The Credentialing Document-Part I: Understanding Medical Education

Credentialing is the process by which a physician (doctor) is certified to practice his/her trade at a given institution. It is a systematic documentation of a physician’s training, licensure and medico-legal history that gives credibility to the physician that enables him/her to practice medicine/surgery at a given institution. It constitutes many steps, which must be documented in detail. This is the first of a yet unknown series on the topic: 

1. Education:
   1. India:

                                                               i.      Medical training: Following the completion of high school (12^th standard), most doctors in India go straight to medical college, where they complete a course that consists of three one and a half year terms of the MBBS, each followed by a university level examination. This makes one eligible for the MBBS degree.

                                                             ii.      Internship (India): In order to get the MBBS degree in India, the trainee must also complete a one year internship, which consists of 3 months each in medicine, surgery, obsterics and gynaecology and preventive and social medicine and their subspecialties (if applicable). It is important to document this entire training history, complete with the number of hours spent on each rotation throughout medical training. Some states like California require at least 4 weeks of training in psychiatry and this must be documented. The internship training in India does not count as an internship in the United States and so almost all doctors traveling overseas despite their training will have to re-do an internship there, which is slightly different.

                                                            iii.      Post graduate training: After the MBBS degree, doctors may apply to get into specialty training programmes, also called residency/houseman/registrar etc. This is usually in a specialty such as Internal Medicine, General Surgery, Obstetrics and Gynaecology and Radiology. The training period usually lasts for about 3 years and consists of 6 month “posts”, which maybe at the same or different hospitals. At the end of a specified training period, the physician is eligible to take an examination and get certain degrees. The most common of these is an MD (Medicine/Radiology) or MS (Surgery/ObsGyn), which is administered by the university. There is also a degree called the DNB or Diplomate of the National Board, which is administered by a central board in Delhi. Other degrees may also be obtained along the course of one’s training and in radiology one may get a DMRD or DMRE also. An individual may hold one or all of these degrees/diplomas.

                                                           iv.      Sub/super specialization: This means training in a specialty area of the specialty area. For example, brain imaging (neuroradiologist). Upon completion of this, one may or may not take the DM examination.

1.  
   1. USA:

                                                               i.      College or pre medical education: After 12^th standard (grade), most US people will go to college and spend four years to get a BS or BA (like BSc, BA, BComm etc). Following this, some people may do a masters and even a PhD. It is not unusual that people in the US take medicine as a second career and may have been Bankers, nurses, actors, military personnel before they go to medical college.

                                                             ii.      Medical education: in the US, this is typically 4 years and has no compulsory internship training attached. The degree at the end of this is called the MD which is equivalent to the MBBS in India and different from the MD in India.  Some people may take longer because they combine their MD with a PhD. There is a small number of people who go to medical college after 12^th standard in the US, and will complete the course in 6-7 years as opposed to 8 years or more for most others (4 years BS/BA + 4 years MD). Training during this time is well documented by most medical colleges and these can be obtained relatively easily by writing to the college.

                                                          iii.           Internship: After getting the MD degree, almost everyone does an internship. This is usually in a “clinical” field that has patient contact such as internal medicine or general surgery. Once this first year is complete, the physician may continue with their specialty training. This is different from the Indian internship as it is not required to get the MD degree and is considered post graduate education. The internship may also be rotating through multiple specialties and maybe referred to as a “transitional year”. This is called the PGY1 (post graduate year 1).                                                    

 iv.      Residency: The next 2-5 years after the internship are usually spent in specialty training such as radiology, surgery etc etc. At the end of this, one takes an examination administered by the specialty board (American board of Radiology/Nuclear Medicine/Surgery etc etc) and becomes “board certified”. There is usually no degree applied at the end of this, but we occasionally use DABR (Diplomate of the American Board of Radiology). An individual, if appropriately trained may have many board certifications.                                                           

v.      Sub/super specialty training (fellowship): After specializing in radiology, one may be sub specialized in neuro/interventional/pediatric/nuclear radiology and take an exam to get a Certificate of Additional Qualification (CAQ). Some people may do the additional training and not take the exam and some may be in sub specialties such as musculoskeletal radiology, where these exams do not exist. 

Bridging the Gap: 

Obviously, USA does not recognize all examinations taken in India and vice versa. Since we deal primarily with physicians trained in India, I will only discuss the qualification of the Indian physician in USA.

The first step for an MBBS physician in India to get qualified in the USA is to pass a set of examinations that adjudge them equally qualified as US physicians. These are called the USMLEs (United States Medical Licensing Examinations) and are the same set of examinations that all US medical students take. They consist of 4 parts: Parts I, II (theory) and CS (Clinical Skills, practical) followed by a final Part II (administered by a state board of the applicant choosing (FSMB) but scores valid in all states). The CS examination is a recent addition and some physicians may not have had to take them. The USMLE examinations were previously also known as ECFMG, FLEX, FMGEMS etc. For all foreign medical graduates, the ECFMG (Education Council for Foreign Medical Graduates) is the body that co ordinates the examinations.

Once all the examinations have been passed, one is eligible to enter the workforce. Again, the hiccup is that if you have done specialty/subspecialty training in India, it is not fully credited in the USA and so re training is required. Equivalency can be achieved in the following ways:

1. Apply to a US residency program and repeat the four years of radiology training and then take the ABR exam again.
2. More recently, the ABR will allow one to join a fellowship at a university hospital with a recognized training program* directly after completing training in India and passing the USMLE. Four years in such a training program, either as a fellow or faculty makes one eligible to take the ABR examination.

Aaloo

Dear Anya,

 

I guess it’s been a while since I wrote. Anyways, I see you every day so it seems strange. I am writing to a person I see every day but to her about 10-15 years from now!

 

Recently, we were visited by an old friend of mine, Modi uncle; the perfect bawa boy that every Avan, Gulshirin and Kushjeher would love to have their daughter married to. Alas, this has not yet happened and he wallows as one of the grand commander of the Loews Hotel in Maimi, FL. We never thought of this, but he decided that the appropriate gift for you was a “Mrs. Potato head” doll, a variant of the Mr Potato Head series. This is one of those classic toys that I think will and should never go out of style. I am happy to say it has you hooked and it is probably the only toy that you play with and ensure you put back in its box with all the pieces every time!

 

Coming to the toy itself, it is a thing of beauty. First off, what a concept, a potato; an easily identifiable and well loved object for every child and an easy word to say (Aloo that is!). Next up, the It has a bunch of holes that are strategically placed to attach a nose, mouth, eyes, ears, hat, hands and feet. Now, even better, it encourages you to attach them in the wrong places as well, with nice illustrations on the box (I like the way you say “funny funny” when you put things in the wrong place). There is a little secret compartment in the back where you can keep extra pieces (that you enjoy). Finally, you can buy other attachments for the Aaloo and can mix and match them to make even funnier figures.

 

So anyways, here’s to finding more old creative toys, and uncle Modi…hopefully Gulshirin/Avan aunty will find him soon and their little Shehnaaz will be happy.

 

Love always,

 

Me

 

Little Italy, Indiranagar, Bangalore: Multiple visits

As a vegetarian, this place is a veritable haven for Italian food. I have seldom gone to Little Italy and gone home dissatisfied or not feeling completely stuffed like a Thanksgiving turkey.

The only things that I don’t really care for too much are the starters. The bread is usually simple white bread or bun bread. The garlic bread is soggy and the bruschetta is OK at best. The nachos are nicely Indianized with rajmah and the yellow cheddar cheese (I think we in India love this stuff and so it is appropriate…even though I may not like it). The salsa is sweet and nicely Gujarat-ized!

From the drinks stand point they have a good selection of alcoholic beverages and fruit juices, most of which are pretty good. They also serve wine.

The main courses are excellent. I like the pastas (a little saucy, but that’s the way I like them sometimes…the gujju in me you know!). They are cooked well, not too al dente and not too soft and the sauces are flavourful. The creamy sauces of course are extremely creamy, but hey it’s an evening out. If you are a health freak, stay off them! The pizzas I would say are excellent. The crust is nice, thin and crispy with a nice assortment of toppings ranging from artichokes to olives and capers. I recently tried the “rustica” from a friend and thought it was excellent. They also don’t overload the pizza with cheese.

Desserts are reasonably good. Kids seem to enjoy the sizzling brownie most.

Overall, plenty of place but still busy, especially on weekends. Courteous staff with good food, a vegetarian’s delight for Italian food.

Ambience: ***1/2

Food: ****

Price: ***1/2

Overall: ****

Papparazzi, Bangalore July 21st, 2007

And finally after all the hype and hoopla of being one of the “top 82 restaurants in the world” (as per Conde Nast Traveller), we managed to get child care and get out to go to Paparazzi at the Royal Orchid.

The restaurant has a nice “new-look” ambience, in a great location (10^th floor of Manipal Plaza, Royal Orchid Central overlooking Ulsoor Lake) with a courteous wait-staff. A little slow, but courteous. After going through a small discussion about getting the table we reserved (overlooking the lake is the recommended seating), they were good enough to find us seating (a little cramped though) overlooking the lake.

The menu is an interesting mix of western, Indian and sizzlers. Prices were quite down to earth for a restaurant of this reputation and location (Rs. 200-250 for mixed drinks, Rs. 200-250 for most vegetarian dishes. My wife tried the ginger cosmopolitan, which she said was pretty good, but not as good as the one we had earlier in the evening at the Leela’s Library Bar (drunks that we are). The Toffee Appletini that I tried was nice, but lacked the taste of apple or toffee. The coffee beans in it though were a nice touch.

For starters, we tried the sampling dip platter, which I thought was very good. It included a hummous, red pepper (capsicum) dip, a cheese dip, corn dip, salsa (pico-de-gallo), guacamole, a honey butter with sesame, and three types of mayonnaise (plain, with garam masala (hmmm) and with either chilli flakes or sun dried tomatoes). The accompanying bread basket was also nice, complete with Dorito chips, nice thin crispy bread, a sun dried tomato bread, a crusty bread and pita. Now only if they had bothered to warm the bread nicely before serving it, things would have been perfect.

For the main course, we opted for angel hair pasta with sundried tomatoes which I thought was very good even though I don’t really like angel hair pasta (I would have preferred a nice al-dente spaghetti). Fresh pepper was brought to the table in a small bowl with a spoon (at which point my wife, who was now down three cosmopolitans was thinking of buying them a pepper mill for their birthday!). I ordered the ricotta and spinach stuffed crepes which came covered in a tomato sauce and a lot of cheese (I still haven’t figured out why we need to put so much cheese but I think it maybe something related to the value for money!).

While the desserts seemed interesting and included a tiramisu and malpua with pistachio rabri, we opted for the caramel calvados crème brulee, which tasted somewhat like what I have eaten before at their excellent buffet at Limelight, the coffee shop at the Royal Orchid near the Karnataka Golf Association, off Airport Road. The burnt sugar layer topping was a little too thick, I couldn’t really get much of a taste of the promised Kalhua; maybe that was my taste buds after all those Cosmopolitans!

On the ambience again, while the location is excellent and early reservations can get you a great table, the major irritant was the constant power outages which stopped the music (which was a little too loud anyways) and then the 5 minute routine for getting the lights to an appropriate level every time the power came back on.

So, maybe I am a little harsh in what I write, but I certainly do not feel that this experience matched up to its top 82 restaurants in the world rating. I would rate it as a good experience. One I would certainly come back for. The ambience and the food are different and interesting, well prepared and served but again, certainly not in my top 10 list.

Ambience: ***1/2

Food: ***1/2

Price: ***1/2

Overall: ***1/2  

Harima, Bangalore: Multiple visits

 Harima is located on the fourth floor of Devdutt Plaza on Residency Road and is one of the few Japanese restaurants in Bangalore. As a vegetarian, it is nice to be able to go to a Japanese restaurant and have a choice (this is a nice thing about going to all restaurants in India!). The décor is very quintessentially Japanese. Nice and neat. A general seating area, a small enclosed area (no longer so) and an area with sunken seating. The viewing area for sushi bar no longer exists. 

We have been to Harima a few times now, and enjoyed the food everytime. It takes a slightly adventurous palate to enjoy Japanese food and one must get out of the “masaledaar” state of mind and try and focus a little more on texture and subtle tastes.

We almost never order soup and also avoid the greens in broth as they absolutely lack taste, but there are many who enjoy those and they are very healthy, so don’t write them off on my opinion. Standard vegetarian fare at a Japanese restaurant includes the usual Teriyaki Tofu (fried tofu with Teriyaki sauce; a brown, slightly tangy sauce) and a bunch of vegetarian sushi rolls, which would be stuffed with anything from cucumber, ogobo (pickled root), asparagus, avocado, tofu, eggs, mayonnaise and a combination of the above among a few others. If you haven’t had rolls before they come with wasabi (crushed horseradish), like a spicy mustard and pickled baby ginger. If you haven’t been introduced to it before, please don’t make the mistake of trying a large quantity at once (unless you want your sinuses cleared…forever!). Alternatively, if you are anything like me, convince your guests that it is a light chutney and then sit back and enjoy! Finally, for the routine fare make sure you order the Yasai (vegetable) Yaki Soba (soba=noodles) nice lightly flavoured noodles (also topped with mayonnaise; optional!)

I usually enjoy a warm or cold saki when I visit Harima. It is a nice, lightly flavoured rice wine which comes in a small carafe with small sipping glasses.

Once you are done with the usual stuff and are feeling a little more adventurous, feel free to try out some okonomiyaki (a dish from Hiroshima) which is a pancake usually made of daikon (a type of radish), but here seems to be made of cabbage, topped with teriyaki sauce and mayonnaise (yes, sounds disgusting but it’s not really that bad). Follow this up with some donburi, a rice containing broth.

For dessert, don’t miss the green tea and wasabi ice cream, certainly something for the adventurous palate. If you are lucky, they would have managed to get the red bean confit, which goes really will with the ice cream.

All in all, a good vegetarian Japanese experience with pleasant service and a nice quite lunch environment.

Overall:

Food: *** ½

Ambience: ****

Overall: ****

Price: ****