|MEDICINE AND SOCIETY
|Year : 2021 | Volume
| Issue : 3 | Page : 246-249
Working as a surgeon in India versus the United States
Department of Surgery (Transplant), Virginia Commonwealth University, Richmond, United States
|Date of Submission||27-Nov-2021|
|Date of Decision||01-Dec-2021|
|Date of Acceptance||01-Dec-2021|
|Date of Web Publication||28-Dec-2021|
Prof. Vinay Kumaran
Virginia Commonwealth University, Richmond, Veterans Administration,
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Kumaran V. Working as a surgeon in India versus the United States. J Med Evid 2021;2:246-9
| Introduction|| |
Many Indian doctors, after they complete medical school, take the United States Medical Licensing Examinations (USMLE) and do their residency and further training in the United States. The vast majority stay there permanently. They have little exposure to the practice of medicine in India other than what they experience during their clinical postings as medical students and during their internships.
A smaller number of Indian doctors go to the United States for specialized training and return to continue practice in India. They have little exposure to the health-care system in the United States outside their training program.
The number of doctors who have spent significant periods in practice at the consultant/attending level is small and most have not shared their experience in writing. This article is intended to be a description of a personal experience of working as a surgeon in India as well as the United States. It is formatted as an essay rather than as a scientific paper.
Briefly, I did my MBBS and MS (Surgery) at the Maulana Azad Medical College and the associated Lok Nayak Hospital, New Delhi. I was a Senior Resident for 2 years at the University College of Medical Sciences and the associated Guru Tegh Bahadur Hospital, Delhi. I did an M Ch. in Gastrointestinal Surgery at the All India Institute of Medical Sciences, New Delhi. I then moved to the United States (no liver transplant training was available in India then) and worked as a Research Associate at a lab working on Hepatocyte Transplantation at the Marion Bessin Liver Research Centre at the Albert Einstein College of Medicine for 2 years during which I took the USMLE exams and interviewed for Transplant Surgery fellowships. I did a fellowship in Transplant Surgery at the Thomas E Starzl Transplantation Institute of the University of Pittsburgh Medical Centre. I returned to India and joined the department of Surgical Gastroenterology and Liver Transplantation at Sir Ganga Ram Hospital in New Delhi. After 3 years, I became Director of Liver Transplantation there. After another 2 years, I moved with some members of the team to set up a liver transplant program at the Kokilaben Dhirubhai Ambani Hospital in Mumbai. After 5 years there, I moved back to the United States to restart a living donor liver transplant program at the Hume-Lee Transplant Centre, Virginia Commonwealth University Health System (where I work full-time) and at Indiana University Health (where I proctor a new living donor liver transplant program).
| Medical School in India versus the United States|| |
- Medical school in India begins after high school. Selection is via highly competitive 'entrance examinations.' In the United States, selection to medical school happens after completion of 4 years of college. The candidate must take the 'pre-med' courses, take the MCAT examination and apply to medical schools, which also conduct interviews. Academics are not the only criterion for selection and life experience and skills other than academics might result in selection ahead of more academically high-performing candidates. Each system has its advantages and disadvantages. It could be argued that the 4 years of college are a very expensive waste of time while others would argue that high school graduates are too young to make the decision to go to medical school. Four years of college and 4 years of medical school are a huge expense and except for the very rich, young doctors emerge from medical school with large student loans which take many years to pay off. The cost in India is variable. The academic government medical colleges, which include some of the best training institutions, are the most competitive in terms of entrance examinations but they are relatively inexpensive in terms of tuition fees and typically have highly subsidized accommodation. On the other hand, good private medical colleges in India may be as expensive as colleges in the United States
- The clinical exposure in an academic medical college with an attached government hospital in India is probably unmatched anywhere in the world. The medical schools in the United States may be more structured and uniform in terms of their curriculum. There is certainly much more variation in quality in medical schools in India
- The 1 year of rotating internship, which is mandatory in Indian medical schools, is not part of the training in the United States. After 4 years of medical school, one emerges with an MD degree but is not yet eligible to practice medicine. Obtaining a medical license requires undergoing residency training. Even Family Practice requires a residency in Family Practice. In India, on the other hand, the rotating internship following 4.5 years of medical school produces a physician eligible to register as a medical practitioner and begin practicing independently.
| Residency Training|| |
The minimum duration of training in a surgical residency in India is 3 years while in the US it is 5 years. However, it may be extended in India by a period as a Junior Resident (House Officer) before residency and as a Senior Resident (Registrar) after residency. In the US, the duration may be extended by elective research years, which may be an advantageous route for surgeons who wish to keep the option of academic positions open. Other specialties have shorter residencies, Obstetrics and Gynecology is 4 years, Family Medicine is 3 years. In both countries, surgery is considered a desirable specialty. Residency positions are salaried. The salaries in both countries are adequate to meet the cost of living for a single person but inadequate to support a family. As with medical school, the variation in quality of surgical residency programs is greater in India. Some private programs are affiliated with hospitals with relatively low volumes, the faculty are in private practice and opportunities for operating independently are sparse. The best surgical residency programs in India are those attached to large government hospitals with rotations through various subspecialties. The clinical exposure at these institutions is probably unrivalled anywhere in the world. Institutions like the All India Institute of Medical Sciences in Delhi attract patients from all over the country. Shortage of beds ensures that only the most interesting (or most politically connected) patients are admitted. Residency programs in the United States are more standardized since the requirements of the Accreditation Council for Graduate Medical Education have to be met. However, within the constraints of the accreditation requirements, there is still considerable variability. The best programs have all the subspecialties and high volumes while some of the smaller programs offer much less clinical exposure. Restrictions on work hours and time off are strictly maintained in US residencies while they are largely ignored in Indian residency programs.
Hospitals in the US typically have Advanced Practice Providers who are Physician Assistants or Nurse Practitioners (NPs) who deal with many of the routine tasks that are performed by residents in India so the residents spend more time in the operating room. However, surgical residents in India deal with such high volumes of cases that they begin to operate independently and develop surgical skills earlier than those in the United States. There is considerably more supervision of residents in the United States.
Upon completion of the residency, US doctors would take a two-step examination of the Board of Medicine in their specialty. The written boards must be passed first followed by the oral boards which are now, in the COVID era, held using teleconferencing and comprise an interview in which clinical scenarios are presented and discussed by the faculty with the candidate. The Indian version is more extensive, involving examining and presenting actual patients, identifying pathological specimens, reading radiological studies, identifying instruments and describing their use and so on. In the US, residents who have completed their residency and cleared their written boards, may accept employment with some restrictions while they prepare for and take their oral boards (they are board eligible but not yet board certified).
In general, I would say, residents trained in the large academic government medical colleges in India are better trained than the average US trained resident and better equipped to practice independently, particularly if they have also spent time as Senior Residents.
I will not go into the process of subspecialty training (fellowships in the US and M Ch./DM/DNB in India) save to comment that the best of the Indian M Ch. and DM programs seem to be more structured than the US fellowships but there is considerably more variation in quality than in the US.
| Working Independently after Completion of Residency|| |
Learning is a process which continues through ones career but there is an abrupt change in the level of responsibility at the end of residency. One is responsible for one's own patients. There may still be a level of supervision if one joins a team with a hierarchical pyramid but those who begin private practice are on their own. This transition is considerably ameliorated in the Indian system by the position of 'Senior Resident' or 'Registrar'. There is no analogous position in the US. The senior resident has completed a residency, has passed the exit examination and is permitted to practice independently. However, the senior resident position is an opportunity to take on an intermediate level of responsibility. They have administrative responsibilities, supervising interns and junior residents, as well as teaching responsibilities, particularly taking a large role in managing the clinical rotations of medical students. They are essentially independent in the emergency rooms in the government hospitals while in private systems, they would still be assisting or at least be supervised by an attending physician or surgeon. This period (typically up to 3 years) as a senior resident is a prerequisite to applying for a teaching position in a medical school and is generally considered desirable when looking at job opportunities even in the private sector. Some of this period may be spent in a subspecialty to acquire skills in an area of interest.
| The Attending/Consultant|| |
Becoming an attending physician (US terminology) or Consultant (Indian terminology) marks the beginning of independent practice of medicine. There may still be a level of supervision if joining a team but from this point on, one is responsible for one's own patients. There are several differences between practice in India and the US.
Cost of health care
The United States undoubtedly has the most expensive and wasteful health-care system in the world and much has been written about its inefficiency and focus on expensive care, often futile, towards the end of life and in patients with terminal conditions and not enough attention to promotion of good health and prevention of disease. India is at the other end of the spectrum where the problem is access to care and availability of facilities. While the best hospitals in India provide a quality of care comparable with the best in the world at a fraction of the cost a similar level of care would cost in the US, it is true that the vast majority of the Indian population does not have access to these hospitals. In general, Indian physicians have done well in terms of being frugal and providing a level of care quite disproportionate to the cost by US standards. As a rough example, a liver transplant in India costs about one-tenth as much as in the US with very similar outcomes. Given the gaps in coverage inherent in the delivery of health care in the US, health-care expenses are the leading cause of bankruptcy in the United States. Of course, after going bankrupt, they are eligible for Medicaid while in India; there is no social safety net for those rendered medically bankrupt.
In a litigious society (the US), a lot of time is spent on documentation of patients clinic visits, inpatient progress, procedures performed and consults. Unfortunately, a lot of the documentation (now largely performed on electronic health-care systems) is designed to forestall litigation or facilitate billing and the important aspects of assessing the condition of the patient and communicating a plan to the next physician who reads the note may be lost in the noise. This is a trend, which is also developing in India as the doctor-patient relationship deteriorates but the US situation is distinctly worse. Finding relevant information in the large amount of 'copy-paste'/'smart-text' verbiage is increasingly difficult.
With a few exceptions, it is easy to get an appointment to see a physician in India within a day or two. In the US, the process is much slower with wait times for some specialties approaching 6 months. However, one must bear in mind that a substantial portion of India does not have this kind of access because of a combination of poverty and the absence of health-care facilities in the vicinity. The most efficient process of evaluation I experienced was in private hospitals in India where I could see a patient in the morning, send them for imaging, look at the imaging with the Radiologist in the afternoon and have a plan and schedule surgery by evening. The same process in the United States would take several weeks.
The operating room
It is probably in the operation room that there are the least differences between a good hospital in India and a good hospital in the United States. I found similar turnover times, similarly skilled assistance and similar adherence to protocols and checklists. That being said, I am well aware that smaller hospitals in India cannot claim to attain such standards. I think the gap between the best hospitals and the average hospital in the United States is much smaller than the gap between the best hospitals and the average hospital in India.
The medical profession is generally well paid in the United States. There is a sharp increase in remuneration between a resident/fellow and an attending physician, a much larger jump than in India. The model of remuneration in the US (other than the Veterans Administration hospitals where physicians are salaried) is similar to that in the private sector in India. There is usually a period of 1–2 years during which a fixed salary is paid. After that, a base salary is guaranteed with incentives if certain performance goals are met. Relative Value Units (RVUs) are used to measure how productive a physician is. Different procedures generate different numbers of RVUs. As in the private sector in India, this produces a somewhat perverse incentive to spend more time on procedures which generate more RVUs, for instance Gastroenterologists tend to want to spend more time performing endoscopies and less time seeing patients in clinics. There is also a motive to order more endoscopies. Similarly, surgeons are judged by how many operations they perform and how many referrals they are able to elicit, a situation very similar to that in the private sector in India.
Advanced practice professionals
Facing a shortage of physicians, the US health-care system has turned to so-called 'physician extenders.' Physicians Assistants go through a different pathway from medical school. They work, typically under the supervision of a physician but have prescribing privileges. Similarly, NPs, undergo training after qualifying as nurses and are allowed to practice in areas they have trained for, in some situations without direct supervision as in outpatient clinics and in Family Practice. This has been a largely successful process.
In India, corruption is widespread, brazen and difficult to avoid. It comprises payment of referral fees to referring physicians, receiving kickbacks from Pathology Labs and Radiology Centres and generally trafficking in influence and power. This makes it very difficult for a young physician to establish a practice without being sucked into the system. It is difficult but not impossible to avoid corruption in practice in India and there are islands of excellence and ethical practice in a morass of questionable practices. In the US, one is generally insulated from this kind of brazen corruption but there are many perverse practices incorporated into the system which are impossible to escape from.
The doctor-patient relationship
As medicine has advanced and treatments have become more effective, converting many previously incurable or untreatable conditions into curable or chronic conditions, extending life and often improving the quality of life, there has been a paradoxical deterioration in the quality of the doctor-patient relationship which has become more and more transactional. In India, there has been a failure of the medical profession to regulate itself, to reduce corruption and to maintain standards. This has led to a lack of trust in the medical profession often manifested in violence precipitated by an adverse outcome. At the other extreme is the reverence the average patient still has for a trusted physician. While practicing in India, many patients would ask their family doctor before they would commit to surgery. In Mumbai there was sometimes the disconcerting request for the family doctor to be present in the operating room (often accommodated by surgeons there) during surgery. While, this may have been somewhat prompted by the regard between the patient and the family doctor, the darker side is potentially in trying to ensure that the patient was not operated on by a junior surgeon and the even darker side might be in using the visit to pick up the kickback for the referral in cash. None of this, of course, would be imaginable in the US where there is considerably less 'doctor-shopping' with the treating doctor often determined by the insurance system and the patient being seen in the clinic by whomever happens to be there from the team that day and the operation (particularly in the setting of transplant surgery) being done by whoever happens to be on call.
An interesting difference between practice in India and the US is the role of the family in medical decisions as well as care. In India, the patient is almost invariably accompanied by one or more (often more) family members who are part of the decision-making process, and in some cases, may even take on the primary role in decision making and exclude the patient from the process altogether. This is particularly likely to happen when the patient is elderly or when the patient is not the person paying for the care. In patients with cancer or other serious illnesses, it is not unusual to receive a request from family members not to tell the patient that they have cancer or they would 'lose heart'. Such requests are often accommodated. In the US, on the other hand, all information is provided directly to the patient and decisions made only by the patient. Other family members would be provided with information only with the permission of the patient. Another aspect of this somewhat intrusive role of the family in making medical decisions in India is that important decisions such as whether to have surgery and where to have it are often taken after consultation with a wide network of family members, friends and often religious influencers. This may sometimes have the effect of delaying decisions or making poor decisions (as when a Guru advises against surgery for instance). In the US, such decisions would typically be made with much greater alacrity by the patient. The problems in the US tend to be misinformation which is rampant on social media resulting in conspiracy theories and mistrust in the health-care system, best exemplified by the refusal of a large proportion of the population to get vaccinated against COVID-19, for instance. Another aspect of closely-knit families in India is that there is almost always someone to look after the patient when they recover from illness or surgery and return home. In the US, on the other hand, it is not uncommon to find that the patient recovers from illness or surgery but has nowhere to go because there is nobody to look after them at home. The elderly, in particular, are quite likely to find themselves in situations where their children might make token calls and visits but be unwilling to actually look after their parents when they are ready to be discharged. Some of these patients find themselves in long-term care facilities indefinitely.
| Summary|| |
In India, as well as in the United States, as health care has become more sophisticated and expensive, the cost of health care has increased and the relationship between the health-care system and the people it serves has become more transactional and less respectful. Neither country seems to be able to solve the problems it faces in the manner in which it delivers health care although there are examples of success, which could well be emulated, from Western Europe, Canada, Australia, New Zealand, Korea, and Japan. If I had to choose between working in India and in the United States, all other considerations being equal, I would choose to work in India, predominantly because it is possible to separate oneself from the 'system' and create islands of excellence and ethical practice and because the doctor-patient relationship is not yet as transactional as it is in the US.
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Conflicts of interest
There are no conflicts of interest.