Tuesday, April 10, 2007

Medical Missions and Capital Markets

I recently went on a medical mission trip to Managua, Nicaragua. At risk of totally blowing my internet anonymity, I'll admit that this wasn't my first trip to this location. As a veteran missionary, I feel that I may have developed some perspective. This post is going to quickly touch on some salient points that I think are often overlooked in foreign medical missions. This is more of a rant than a well organized post.

The problem in Nicaragua (or India, Malawi, Haiti, etc...) isn't a lack of medicine. The lack of medicine is a symptom. The problem isn't a lack of doctors; heck, Nicaragua has "universal healthcare." The problem is an underdeveloped economy. Let me clarify:

Most of the patients that I saw in Nicaragua live on less than $2/day. The majority of our interventions were minor. We gave out huge amounts of Ibuprofin and Amoxicillin, with the occasional package of iron pills . The first thing one might notice about this, is that all of these things are really cheap. In fact, they probably all cost less than the average american spends on coffee in the morning. Yet, my patients in Nicaragua couldn't afford them. You see, the problem here isn't a lack of access to healthcare; it's a lack of money. All Nicaraguans have access to "healthcare," but this healthcare often lacks even the most basic interventions.

Don't get me wrong, I actually love helping people in Managua. My work there is a selfish endeavor, and I derive a level of pleasure from what I do that probably supercedes what I can give to the people who I am helping. However, I cannot save Nicaragua. The larger organization that I work with is trying to start a long term clinic, but even this is unsustainable without continuous contributions from the outside. It is most definitely not self-sustaining. It can't be. To be self-sustaining, a project has to atleast break even. To break even, someone has to pay. For someone to pay, someone has to earn some money. For people to earn money, there has to be an economy.

In the end, I could probably do more for Nicaraguan healthcare by building a factory or even promoting tourism. A higher income by the average citizen would do far more to create a healthier life than I ever could. A water supply that didn't have parasites, which requires money to maintain, would do more for health than I could even dream of doing. Higher income correlates to higher education, better access to healthcare, and a better quality of life. Until then, I'll continue to go down and catch an occasional emergency in a sea of ignorance and poverty. It's sad, because I know that there is a way to fix it.


Anonymous Old_boy said...

Very good post! ...and so true.

Reminds me of Mountains Beyond Mountains about Paul Farmer. He has done great things in Haiti, don't get me wrong. But a functioning democracy would do far better things. He should stop extolling the virtues of Cuba and make nice with US business interests that may be able to create a growing economy, which in turn will improve healthcare.

10:36 PM  
Blogger MiamiMed said...

I've actually had many conversations with people about Dr. Farmer with the exact same premise. Thanks for the post.

5:57 AM  
Blogger Med said...

ya thats true.. i come from india.. But its not that bad in here. peolpe can affrord though they are poor, but they cant afford affordable health care.

12:32 PM  
Blogger MiamiMed said...


I'm really interested in your perspective as a foreign physician. Could you clarify your response a bit?

4:53 PM  
Anonymous Half MD said...

Your post is very insightful, miamimed. However, no one is going to want to be the outside source of funding for the Nicaraguans. While we may spend a week there or throw a few dollars at the clinic, few Americans will commit to protecting the citizens of another country.

When I was shopping in one of the convenience stores, I noticed that a bottle of liquor was cheaper than a box of cereal. I think that there are other problems beyond just the economy. The whole nation suffers from a culture that puts some priorities---such as church and protecting the family name---above other, more economical ones---education and proper hygiene.

10:57 PM  
Blogger MiamiMed said...

Hey Half, Thanks for the reply.

I agree that the culture has something to do with it. In fact, the recent election of Ortega shows a pretty significant disinterest in the development of a strong economy. However, part of the reason that Liquor is cheaper than cereal, is that by and large, Nicaragua produces its own liquor (Flor de Cana being pretty good actually) but doesn't produce most of its own cereal. The ready availability of liquor is a testament to part of the economy that's working well.

There is a lot of ignorance when it comes to hygeine, and that hurts. However, a well developed economy, where people have more money tends to create atleast some basic knowledge about these sorts of things, and basic hygeine becomes a pre-requisite for work. With something like 40% underemployment in the country now, this is not happening.

Overall, I think that you're putting the chicken before the egg. With many people making less than $2/day, even clean clothes and a toothbrush are real expenses. Economic development needs to come first. Which means that a government that is accomodating to economic development is vital.

I agree with one thing you said for sure. Most Americans won't spend lots of money on Nicaragua. That's my point. What we do is a band-aid, because we won't have the resources to do more. In order to truly fix things, they need a stable growing economy capable of supporting a quality healthcare system.

6:07 PM  
Anonymous Karen said...

Miamimed, just wanted to compliment you on your series of articles here, especially on the economics of residency.

I'm in training to be an NP myself-- I'd considered going the MD route, aced all the tough courses in O-chem and cell biology and even kicked a** on the MCAT, but when I saw how awful residency was not only for the surgeons but also for the internists, even the peds and radiologists (who also have to take night call), and all this on top of a horrifically crushing debt, I realized that medicine is probably a terrible career choice these days for otherwise bright people.

I hate to say that but it's the truth.

Like you write, medical residents seem to get the worst of all worlds-- they're cheap labor and everyone knows it.

One of the things that convinced me away from medical school, was encountering a depressed, sleep-deprived IM resident who was post-call-- up for about 28 straight hours-- who was in a state of zombie-ness, getting abusively yelled at by his attending physician for some minor issue or another at a time when he could hardly process his own name in his exhausted mind, let alone detailed medical decisions. The volume at this hospital was so high, he'd had something like 5-6 very complicated admissions overnight on top of his beeper constantly going off. No sleep.

A couple weeks later, I learned that this poor guy had wound up in a nasty car accident. He suffered only minor injuries himself, but his car was totaled and he was financially ruined by it-- his car insurance premiums were so sky-high that he couldn't afford another car, and had to arrange some awful car-pooling stint in a place with so-so public transportation. (This was in northern Cali.) The other medical residents at this place were to a man and woman, burned out, frustrated, constantly with bloodshot eyes, broke (in serious debt), and generally quite bitter, with good reason. They're busting their tails for 80 hours a week as cheap labor and they're now indentured servants.

And note-- this was *after* the work hours limit rules change which "reduced" residents to 80 hrs a week but still permits these ridiculous 30-hour shifts.

Now, my understanding is that in the old days, even though residents had 30-hour shifts, they still slept the vast majority of time on call, often 5-6 hours or more, being woken only for emergencies. Hospitals weren't supposed to be doing admissions all throughout the night, except for emergencies, and when those admissions came, there'd be a sort of night float system for them.

But now, with the volume at big hospitals so ridiculously high, the acuity so unbelievably awful, and the staff at hospitals so woefully low (again, cost-saving bullsh*t at the expense of the residents), residents routinely work all the way through the night. "On call" is no longer "on call for emergencies" but working literally for 30-hours straight. And worst of all, you don't get paid any overtime for it, you're paid below minimum wage. On top of that, you have to pay ridiculous fees for all the damn board exams and licensing boards that come up during med-school and residency.

I've given career advice talks to bright-eyed and bushy-tailed high-schoolers and top-drawer college students heading for Phi Beta Kappa, and I routinely discourage them from seeking a career as a doctor. Your finances and your health are basically ruined by medical school and then residency these days, and when you get out as a young attending, the malpractice environment is so awful that even if you never slip up, you're gonna be sued 3-4 times in your first 10 years, with all the financial and emotional strain that causes.

Heck, these days, even dermatologists and ophthalmologists doing cosmetics (let alone more serious pursuits like dealing with drug rashes or healing scars) are slammed hard by malpractice.

To add further insult to grievous injury, now Congress is harshly cutting Medicare reimbursements for doctors, whose income even after residency is plummeting across specialties. Unless you're doing Botox injections for celebrities in Beverly Hills, you'll have a hard time paying back your med-school loans. But I guess it's more important for the United States to piss away hundreds of billions of dollars on stupid wars, bigger and badder nukes and warplanes, aircraft carriers and corporate kickbacks, rather than to actually pay something resembling a fair wage to resident physicians who work their tails off to utter exhaustion.

Honestly, if you do want to go into medicine, my recommendation is to leave the United States and train somewhere else-- which, probably, means emigration, since it's hard to transfer a license between countries. Canada's maybe a bit better though it too is starting to move toward the crazy American system, while the UK and Australia also seem to be getting sucked into the USA "cheap labor resident" model. (I once met a resident from Australia and she was almost as miserable as the US residents, working those same crazy shifts.) It's a ridiculous waste of resources to take such bright, dedicated and creative people as young doctors are, and put them through such a meat grinder that they hardly care anymore, just try to survive. It makes me understand how the US and Britain are both heading for national bankruptcy these days.

Honestly, it seems like the most humane medical training environments-- with the best care, paradoxically-- are in places like France, Belgium, Germany, Austria, Venezuela (damn good specialty clinics there), Chile, China and Japan.

Which means that you'll have to learn a new language and train in it, something like French, Dutch, German, Italian, Spanish or Chinese (especially if you have East Asian ethnic connections or were born in China or Taiwan for example).

But honestly, it seems worth it for the minor hassle of learning a new language, since you'll be able to train in a place that treats you like a valuable human being rather than expendable cheap labor. And that PAYS you for your work!

I spent some time in Belgium, Austria, Germany, the Netherlands and Venezuela, doing medical-exchange type things. And honestly, the medical residents and the doctors there are much, much happier than any I found in the US, Australia or Canada.

They don't necessarily make quite as much money, but then again, they're still well-paid and they have much, much less debt, since the countries subsidize medical school education. They're also better-rested, healthier, not anxious about lawsuits with every move (the countries have a "general fund" that provides payments to patients regardless of fault, and provides extra education to physicians as needed), fairly paid as residents or their equivalents, and generally, actually have a life. They're greatly respected, but they're not used as cheap labor. They work somewhat long (50-60 hours) but entirely reasonably hours as residents and get paid overtime, and the hospitals hire the staff that they need.

IOW, if you're smart enough to get into a quality medical school, then you should be smart enough to realize how screwed-over you are as a resident in the USA or UK, learn a language and train at a better place.

Or don't go into a medical career. Honestly, it's not worth it-- economically, emotionally or socially.

10:35 PM  
Blogger MiamiMed said...

Thanks for your reply,

Yeah, the residency thing is totally out of control. When most of the attendings at hospitals talk about the old days of 72 hour shifts, they often neglect to mention the MUCH lower acuity of the hospital at that time. The reality is, that 50 years ago, virtually every admitted patient in a modern hospital would be dead. It's a testament to the vast breakthroughs that we've had in medicine, and our unwillingness to change the system in the face of changing circumstances.

One thing I do disagree with however, is that other countries have it better. I agree that residency is often a much more humane experience abroad. However, US physicians still earn far more than their counterparts in any other country (except for now where I think that GPs in Britain have edged out FPs in the US by a touch). The US still provides the majority of the world's medical breakthroughs. We have a lot of problems, and I agree that the vested interests take advantage of those who pursue medicine. However, this is still the place to do it.

Just my thoughs. Thanks again for your thoughtful reply.

5:52 AM  

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