Will US Healthcare Reform Result in Canadian, Mexican or Indian Healthcare?

United States’ healthcare reform is being discussed and debated constantly in America right now, but the discussions appear to be based on many assumptions. Assumptions about what the current “Healthcare Bill” now in Congress actually proposes for one. Someone in the debate will argue that a proposal will turn our healthcare system into the “Canadian’s Healthcare System”, and appear to assume that the listener will automatically understand that outcome to be a bad one. Other countries’ healthcare systems, especially England’s, are mentioned in the same manner.

Since starting this website and blog a short time ago I have received emails from doctors in many countries, which is of course wonderful. As an American doctor who started this website out of frustrations I experienced opening my own practice, I realize I was a bit myopic to assume that private practice issues we face are unique to America. In fact, the issues and the processes are often identical, no matter how a country’s healthcare system is structured. I think it’s safe to say that many things will not change even under healthcare reform because, after all, being an excellent doctor supercedes politics and finances.

Several of the international physicians have kindly submitted articles for inclusion on this website. I hope they represent a trend that will continue as we can all learn from each other. The original tagline for PrivatePractice.MD was “Doctors Helping Doctors” and that’s a sentiment I hope to always encourage. Dr. Lawrence Kindo in India has written several articles. The first is entitled “A Perspective On The Indian Healthcare System” and shares his opinion and overview of the medical system in India. I found it interesting that he believes medical tourism will become a big industry for India, and I had the thought that we American doctors never think about our healthcare system in that way (at least I haven’t). Yet we know that people travel to the US from all over the world for the excellent and advanced medical care available in the US. Dr. Kindo’s other article gives a overview of the training Indian doctors receive. It is entitled “Medical Education In India and the US: A Comparison.” I think you’ll find it an interesting article also.

Dr. Rodrigo Rubio , a Mexican anesthesiologist and MBA student, kindly offered to share his knowledge and insights about private medical practice from a Mexican perspective. He has proposed a series of articles, with the first article talking about the value proposition we physicians bring to our patients. I think you’ll agree that the principles are universal and location- independent.

I encourage everyone to write and share their experiences and perspective.  Please leave comments as well!

Cycle of Value for the Patient – First Stage: Identify the Value

First stage- “Identify the value”

In commerce, when you speak about identifying value what you mean is finding the need the customer wants satisfied, but the market has not provided a satisfactory solution if any solution at all. All products and services in the end try to solve an unmet need and by doing so create a better quality of life. If a product or service doesn´t solve a need it will hardly last because it doesn´t have a reason to exist. Identifying the value tries to find this need.

Not As Easy As It Might Seem
In medicine, this stage sounds easy to achieve but it apparently is a difficult problem. Even with modern medical advances, doctors are repeating the same mistakes that have occurred for years. They earn their medical degree, specialize, set up their practice and wait for patients to arrive. The typical scenario: the patient arrives to the office, signs in, fills out paperwork, then waits for you to see him or her. Finally the patient is escorted to the exam room and undergoes the common procedures (clinical history, physical exam, etc.). You give a diagnosis and finally recommend a treatment. The patient pays and leaves the office.

The idea is that at the moment you meet the patient you need to ask yourself this question: What does this patient need? If your answer is simply to solve their problem that brought them to you in the first place, you are partially right. Partially correct because these days patients need more than just a few moments of your time and your treatment recommendations. Patients are in search of a whole service and your time and treatment are just part of this service.

Let me use an example: There are a lot of people that participate in sports. In Mexico, a popular sport is horseback riding. Horseback riding often causes injuries requiring the expertise of an orthopedic surgeon. In the community of people that practice horse back riding the members often consult the same orthopedic surgeon. Why? It is an easy answer: this doctor found the right niche and bécame expert about the common injuries and pathologies that occur with horseback riding. But there is more to it than knowing about the most common presentations. The best doctor for these patients is one of them. He is an avid equestrian himself, and because of his own riding experience he makes everything possible for his patients to get back on the horse as soon as possible. EVen more, you can often find him at the equestrian events where patients can talk to him outside the office and more as a friend. He does more for horseback riding patients than any other orthopedic surgeon in the area.

Now that you have answered yourself this, you must make yourself this other question:

What else

does patients need?

When you ask yourself this question about what are my patients’ unmet needs, the answer you are looking for goes beyond the expected. Even when you believe you have an answer you must question it again and again. Always ask yourself “What else does my patient need?”

Get Specific and Personal
Up to now in this discussion, we have made the question generic. Now it is important to make it personal. Ask what does MY patient need? I must admit that I really hate it when doctors say “my patient” because it is egocetric and they have not understood yet that doctors don’t have patients, patients have doctors (do you know how many of “your” patients are loyal to you?).

Now that we made clear this topic, asking yourself the question: what does my patient need? You pretend to find an answer that is specific to you and your practice. You have to remember that little things make big differences so maybe patients are not just searching for the doctor that have more titles or articles published, maybe they want smaller things like punctuality, to be heard, empathy, respect etc.

In identifying the value big companies in the world spend a lot of money doing research, market studies, focus groups and whatever else to understand what people want so they can attempt to give it to them. For physicians it is a little bit harder to do such big research studies. But there are ways to find this value with small polls or surveys that you can give to the patient at the end of the consultion, or via email. Be creative. It is also very important to listen to your team, your receptionist, nurse, administrator, assistant etc. They spend a lot of time with your patients and hear feedback patients may not share with you. You need to listen to what they have to say.

So think about it, talk to everyone, and always ask yourself questions to try to find out WHAT DOES YOUR PATIENT NEED?

Rodrigo Rubio, MD
Mexico

Medical Education in India and the US: A Comparison

Medical education in India encompasses allopathic medicine and other indigenous systems of medicine. Allopathic medicine is by far the most favored of all systems because of its wider acceptability and global recognition. This article deals only with allopathic medicine.

Like in the US, medical education in India involves a lengthy and arduous process.
Pre-University Course or HSSLC: It consists of pre-university studies or Higher Secondary School Leaving Certification (HSSLC) in the Basic Sciences with Physics, Chemistry and Biology as its major subjects for 2 years. A prospective medical student should have attained an average of 50 percent of the marks to qualify for medical education. A prospective medical student should apply for various competitive exams to attain a seat at any of the medical colleges or universities across the country. In the US, this stage is termed undergraduate education and consists of 4 years.

The Medical College: A medical college is a medical institution approved by the Medical Council of India (MCI) to train medical students and confer them the MBBS degree, also called Bachelor of Medicine and Bachelor of Surgery. Medical colleges are state-owned, state-aided or private institutions.

Undergraduate Medical Education: Five years of meticulous study of preclinical, paraclinical, and clinical subjects prepare the medical student to appear for four quality assured professional exams through the years of study. The preclinical study consists of one year study of Basic sciences like Human Anatomy, Human Physiology and Human Biochemistry. This prepares the way to a more thorough and in-depth overview of paraclinical subjects of Pathology, Pharmacology, Microbiology and Forensic Medicine for two years. This is accompanied by an introduction to the clinical sciences and learning in the clinical setup. The next one year covers Community Medicine, Ophthalmology and Otorhinolaryngology with clinical insinuation and glimpses of the practices of medical and surgical specialties. The last one year is dedicated to the clinical subjects of Medicine, Surgery, Orthopedics, Obstetrics and Gynecology and Pediatrics with all the sub-specialties. Having cleared the Final Professional examination, a medical graduate is required to complete one year of internship covering various specialties.

Internship Program: It consists of one year of rotating internship in various specialties. Only on completion of the internship is a medical graduate awarded the MBBS degree and a license to practice medicine anywhere in the country as a General Practitioner or Medical Officer. He is also prescribed the title Doctor. Permanent Medical Registration is required either in the Indian Medical Council or State Medical Council to practice. This is in contrast to the 3 to 7 years residency program required to practice in the US.

Post-Graduate Medical Education: This equates to the residency program in the US. Entrance to a Post-graduate degree program is through competitive exams conducted by the concerned college or university. It consists of 3 years of study to achieve an MS or MD degree in any surgical or medical specialty respectively. Following this a Doctor in India can practice in that said specialty as a medical or surgical specialist. There are also post-graduate diploma programs and Diplomate of National Board (DNB) programs for furtherance of medical education. Fellowship programs in various specialties can also be pursued.

Super-Specialty or Sub-Specialty Medical Education: A doctor who has attained a specialty post-graduate degree is qualified to pursue super-specialty or subspecialty education in their field of interest.

A medical graduate in India has the license to practice the broad specialties of Medicine and Surgery but is required to refer patients to a specialist to handle problems that require a particular expertise. Thus, it can be a long journey for the Indian medical graduate before he can settle down, unless he/she is satisfied to practice as a general practitioner.

Dr. Lawrence Kindo

A Perspective on the Indian Healthcare Industry

India devotes only 5.1 percent of its GDP in the health sector. India’s burgeoning healthcare sector has created waves across the world with its enticing medical tourism venture. This and a steadily rising economy have been the two factors that have made the Indian healthcare industry a serious contender to global healthcare leadership. Despite these developments, the health status of millions of its citizens remains below standard. Utter ignorance in the rural areas and the blatant misuse of people’s money by those in power has brought about a vast difference of healthcare status between the rich and the poor.

The Indian healthcare industry is a conundrum. The state-of-the-art healthcare institutions in the public sector cater only to the few that make it to the privileged list. The few mentionable exceptions are just a handful. Most of these so-called centers of healing are very poorly equipped in terms of manpower, medical equipments, and resources.  The input from the government coffers for these institutions is quite less compared to the population it has to cover, but misuse of resources have made an  indelible mark in the Indian public healthcare sector making the scenario worse.  Surprisingly, only 0.9 percent of the country’s GDP is dedicated to the public healthcare which is a gross understatement. There is much to be done to recover the lost glory of these government-owned institutions, and most people are much too disillusioned to try anything new. The healthcare education provided by many of these institutions is also below par and need overhauling.

With regard to the private sector, the monetary aspect is ingrained deeply, and most of these institutions cater to the high and mighty. Exceptions are few and far between where healthcare is provided without this distinction. Charitable institutions worth mentioning are few. About 4.2 percent of India’s GDP lies in the private health sector. This makes healthcare costs reasonably high, driving most of its own citizens to the doors of dilapidated government institutions which merely exist. The investment made by these private institutions is recovered by a steady flow of medical tourists from across the globe. The comparatively lesser cost in these high-end institutions is a boon to the medical tourists who avail the same treatment at a fraction of the cost they would have incurred abroad. An estimate that a mitral valve repair surgery in India would cost only around $ 7000 compared to the $ 200,000 in some of the hospitals abroad is just the tip of the iceberg. This is just one example of the cost-benefit aspect for foreign medical tourists. The healthcare standards in these institutions are comparable to those abroad and hence are a low-cost, affordable option to foreigners. Qualified and experienced specialists in different medical and surgical specialties, excellent nursing and paramedical staff, and affordable charges make these institutions successful and popular.

Medical Tourism Can Provide Much Needed Capital. Having stated these differences, there is hardly a reason why one should not consider options elsewhere when healthcare costs are high. Numerous other countries have made inroads in the medical tourism industry making billions in the process. Medical tourism has rooted itself deeper due to the current depression in the world economy forcing people to look for viable options. India is a rapidly growing economy and would look at medical tourism seriously if it ever thought of making a mark in the global market.

Dr. Lawrence Kindo
India

Rural Primary Care Denied

Garden Vegetables To Thank The Doctor

Today one of my patients kindly gave me a basket of tomatoes and other vegetables harvested from her garden just this morning. I was touched by her friendly gesture, and surprised because I practice in that urban mecca called Hartford, CT. I’m not sure how many productive gardens there are near me (not to mention that few tomatoes have survived the blight wiping out the tomato harvest in Connecticut this summer).

Reflecting on my day during my drive home, I recalled a wonderful and eye-opening family practice rotation during my fourth year in medical school (1987) to fulfill the AHEC requirement. I lived with a family practice physician’s family in a small central Ohio farming community for one month. Everywhere she went, I went. I scrubbed in and watched her deliver babies. I observed her examining endless patients in her office until early evening many days, helping or assisting when I could, and then went to her home for dinner before crashing into the spare bed in her guest room each night to sleep. Her family welcomed me, as did her many patients.

Maybe Doctors Feel Like Celebrities in Rural Communities (but are too humble to admit it.)

By the end of the month I was recognized and greeted as “doc” by people I passed on the street as I walked to the post office or corner store (pretty cool experience for a new doctor), and I couldn’t help but smile and feel lucky to be there. These patients often brought my hard-working preceptor vegetables from their garden, or a freshly baked pie, or a scarf knitted just for her. Clearly they welcome their doctors into their lives as another family member.

The family practice rotation accomplished its goal of exposing a city boy to rural primary care medicine. I didn’t even think about the logistics and practice management aspects of my preceptor’s practice, so different from others I had seen up to then, or talk to her about her salary. She mentioned she loved the “life of a country doctor” and “don’t consider it if you want to make a lot of money”. Practicing medicine for the sake of practicing medicine, and being such an important part of these patients’ lives and families, was definitely appealing to me.

What Do You Mean You “Want To Be A Country Doctor”?

When that rotation ended, and I returned home to my reality, I was convinced I would follow in that inspiring family physician’s footsteps and hang up my shingle in a small rural town someday. Alas, it was not to be. For reasons you can guess, trite reasons to some degree I’ll admit in retrospect, I was tempted by the fruit of other specialties and ended up denying my dream of a rural primary care practice. It was the right decision for me then, and I enjoy my medical practice now, but I still remember that very special experience in small town America and sometimes even let myself wonder how my life may have been different had I chosen that career path.

A basket of garden vegetables brought it all back for me today.

Ideal Medical Practices

In my constant searching and researching for useful information to share with my fellow physicians in private practice, I have found a number of useful and interesting blogs and websites which I will share with you from time to time.

Recently I discovered the blog Ideal Medical Practices which is a group or collaborative blog (like I’m working to build here at PrivatePractice.MD). In their own words, the authors state their blog’s purpose is “to pursue, support, evaluate, and educate others with regard to delivering superb health care in a vital and sustainable environment. ” I share that goal!

Currently they are sponsoring a blogging contest for participants at their IMP Camp in Seattle, WA August 14-15, 2009. Participants will blog at the camp about their concept of an ideal medical practice.

Go check it out. I think you’ll find it as useful and interesting as I have!

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