Monday, August 20, 2012

A patient of acute popliteal artery occlusion and thoughts on the Lancet article: Transforming Education to strengthen Health Systems in an interdependent world

We run a patient centered network that receives patient information from rural remote towns in India often with the intent of offering therapy either in the form of information (even prescriptions) or procedural interventions (for which they are encouraged to attend the nearest feasible set up). Day before yesterday night i got a call from our social worker in one remote town who related the story of a patient of sudden popliteal arterial occlusion (a little on phone and mostly on email along with the doppler reports etc) and a quick review of the evidence based literature ( other than background knowledge) told me this needed urgent popliteal arterial embolectomy as a current best option if performed within hours.

The biggest problem was that he had been given an estimate of 1.25 lakh rupees from the fee-for-service facility in the nearest town/tier2 city that could do the procedure. The patient was a near unemployed young man (surviving on private tuition to school students) and we needed to find a govt facility where the procedure could be done for much less (if not free) and as time was of the utmost essence we activated our web based global network.

The nearest govt medical college was still a few hundred kilometers and we were not sure if it would have facilities for popliteal embolectomy so yesterday morning the patient set out for the nearest metropolitan city to meet one of our network members, an intern in another govt medical college (which had vascular surgery facilities) to find if this could be arranged there on an emergency basis.

One of our US based members skyped me yesterday night to contact another senior vascular surgery colleague who was supposedly in the same metro-city in a Govt Post Graduate institute. Today morning as the patient reached the metro-city i learned that the senior vascular surgeon had been transferred to the same nearest govt medical college the patient came from and also the facility required for a popliteal embolectomy was currently non existent in that govt medical college.

Even as i write the patient and his relative have already boarded the train for Bhopal ( 1,500 kms from their home) because even the health care system in the govt medical college in their nearest metropolitan city (as per available information from the social worker, patients and intern) was not designed to provide emergency popliteal embolectomy (although they had the facility for vascular surgery with even regular Mch courses, so it was perhaps just our inability to approach the correct people in power there).

Our private medical college charges 3000 rupees for any operation (a limb amputation is what this unfortunate patient may possibly now require) and a fee for service vascular surgery practitioner in Bhopal who i contacted said it would cost 30,000 for a popliteal artery embolectomy.This is still much less than the 125,000 estimate the patient was given in the tier 2 city near his hometown.

Now let us take a look at the key components of a health-education-system identified in this Lancet article:

(1) stewardship and governance, (2) financing, (3) resource generation
importantly faculty development and (4) service provision

From a bottom-up patient centered perspective we start with (4) and from this evolving case-story it is obvious that we have to equip our rural district hospitals and medical colleges with both equipment and (3) trained health care professionals to enable them to handle any emergency procedure.

Actually the Fogarty catheter, that we require for this procedure doesn't seem to be currently available in our medical college also although we are lucky to have a general surgeon with a heart of lion who can tackle most procedures.

It is disappointing to see how so very often doctors are forced to overcharge their patients for a small piece of plastic equipment ( this is to highlight how locally designed low-cost technology can transform health care) and a procedure that could have been performed by any general surgeon has been restricted to only a few trained sub/super specialists.

In-spite of the large volume of doctors graduating from the 300+ medical colleges in the country, training in procedures and clinical decision making is finally being provided to a much lesser percentage than the actual need.

In summary: There are issues that need to be addressed from a bottom-up individual patient perspective.on how to optimize our entire workflow (training and equipment to help our individual patients).

At the same time from a policy maker's top-down  population-perspective (1) stewardship and governance and (2) financing can only be optimally implemented for the maximum benefit of a larger population.

Finally to integrate both the patient and population perspectives i leave you with these questions:

How do we ensure that such individual patient stories at the interface of health-science and suffering also have a happy ending?

Could awareness of these stories (collected in an online repository) that otherwise regularly go unsung from every corner of the country help our policy makers to decide better? Can converting district hospitals into 'functioning' medical colleges also address the above problems?

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