I’ve spoken a lot about the poor financial conditions for patients in Nepal, but there is another population here that falls victim to the same struggle which is hard for some westerners to believe: Doctors.

Over here, when you hear how physicians are compensated, it makes you want to cry. It’s not enough, plain and simple. Not when you give up your twenties buried in books and then finish your specialty training in a system that has little employment opportunities, forcing you to take meagre positions. It’s not a money-making career; it’s barely even a money saving career.

This feels especially cruel when you realise they are far more than just doctors here, they are important community figures. Every day on service I watched the attendings embrace with patients in a manner more intimate than I would expect, ‘this is a friend of my uncle,’ ‘this man has been my patient for 12 years,’ ‘this person is from the neighboring village to mine.’ They deserve so much more.

Some of their personal stories I heard were the stuff of literary writing.

One had to send his child away to Khatmandu to stay with his father-in-law because he was tied to his work at LMC and there were no good schools or opportunities for his son here. From a rural village, his mother was sick and his brother had alcohol dependence.

Another lived here to provide for his wife and daughter in another province, seeing them sparsely throughout the year.

I had another tell me about how he grew up in a village where there were no roads until he was in seventh grade, and no electricity until secondary school. It sounds like I am talking about an old-head who trained decades ago, but this guy was my age, still in training. 

‘When I was in school I studied with a kerosene lamp,’ he told me. ‘I was determined to find opportunity outside of my village, so I studied and studied. I had to score first in the district on the secondary exams to get a scholarship to study medicine and I succeeded. I then had to do my medical officer years to save money for residency. In America you make a salary as a resident, yes?’

‘Yes, that’s right,’ I answered.

‘Here in Nepal we have to pay for our residency. Can you believe that? It costs around 20 000 USD a year for us. They work us so hard. Even if they ask us to do things that are not reasonable, violating our duty hours, they threaten us saying that we will not be able to write our membership exams if we don’t do as they say. I cannot change anything now, but someday I will,’ he told me.

A sentiment I understood.

These residents work 24 hour calls every three days all through their residency. The only ‘weekend’ day is Saturday. And they still round on Saturday mornings but get the afternoon off from the clinic. They work so goddamn hard for such little pay, it makes us all over the West forget to appreciate how lucky we are.

Just about every resident I spoke to said their master plan was to get out. Australia, America, the UK, anywhere that paid better and gave them real security. Many would try but not all would succeed. The brain drain continues.

I remember in my own hospital in Philly as a final year resident when there was a push to unionize. Whispers were going around, with people taking up the mantle of the disgruntled workers against the corporate machine of PennMedicine. Honestly, at first I couldn’t believe it. It nearly even made me angry. 

You guys don’t have a damn clue what it means to have lousy working conditions, I remember thinking to myself. Pennsylvania Hospital was a utopia. Yes, I worked a lot, but it was manageable. It was a positive workplace, with possibly even too much kumbaya than was good for us. I made a comfortable living. I went on vacation. I went out to eat with friends. I got a food stipend and a company phone. I even got to save money. Then I walked out of training into a career that pays absolute fortunes. Imagine what these guys would do for that.

It turns out that the residents in Nepal were craving that kind of set up. In my last week at LMC, I showed up to morning conference and found the room empty. I waited for a while and then put a message in the group chat. I waited for a while longer and clued in that something wasn’t quite right.

‘Dr. Juan,’ Dr. Himal said, appearing in the doorway. ‘I am sorry nobody told you. The residents have gone on strike today, they will not be coming.’

‘You don’t say,’ I answered.

‘Dr. Udip is rounding in the ICU if you would like to join him,’ he said.

So I walked to the ICU and found a Dr. Udip somewhat out of his element writing notes on patients and reviewing charts.

‘I will be your resident today,’ I said.

He laughed.

One of the medicine residents scheduled to be on call for that day was the only one to join us. We worked through rounds together, just three people instead of the sentient mass of white coats that usually buzzed from bed to bed like gnats. Rounds certainly went by much quicker than usual, although I am not sure I can comment on the change in handwriting in the charts.

Walking into the courtyard after rounds I found the gnats jumbled en masse in-front of the admin building.

They were picketing.

Chatting with the picketing residents, I learned that the strike had been coordinated by a central resident interest lobby in the capitol since there was no formalized union. The strike itself was limited only to outpatient and elective services, in an attempt to impact the financial bottom line of the institutions as opposed to compromising patient care. This also meant that the 4 attendings now had to man the 160+ patients a day in the outpatient clinics. They were striking because residency training pathways in Nepal fell into one of two camps: government programs that paid a salary, and private residencies that didn’t. The national regulatory body for medical education had no controls for pay or duty hours, leaving the system ripe for exploitation. The intention was to spur government officials in the regulatory body to make it a policy that residents must make the same salary across government and private programs and protect duty hours from abuse. Good for them I say.

The absence of the residents made the last three days of my attachment take on a far more relaxed disposition. I took the chance to catch up on some writing and put some pieces together for the triumphant return of money to my bank accounts. Paperwork was taking shape for a pretty sweet job requiring my services for 6 months a year, leaving me the other 6 to keep this party going.

I couldn’t help but feel a paradox of injustice when I sat across from Dr. Udip, Pandey, Yadav, and Himal at my farewell dinner. Here were these heroes of what it means to practice good medicine from the soul, thanking me with gifts of food, drink, trinkets, and a positively good time. All the while, the work contract I had just signed would have me making double their combined salaries for half a year of work. It’s unfair. I should have been the one thanking them.

So it is in my final reflections on my time in Nepal that I realize I will forever remain in the shadow of the Pandeys and Udips of this world, who give themselves to their people when so many others flee in search of more prosperous pastures. They are my inspiration. I can only hope to pass their stories along through these journals. Don’t toot my horn, toot theirs.

And as always, thank you for reading.

Until next time,

Juan