It’s A Small World After All
In Part 1 of 2, Dr. Deol discusses the cultural differences she has experienced during her international exposure to the world of medicine.
February 22, 2010
I have written several columns recently on the state of health care in the US. I say “column” because I can’t stand the sound of the word “blog”. It sounds like something that will eventually lead to a heart attack rather than a form of literary expression. However, before I launch into an analysis of the bureaucratic differences between nations, I should make a note of some of the cultural differences I have experienced thus far during my international exposure to the world of medicine. So, as I sit on the plane bound from Dubai to Jordan, I will jot down three experiences that I have had with foreign medicine: one as the family member of a patient, in the country of Iran; one as a practicing surgeon in the country of Australia; and one as an American (patient) in Paris.
In 2003, my father-in-law suffered a heart attack at his home in Tehran, Iran. Having traveled there previously on visas I obtained on my British passport, I was comfortable with the intimidating process of passing through their border patrol. However, the nature of this emergent trip necessitated a spur of the moment departure, not allowing me time to obtain the appropriate visa. As happenstance would have it, this was also the same time as the Bam earthquake in Iran. At that time, the country had temporarily opened its borders to the outpouring of International relief efforts. My husband assured me that, as a physician, I would be allowed entry into the country despite the absence of a visa. So, I took a leap of faith (and a shot of vodka) and jetted off to Iran. My US passport was always something that I kept carefully hidden whenever I entered or left Iran, so my plan was to use my British passport to connect with the Swiss Red Crescent team already deployed there.
Upon arriving in Iran, I was granted a three-month visa, the longest I had ever received. I was welcomed with much more warmth and gratitude than I would have ever expected based on my previous experiences in that country. It is amazing what a common sense of purpose, for the good of humankind, can do for International relations. I was then ushered by my in-laws directly to “Day Hospital”, where my father-in-law would be having his surgery. He was admitted the night before, as is common in many foreign countries, to have pre-op testing and to settle in. When faced with the possibility of death, people of every nationality seem to have a common tradition of meeting with their “chosen person” for last minute counseling and/or guidance. For some people, that person is a priest or a rabbi, for others, that person is a Reiki master or spiritual guide, for my father-in-law, that person was his barber. Needless to say, my husband’s family is not your traditional Muslim family. Surprisingly, I did not find many Persians in the massive, bustling city of Tehran to be very traditional. They seemed to be guided more by the “Book of Business Pragmatism” rather the Qur'an. The barber spoke the “word of mouth” which is indispensible to any businessman. As such, once you found a barber who brought you business, he was considered good-luck.
So, as my father-in-law received his final counsel (and a haircut) from his barber, I reviewed his chart. Snag number one, it was written in Farsi. No problem, his surgeon went to medical school at Michigan State University and did his residency at the Cleveland Clinic, so he translated for me as we reminisced about our mutual alumni. Everything seemed to be in order, until we were sent out of the room, while the nurses shaved and prepped the patient. It wasn’t being sent out of the room that bothered me. It was where we were sent. We were given directions to the pharmacy where we were to purchase an oxygen tank for our beloved’s anesthesia. To make light of the situation, I told my father-in-law that we opted for a helium tank instead since they were on sale. I assured him that he would wake up on cloud nine … literally. But I couldn’t help but wonder if there was a Sam’s club nearby where we could purchase the industrial sized version in case one tank was not enough. Or, was there a slot machine outside the OR where we could just insert quarters as needed to keep the oxygen supply going?
There was no specific waiting room, so in true Persian fashion, we bribed an orderly to spy on the surgical progress for us, and keep us abreast of the situation. However, the orderly took full advantage of his newfound importance and milked it for all it was worth by creating dramatic turns of events, which caused everyone to drop to their knees and wail as though the patriarch of the family was slipping away. However, once I was able to digest the translated information, and subtract the dramatic performance, it was clear that everything was proceeding as scheduled. Once in his room in intensive care, I inspected his lines, monitors, and drips, and I was satisfied that he was receiving appropriate, if not excellent care. The following day, he was transferred to a regular floor where his tubes and lines were removed, and I was surprised by the lack of any monitors, which made me slightly nervous.
Despite his cardiologist’s insistence that nothing was needed, I pulled out own my pulse-ox and BP cuff and sat vigil at his bedside for the next 48 hours, during which time I diagnosed the predicted episode of a-fib that so frequently follows this procedure. Reluctantly, his cardiologist ordered the appropriate treatment and Don Corleone snapped back into normal rhythm. It turned out that my butting of heads with his cardiologist was less of a cultural thing and more of a football thing. While I was an MSU girl, he was apparently a U of M kind of guy. It really is a small world. As the competition between the rival universities continued throughout my father-in-law’s five-day hospital stay, we eventually called it a truce and shook hands before I left.
My experience in Australia came from a mini-fellowship I did with a surgeon I consider to be my mentor. What stuck me the most about their system was the civility of it all. The doctors were paid well, the patients were treated well, and the outcomes were honest and good. There was clearly a lack of animosity between doctor and patient, which surprisingly lead to a phenomenon that I was unfamiliar with in my young surgical career: trust. With the element of “ulterior motive” removed from the minds of the patients, what was left was an open honest dialogue which not only allowed the surgeon to make decisions based on science, rather than potential litigation, but it also gave the patient the confidence to follow doctor’s orders, thus leading to better outcomes. I struggled in my career as a bariatric surgeon to uncover the differences in outcomes from one country to another. I identified some as technique and some, sadly, as a manipulation of the data.
In Australia, however, I discovered that the difference in outcomes was a direct result of the honesty than ran wild between both doctor and patient. For example, in one instance I listened to the surgeon explain how things did not go how he would have liked, and if they did not get the results he wanted, he would take the patient back to the OR and try again. The patient digested the information, agreed to keep the surgeon abreast of his progress (which he did), and went home with a clear plan of action (which did not include contacting the law offices of “Gonna, Getcha, Money”). Not only would this plan of action not occur in the US, it would not be covered by insurance and/or the patient.
Part of this ability to create an open honest relationship comes from the lack of a litigious society, and part of it comes from a health care system which allows the patient to receive appropriate care when needed and the surgeon to be reimbursed for said care. When the patient is denied coverage, and the doctor is denied reimbursement, there is a natural adversarial relationship that develops which is fertile breeding ground for litigation.
Currently, Australia has both a public system and a private system. Their public system covers about 67% of all health care expenditures, while private insurance covers about 33%. In order to encourage the purchase of private insurance, there is a tax on people with higher incomes who do not purchase additional private insurance, and incentives for those who do purchase private insurance. This balances out the public funds to be more available for those in the lower income brackets. There is a healthy competition between private insurance companies, which does not set the stage for a monopoly. This system also provides a national database, which can be used for quality review and scientific research. I do not think that any country in particular has achieved the perfect health care system; however, I think Australia’s system deserves a closer look from the team in Washington who is responsible for revamping our own system.
Stay tuned for Part 2 of this column in Tuesday’s First Cuts newsletter.
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Dr. Deol is a self-employed, board-certified general surgeon.