I'm linking here a post from The Health Care Blog which reminds me of a conversation I had with our pediatrician when our children were born in the Seventies. Having selected what was then one of the metro area's best hospital, I mentioned casually that it seemed to be the best in town. He replied that yes, it was very good, but for any kind of neonatal complications Atlanta's Grady Memorial Hospital would be the place of choice. This surprised me because Grady was (and still is) the treatment center for indigents. But precisely because it is a "charity hospital" the volume of all types of trauma and complications gives the staff and support facility far more experience "practicing" medicine than most other hospitals. Other than TV programs and a limited time as an Army Medic in Korea in the Sixties, that is my only background regarding high-volume, low-budget hospitals.
This post caught my attention immediately because I expect feedback and impressions from readers here. Something tells me Ruchira's circle will be an excellent source of second opinions. In fact, I would not be surprised if Dr. Ashish Jha is known by someone here.
Ashish Jha, M.D., M.P.H. is Associate Professor of Health Policy and Management in the Department of Health Policy and Management at the Harvard School of Public Health. He is also an Associate Professor of Medicine at Harvard Medical School, associate physician at Boston’s Brigham and Women’s Hospital and VA Boston Healthcare System. Over the past three years, he has served as Special Advisor for Quality and Safety to the Department of Veterans Affairs.
Dr. Jha received his M.D. degree from Harvard Medical School in 1997 and trained in Internal Medicine at the University of California, San Francisco where he also served as Chief Medical Resident. He completed his General Medicine fellowship from Brigham and Women’s Hospital and Harvard Medical School and received his M.P.H. in Clinical Effectiveness from Harvard School of Public Health in 2004. He joined the faculty in July, 2004.
The reason for my interest is simple. Most Americans live in a cultural bubble, insulated from most world realities by layers of commercial messages and political myth-making. Perhaps last night's tryst between Bill O-Reilly and Jon Stewart remains fresh in my memory.
There is a grim joke that the reason God allows wars is to teach Americans geography. My Facebook timeline has at the moment two links to politicians whose ignorance forms part of the basis for their supposed electibility. One is affirming his belief in Creationism (no, not the ID kind, the other one, that the world was created in six twenty-four hour days) and another, some guy in Arkansas, is quoted as having said that slavery was a "blessing in disguise" for Africans brought to North America. But I digress...
I visited Safdarjung Hospital in New Delhi today – an institution with 1,531 beds and 145% occupancy rate. Yes, 145%. You do the math. A lot of bed sharing and asking families to bring in cots. It’s right across the street from the All India Institute of Medical Sciences (AIIMS), the premier public healthcare institution in India. While both AIIMS and Safdarjung are run by the federal government, only AIIMS is renowned for famous specialists, world class facilities, and an international reputation to boot. Safdarjung doesn’t suffer such burdens – its specialists are not well known, facilities are dilapidated, and you probably have never heard of it.
I spent several hours walking around, talking to lots of physicians, visiting ICUs and cath labs. I visited the outpatient department where 7,000 people show up every day, many lining up the night before, to get a ticket by 11 a.m., when registration closes and those who haven’t gotten a ticket are out of luck. In the ER, there was a line of between 50 and 100 people waiting to get rabies shots. This is the hospital where every poor person in Delhi unfortunate enough to get a dog bite is sent. They have the rabies serum. Most other public hospitals do not.
Safdarjung has “efficiency” baked in. In a typical year, they do 800 cardiac surgeries, 2,000 angioplasties, 3,000 echocardiograms, and 100,000 EKGs. They see tens of thousands of patients in the cardiology clinic. They have 4 (yes, four) full-time cardiologists on staff. The rest of the work is done by medical residents, who call when they get into trouble. Brigham and Women’s Hospital, which probably doesn’t have one quarter the volume of this place, has 140 cardiologists. The patients at Safdarjung pay essentially nothing. Even their medications are free. For those who are not extremely poor (and I doubt there are many non-poor patients who go to Safdarjung), you do have to pay for your own devices. Need a stent? Bare metal ones cost $200 to $1000. Drug eluting stents are $1500 to $2500. You get to decide which one you want. They have a chart with pictures and prices that looks a lot like a dinner menu.
Go to the link for the whole account. A few parts that struck me include these...
...If you believe in the data on the volume-outcome relationship (and you should), it’s clear why this place claims to have terrific outcomes. They very well might. Yet, as I walked around with the chief of cardiology, I asked him about their cardiac surgery mortality rates. He assured me mortality was low, “comparable to international standards” (whatever that is). I pushed him – he said very few patients died after procedures. When I pushed a little more, he got annoyed, wondering if I was accusing him of running a poor quality hospital. I backed off.
This tells me that there is a degree of professional pride in the operation of the hospital that most US corporate environments would envy.
Do they track data? Nope. And when questioned about that "...several clinicians seemed to grow tired when I asked gently if they tracked their data. They didn’t." And later...
...In the cardiac unit, there’s one monitor for every two patients, and they switch off depending on who is sicker at any given moment. In the U.S., we obsess if it’s OK for a patient to take off their cardiac monitor for 10 minutes to take a shower. This is how Safdarjung does so much with so little. Their clinicians “cut corners” we are not willing to cut. Its not clear to me that they are practicing worse medicine than I am. The corners they cut are often of little or no clinical consequence.
Safdarjung is an amazing place: a high volume, efficiency-driven institution that seems to deliver pretty good care. If it could just sprinkle in some quality measurement and make quality improvement a routine part of how it delivers care, it would likely have a profound effect on how hospital care is delivered across India and beyond. Who knows, it might even have something to teach U.S. hospitals.
I'll be interested to see if comments left at The Health Care Blog connect any of the dots so clearly drawn here with shortcomings of health care in the US. And I am even more interested in comments here.