“This trip confirmed that global health is really my passion,” she said. “My long-term goal is definitely to get a job with a global health organization where I can do a long-term placement.”
“I would recommend this trip especially for those interested in seeing different healthcare systems and the policy side of things,” said Bhatt. “Just seeing how different hospitals function in different places really changes your perspective.”
“There's a lot that we have in in the Boston area, but it's a big world,” said Desai. “I love that the IHP provided this opportunity.”
Do you have a story the Office of Strategic Communications should know about? If so, let us know