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Tuesday, October 30, 2012

What is health care like in India, why do Indian doctors come to the US and why are so many patients septic these days?

Lately I've been working in an unfamiliar state in a rural, but not small, hospital, and have been noticing all kinds of curious things. This is not the first time I've noticed these curious things so now I am sure that they mean something.

1. There are a lot of Indian doctors, especially in small towns in the US.

2. Small hospitals outside of major metropolitan areas often find it difficult to hire physicians, even though they pay lots of money.

3. There are many foreign doctors in the US who are not employed as physicians. They often work in hospitals but not as doctors.

4. In many hospitals patients are admitted to the hospital when they are not very sick and then proceed to have scads of tests and procedures done that are really expensive and not particularly helpful.

5. People who are not particularly ill get admitted to hospitals with the diagnosis of SIRS (systemic inflammatory response syndrome) which is a kind of synonym for "sepsis". (When I was training, sepsis was actually a really dangerous condition of which one might reasonably expect to die if not treated aggressively.)

A little more on SIRS. When a person gets really sick due to a life threatening infection, the body turns on all of its resources to kill bacteria. Our temperature goes up, our heart pumps faster, the blood vessels dilate, we breathe faster. Our white blood cells come out to fight and if we are really sick they are consumed in the battle. The 4 criteria for systemic inflammatory response are a high heartrate (over 90), a high or unusually low temperature, a low carbon dioxide level or high respiratory rate and a high or unusually low white blood cell count, especially with immature cells present. If we have two of these we qualify for SIRS. Today I had two patients with SIRS. One was a woman who developed chest pain while barbecuing, came in, belched and it went away. Her tests were all normal except that she had a slightly high white blood count with immature cells and a low temperature. She also felt fine. She was started on heavy duty antibiotics and had a super expensive stress test and went home, grateful for the care she had received, which was actually completely unnecessary. The other one was a man who was chronically ill with hepatitis who had a cough. He was bedridden so when he got to the hospital his heartrate was somewhat elevated and his respiratory rate was up, and because of the hepatitis he had a low white blood count. He was diagnosed with pneumonia and SIRS. I know what pneumonia with sepsis looks like and it is a medical emergency. It is also not what he had. He had a cough and some changes in his vital signs.

So why does everybody and his brother have SIRS now, even if all they have is a cold? Because hospitals get reimbursed according to how sick the patients who are admitted to them are, and hospitals pay our salaries. And when a hospital does well they get remodels with big fish tanks and fountains and flat screen TVs which makes everybody happy. So in another few years when they do studies on survival from SIRS, they will find that we are much better at treating this dread disease than we used to be. Probably because we have better antibiotics. Oh yes, that must be it.

At this hospital where I have been working I met two interesting doctors from India who were not doctors in the US. One was a cardiologist who was working as a computer tech at the hospital, teaching people how to use the computerized health record system. She was planning on doing a residency in the US which is what she will need in order to actually work as a doctor here. She will have more, but very different experience, than the other residents in her program, since she has already done a residency and fellowship training, but she will also have to settle for a probably not excellent training program because, as an Indian trained physician she will not be very competitive. The other was a dialysis and IV tech who was the go-to person when any intravenous catheter was needed. He had finished medical school but never practiced as a doctor in India, but he did own two hospitals there, which his brother was running while he was in the US. He answered several questions I had about medicine in India.

In India there are private hospitals, which are entirely funded out of pocket, and there are government hospitals, which will serve anyone who can't afford to pay. Most people prefer private hospitals because the care is better and the hours are better and because they are actually pretty inexpensive. "If you need a coronary artery bypass," my friend said, "and you have $2000, we can get you one." They buy medical equipment from China, where it is cheaper than in the US. He bought an EKG machine for $1700 that he priced in the US at $17,000. This allows him to provide services for costs that regular people can afford.

So why do Indian doctors want to come to the US, then? It sounds like things work pretty well there. Actually things don't work very well there, from many different perspectives. Infant and maternal mortality rates are very high. Emergency care is extremely poor, even in big cities. Here we pride ourselves on getting peoples' heart attacks and strokes treated within an hour, which saves people from long term disability. We have well trained paramedics and EMTs who can rescue people in the field who have accidents or injuries. This kind of care is rarely available in India. And then, of course, there is the money.

Doctors in the US can make a lot of money. Huffington Post had an article that looked at the best paying jobs in the US, and doctors and surgeons were at the top of the list. The doctors who make the most are in varying fields, some of which might be considered the dirty jobs that nobody in their right mind wants to do. Some of these dirty jobs are in the field of internal medicine, my chosen specialty. Internists often go on to specialize in hospital medicine and nephrology (kidneys) which are jobs that put one in the position of always treating patients who are pretty sick and having terrible hours. Hospital medicine is usually in 12-14 hour shifts during which one must see a crew of up to (or even more than) 20 patients, all of whom could, conceivably, need the doctor at the same time. Nephrology involves knowing the sickest of patients, folks whose kidneys no longer work, who have dialysis 3 times a week, which they don't love, and which is the nephrologist's bread and butter. It is not at all uncommon to see a large proportion of hospitalists and nephrologists who are graduates of foreign medical schools, especially Indian ones.

Doctors in the US have to put up over a quarter of a million dollars just to go through medical school, and since a fair portion of this for US trained docs is funded by loans, early in a doctor's career quite a bit of salary goes into paying off loans. In India, though, tuition and fees at a medical school are nominal. The medical education system is run by the government, or so says a friend who trained there, and many (though not all) of the schools are excellent. Education is in English, so Indian doctors do not have much of a language barrier once they have finished school. How very very tempting to come here, repeat a little medical training and then make more in a year than you could in 10 or 20 years in India. But why the US? Certainly other countries also pay doctors huge amounts of money. Well, actually, no.  Although some articles looking at cost of living and such say that the US is right in line with other developed countries, I don't entirely buy that. Our absolute salaries are definitely higher, and a person can live on very little money in the US if they put their minds to it. A doctor practicing long hours can eat at the hospital for next to nothing, sleep and shower there, and some do, especially foreign medical graduates, who are probably supporting whole extended families on their very generous paychecks.

So here's how it goes, how the little mysteries arrange themselves.  America loves medicine (gross generalization, but based in truth.) We pay our doctors really well (except primary care, because it's sexier to cut people open and save them from the jaws of death than keep them from getting sick in the first place.) We have to be paid really well because medical education is really long, hard and expensive. Hospitals are becoming the pocketbooks for the American healthcare dollar. They
pay us really well because otherwise we would refuse to work for them. They get us to admit lots of really not very sick patients in order to stay in the black and we cooperate because they pay our generous salaries. Patients get procedures that they don't need and become convinced that they are really sick and really depend upon the medical profession or they will certainly die (of sepsis.) Foreign physicians come here because the pay is so good that it is worth working in hospitals that are in the middle of nowhere after journeying far from the land they love.

What is the actual problem, though? We are wasting our time and energy treating patients who are not sick and convincing insurance companies that they are sick. This is bad for everybody. Some of it may be driven by fear of being sued, but more, I think now, is driven by money. We have such wonderful technology now for treating truly sick and salvageable people, but we waste it on people for whom it is not appropriate. It is not a problem that we have lots of foreign doctors (other than the issue of stealing them from their generally underserved countries.) They have interesting perspectives and skill sets and they take care of patients in rural areas and in unloved specialties. The fact, though, that foreign doctors are flocking to our shores may mean we are paying doctors too much money.

Second thoughts about my ranting:
In addition to the apology, above, to hospitals which are trying to make enough to survive, I realize that I have also been somewhat misleading to patients who may be reading this and have been admitted to the hospital. There are still plenty of patients admitted to the hospital for very good reasons. There is no actual shortage of really sick people, truly and dangerously sick people. But there are more not-very-sick people in certain hospitals than would be ideal, and once admitted, such not-very sick people can stay there for a long time. (An old adage says "no reason to admit means to reason to discharge.") The culture of a hospital and the population it serves determines how many of the patients inside are really sick. Some hospitals are at capacity for the population they serve, and simply cannot admit patients who don't really need to be taken care of in a hospital. Inflating the severity of illness in documentation is common even in these high acuity hospitals in order to get stingier payers, like Medicare or Medicaid, to pull their weight. These two entities pay far less than private insurers and usually require much more specific documentation. They will pay our hospitals more if we, for instance, document "hypokalemia" when the patient's potassium level is a little low, but if we say "the potassium is a little low" that won't count. So we end up making long lists of little picayune things that are wrong using big Latin derived words which makes a patient appear to be horrendously complex and gravely ill. Right now I could probably give myself a list of dire sounding diagnoses if I really put my mind to it (I'm thinking rhinorrhea, actinic keratoses, menopausal syndrome, shift work sleep disorder, presbyopia, irritable bowel syndrome, female pattern alopecia, chondromalacia of the medial femoral condyle, bunion deformity) though I'm actually vigorously healthy. Just going through this exercise makes me want to start thinking about buying a prepaid funeral policy. I will continue to assert that inflating diagnoses and severity is wrong, but it is based in our perverse payment system, not a result of individual greed or dishonesty. 

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