Dr. Craig Hunter works with Urology Specialists of Nevada.
Choosing to move my wife and four children to India for an extra year of medical fellowship training was a difficult right choice. I knew the experience would bond our family together. I knew we would go through discomfort and stress, but we would emerge as better people. I was not disappointed.
After training in urology in Detroit, Michigan, I was fortunate enough to secure a male reconstructive urology position in Pune, India. Pune is a beautiful city of more than 6 million people and a three- to five-hour drive from Mumbai. Those who have experienced the traffic in India can understand the variable time frame. Dr. Sanjay Kulkarni is one of the world’s leading experts in urethral stricture disease and operates out of his own hospital in Pune. His expertise draws patients and surgeons from around the world travel to his three-story, 20-bed hospital.
The average Indian urologist just out of training makes approximately $1,000 per month, providing them a comfortable upper middle class lifestyle. I could eat breakfast, lunch and dinner for less than $3 a day. Almost a third of the population of India (approximately 400 million people, more than the entire population of the United States) earns approximately $1 per day. These numbers became personal and very real in my own neighborhood of Bavdhan. On a morning run, or when returning from work, I would commonly see naked 4-year-old children wandering the streets. They were looking for something to eat. It was heartbreaking. All the gifts my children gave away on Christmas morning could not dent the poverty of these beautiful people.
Are patients different? Patients in India came to the clinic from across the country, sometimes taking a 17+ hour train ride. These patients arrive at the train station with family and luggage in hand. They don’t have an appointment. They will wait in the waiting room as long as it takes to see the doctor. Sometimes we housed the entire family in a hospital room as we continued medical testing and workup. Sometimes Kulkarni operated on patients on the day of arrival.
A precious piece their luggage is their “medical history bag.” I quickly began to recognize the medical history bag. The bag resembles a well-used reusable canvas shopping bag or tote bag. It invariably contains years of paper copies of lab results, operative notes and medications. I have looked at tattered and torn x-ray films, the details lost from the wear and tear of 15 years. In the United States, too, often I see patients who have no idea what medications they are on, what imaging tests they have had, or even what surgeries they have had. I consider myself lucky if my patients remember to bring a CD digital copy of the CAT scan images they received from a hospital equipped with a complete electronic medical record.
While in India, my 7-year-old daughter had an accident that I assumed was a broken arm and we brought her to another local hospital (our hospital was a specialty hospital that didn’t have a “general casualty” — what we in the United States would refer to as an emergency department or ER). It was an amazing experience. Upon arrival and check-in, I met an ER physician within minutes. I was directed to the cashier to pay for an x-ray and then I took my receipt from payment to the x-ray department and obtained my daughter’s films. I took the hard copies of the x-ray back to the ER. The ER doctor and an orthopedic resident took a look the films. The orthopedic resident discussed the case with his attending physician and a follow-up appointment was made for two days later. My daughter had a greenstick fracture of her arm (when a bone bends and cracks, instead of breaking completely into separate pieces — most often seen in children) and she needed a temporary soft cast. The orthopedic resident directed me to the same cashier to pay for the cast supplies. I took the receipt to the supply depot and returned to the ER with my supplies. The orthopedic resident applied the cast. The extra supplies I returned to the supply depot and was given a reimbursement. Total time door to door: 45 minutes. Total cost: $25.
Prescriptions? If I need an antibiotic, I show up to the pharmacist and ask for it. No prescription needed.
Patients pay for consultation with the surgeon — the average cost is $10. The patients are then given a quotation of the cost of the procedure. For Kulkarni (at the center where I carried out my medical fellowship), if the patient can afford the cost, he charges a surgical fee for a urethroplasty of about $2,500. What if they can’t afford it? Dr. Kulkarni turns the question around and asks the patient what they can afford. He asks the patient to pay what they feel they can pay, sometimes $800. What if the patient and family have no money? He’ll do the surgery for free.
If the patient has the funds necessary and deems the procedure important enough, we proceed with surgery. Sometimes the patients go home and return weeks or months later with saved money for their upcoming surgery. One man offered to sell his “2 wheeler” for the $800 needed for his 6-year-old daughter’s surgery. The motorbike is not just a method for him to earn his living, but serves as the main transport for his entire family. Kulkarni did the complex surgery for free.
Urologists in India either own their own hospital or travel to different hospitals with their own instruments. Kulkarni had his start traveling around the city with his own surgical instruments. He now owns his own hospital and makes the medical and business decisions. The hospital is a three-minute walk from his home, but unfortunately the three story building has no elevator. The operating theater (operating room) is on the second floor. Patient rooms are on the first and third floors. While patients are awaking from anesthesia, they are carted by hand by anywhere from four to six people up or down the stairs. The obesity epidemic in the United States would certainly complicate this arrangement. I was in the hospital the day a new x-ray machine arrived. This 500-pound machine was carried by hand by eight people up to the second floor.
In a neighboring village, I visited a hospital owned by a general surgeon. It was a full service hospital, including a dialysis unit and a laboratory. He had arranged for Kulkarni to operate on a few patients. Between surgeries, I joined the surgeon and Kulkarni in an upstairs room for a quick snack in what I assumed was a doctor’s lounge. The lounge had a kitchen and dining room. We sat at the dining room table, ate chipati (a type of flatbread), tea and Indian sweets. During the course of our enlightening conversation, I found out that I was actually a guest in the home of the surgeon. This lounge was his actual dining room — he literally lives at his hospital. He was there 24/7, rarely taking a holiday. He was committed to providing a service for his village. Without him, the local poor in his area would not be able to make the 150-kilometer trek to the next closest hospital.
Our time in India provided a unique opportunity to view different health care models.
I was a beneficiary of superior surgical training, but the surgical training was just a small portion of my overall experience. I was able to broaden my horizons on differing methods of delivering care and providing a service to those who need my expertise. I now have a clearer perspective on my position in a worldwide society made up of 7 billion people.