We've got it pretty good

Surgical Rounds®, December 2007, Volume 0, Issue 0

Bernard M. Jaffe, Professor of Surgery, Department of Surgery, Tulane University School of Medicine, New Orleans, LA

Bernard M. Jaffe, MD

Professor of Surgery

Department of Surgery

Tulane University

School of Medicine

New Orleans, LA

Over the last few years, we surgeons have done a great deal of complaining, and mostly with good cause. Because of lower reimbursements, we have had to work a lot harder to try to earn the same level of income. Malpractice claims continue to skyrocket and have reached epidemic proportions. Administrators rule our hospitals and pay no more than lip service to physicians' needs. Quality of care is an issue primarily for journalists, who seem to enjoy misrepresenting data and embarrassing doctors. Yes, being a surgeon is not all it is cracked up to be and surely is not as rewarding as it was in the not-too-distant past.

And now for a touch of reality! After returning from a medical mission in Phnom Penh, I realized we've got it pretty good. Let me be clear: I really enjoyed staying and working in Cambodia, and I love the people who live there. Yet all it takes is a brief experience working in this emerging country to put America's problems in perspective.

Let us start with access to health care. As poor as they are, Cambodians must pay for all their medical care. While these costs are not excessive, even by Medicaid standards, relatively few can afford them. When someone gets sick, family members beg, borrow, and scrape together the funds to buy care. Often this involves selling the last vestiges of family property. If they cannot garner the necessary resources, the patient dies. Long-term care is not realistic, so chemotherapy is rarely administered, and there is no such thing as rehabilitation. Access to care is a serious and unforgivable problem in the United States, with about 40 million uninsured Americans, but compared to Cambodia, it seems barely worth mentioning.

Cambodia relies heavily on the generosity of the multiple nongovernmental organizations (NGOs) that come from afar to volunteer and provide free care. An excellent NGO that operates in Cambodia is Operation Smile, which for several years has supplied teams of surgeons, anesthesiologists, pediatricians, and nurses to repair cleft lips and palates. Volunteers for Operation Smile provide yeoman's service, and, as the organization's tagline states, they are "changing lives one smile at a time."

As is the case in many third-world nations, Cambodia's hospital care does not include food. Nutrition is provided by family members, who cook in the hospital corridors. Inpatient nursing care is said to be included, but it is so scarce that relatives attend the patients and provide almost all care except administering medication. Speaking of medication, it must be paid for separately both during and after hospitalization. Similar to what is all too common in America's few remaining public hospitals, Cambodian patients simply cannot afford to purchase medicine, and many illnesses are never totally eradicated or recur.

Next, I would like to mention the hospital environment. Americans expect clean hospitals and sterile conditions; that is not what you will find in Cambodian hospitals. Corridors are laden with refuse, and trash is stockpiled on the hospital grounds just outside the buildings. I cannot understand the lack of sanitation, since there is an ample work force to keep the institutions clean; obviously, it is not a priority. I am sure you can imagine the one exception to this disorderliness rule—yes, the administrative wings are neat and clean, obviously tended to, and well furnished. In the working areas of the hospitals, sterility is a goal never quite achieved. You and I would hesitate to practice in operating rooms and intensive care units such as these (I hesitated but did take the plunge), but somehow rates of wound infection are no higher than American standards. This is even more impressive when you consider that Cambodian hospitals sterilize and reuse materials that we consider disposable, and the majority of wound care is provided at home by family members, rather than medical professionals.

I likely do not even have to mention the startling lack of medical equipment. Such devices as monitors, ventilators, electrocautery units, and anesthesia machines are scarce, arcane, and often in serious need of repair. The Cambodian health department's equipment budget is miniscule, and hospitals and physicians must rely on gifts from the outside world to keep them at what is barely a subsistence level.

We scorn the Accreditation Council for Graduate Medical Education (ACGME) 80-hour-per-week work regulations, but Cambodian residents do not work anything like that. During my recent visit, I chatted with a young internal medicine resident who was completing a mandatory 2-month surgery rotation. She dismissed surgery as a career choice because of the excessive hours: 8 am to 11 am and 1 pm to 5 pm for 5 days each week. While there is an on-call duty physician, the large number of trainees makes summoning him or her a rare event.

So far, I have focused mainly on the disadvantages of practicing surgery in Cambodia, but there are some strong positives. As it was previously in our country, patients are genuinely grateful for the care they receive and are appreciative of doctors. Nurses respect physicians and defer to them. There are no insurance companies to fight with and no need for precertification. Billing is easy; there are no computers, just hand-written invoices. There is no malpractice litigation, so there is no need for malpractice insurance. And the best and the brightest students select careers in medicine, rather than going into business, law, or finance. Finally, there is no continuous striving for a higher income level because there is simply no money to be had.

Practicing medicine in Cambodia in 2007 seems, in many ways, like practicing in the United States in the 1960s. I recommend that all of you volunteer; give foreign missions a try, and see this for yourselves. I guarantee that it will be unbelievably rewarding. And when you return home to your respective medical environments, I am confident you will agree with me that we've got it pretty good.