After almost twenty years I experienced the United States (US) medical system up close and personally. A close family member underwent a major ‘joint replacement’ operation.
Twenty years ago I was a surgeon performing open heart operations in US hospitals. Now in a role reversal I was in the hospital as a relative of a patient.
As a physician it was often difficult for me not to ‘interfere’ in how my patient was being treated but then I realised that a patient’s relative however qualified a physician he or she might be would only make things worse for the patient by interfering too much.
So, I restrained myself and let the medical staff in the hospital do what they were trained to do. Frankly the nursing care was quite adequate and there was little I could really complain about.
Now to what has changed since I last operated in the US some twenty years ago. Most changes were already starting to happen when I came to Pakistan all those years ago. Obviously actual medical treatment evolves as it always has, based upon new medicines or new surgical procedures and refinement of existing methods.
From my perspective I have stayed pretty much in touch with newer treatments and surgical procedures that have become established in the US. Also, many if not all the new treatment options available in the US are also available in Pakistan.
The major change in how medicine is being practised in the US at this time is the ever increasing ‘paper work’ that happens before and after any hospital stay. My physician friends and former colleagues had complained a lot during the last many years about how they were all ‘drowning’ in this paper work.
But during this visit I also saw how the patient was also being inundated. Simply put even if a patient has excellent health insurance, without the correct approvals, some or all payments could be denied forcing a patient to pay thousands of dollars ‘out of pocket’.
Also before undergoing surgery the patient has to sign all sorts of consent forms. The one consent form that surprised me was about receiving a blood transfusion if needed. During my time, blood transfusions were an accepted part of any major operation and a separate consent form was not needed.
During the 1980s when the AIDS epidemic was happening in the US, as we found out, many patients that received blood transfusions during surgery developed AIDS later on. So a determined effort was made to cut down drastically if not completely on blood transfusions during surgery.
Once the virus causing AIDS was identified, blood was tested and transfusions became safer but the efforts to reduce the use of blood transfusions continued. It became such that for a while giving a blood transfusion to a patient without appropriate and accepted medical reason and without the patient’s consent was considered almost a criminal act.
One ‘improvement’ that has occurred in the US is that hand written medical prescriptions are becoming rare. Most doctors now e-mail the prescription directly to the pharmacy and the patient can pick up the prescribed medicine from there. This has taken care of many prescription errors that occurred due to ‘illegible’ doctor’s handwriting.
The major change that I saw in patient care was the almost complete reversal in prescribing medicine for pain. Due to the ‘opioid overdose’ crisis in the US with thousands dying every year, prescriptions for ‘habit forming’ pain medicines have become very difficult to obtain due to legal restrictions and official oversight.
Twenty years ago the emphasis was to make a postsurgical patient as comfortable as possible and even strong pain medications were prescribed freely. Today the pendulum has swung in the opposite direction and getting adequate pain medicine after surgery has, as I found out, become quite difficult.
In summary, what physicians do has not changed much but what has changed is how they do it. The attempts to cut down the number of days spent by a patient in a hospital after surgery or during treatment for a medical problem was already happening when I was practicing in the US but it has now become much more ‘aggressive’.
And at least as far as surgery is considered, the surgeon still has to ‘physically’ perform the operation. An autonomous machine cannot yet replace the surgeon although algorithms are rapidly replacing a lot of medical decision making.
Now a comparison between how medicine is practised in Pakistan and what I observed in the US last month. Obviously, Mayo Hospital cannot be compared to any modern hospital in the US. However, some of the better run and pricier private hospitals that can stand some comparison.
Even though many of our medical consultants are now locally trained and have never worked in a modern western hospital but information available on the internet has made it possible for any physician to know what is happening in the world of medicine. That said, these are important differences in how patients are treated in Pakistan and how they are treated in the US.
Without generalising too much, it is fair to say that doctors as well as most members of the medical profession, including hospital administrations are much less sensitive to the rights of the patients. Yes attempts are made to improve how patients are treated. But without a proper ‘malpractice’ legal system that punishes bad medical practices there can be little uniformity in patient care.
In the case of my patient in the US, there were a series of meetings between health workers and the patient to educate the patient about virtually every aspect of the procedure and what normally happens before, during and after the operation. The patient was even provided with access to movies showing the operation being performed on a real patient.
The surgeon made a point of meeting the patient and a close family member (me) just before the day of the scheduled operation to explain the procedure one last time and answer any questions the patient might have. All this is accepted medical practice in the US.
In almost a decade of medical practice and having many close friends and family members undergo major operations in Pakistan I have always missed the efforts to educate the patients and explain everything to them as even I had done when I was practising heart surgery in the US.
I have often heard the excuse from my colleagues and other physicians in Pakistan that patients don’t really want to know all the ‘gory’ details about what happens during and after a major operation. My personal experience in the US as well as in Pakistan is different. Even the most illiterate patient really wants to know what happens.
And that is the biggest difference between how medicine is practised in the US and in Pakistan. Patient education is not usually considered a priority in Pakistan. As a consequence of this lack of education if things don’t work out as expected the patient and the family are often entirely unprepared.
The author has served as Professor and Chairman, Department of Cardiac Surgery, King Edward Medical University