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    Sunday, April 09, 2006

    Practicing at the Extremes: Dr. Robert McKersie is a family physician who practices at the extremes of medicine - from the South Side of Chicago to the foothills of of the Himalayas. Two very disparate environments, to be sure. He's written a book about his experiences, In the Foothills of Medicine : A Young Doctor's Journey from the Inner City of Chicago to the Mountains of Nepal.

    Providing medical care to remote regions of Nepal isn't easy. It often involves trekking up mountain paths for days to go from one remote village to another. And treatment options are limited to those that can be carried on the back. Access to care for the rural Nepalese is no easier - many of the patients seen by McKersie and his colleagues had to be carried by their familiy members on mountain paths no less exhausting just to reach the doctors. To make matters worse, there are Maoist rebels in those hills to whom a Westerner is a Westerner is a Westerner, regardless of his mission.

    While the Nepalese have to go to extremes just to get to the doctor, McKersie makes clear that his patients in the United States are just as removed from decent healthcare, even as they sit smack in the middle of abundance. His practice on the South Side is made up largely of Medicaid and uninsured patients - a group for whom it is often difficult to find needed referral and specialty care. After reading his book, I asked him some questions, which he very kindly answered:

    1.Your book describes your experiences as an intern in an inner city Chicago hospital and your medical mission (for lack of a better word) trips to the Himalayas to provide care for rural Nepalese. You are a full-fledged physician now and still practice in inner city Chicago. What is your practice like? Are you practicing in a solo position, a group, a university clinic, or a community health center setting? What is your patient mix like - mostly uninsured? Medicaid? Medicare?

    I presently work at a Federally Qualified Health Center (FQHC) on the South Side of Chicago; the name of the clinic is Chicago Family Health Center. I am one of a dozen physicians at the clinic; we have a nice mix of family medicine, internal medicine, oby/gyn, and pediatric physicians. At present, I am also a clinical associate in the Department of Family Medicine at the University of Chicago Medical School; in this capacity I precept medical students in my clinic. Our two clinics serve two underserved areas on the South Side of Chicago, one predominantly Mexican-American and the other African-American. Our payer mix is roughly 40% Public aid (Medicaid); 35% Sliding Scale; 10% Medicare; 15% other (HMO, private insurance, etc). Sliding Scale is for individuals who have no insurance and cannot qualify for Medicaid or Medicare and most pay no more than $10 per visit to our clinic. This coming academic year I will be a Maternal-Child Health fellow on the West Side of Chicago at another FQHC called the PCC Community Wellness Center.

    2.You often mention your frustration at trying to find appropriate care for your patients during your internship year. Do you still experience those same frustrations now that you've finished your training and have worked within the system for a few years?

    Absolutely! Nothing has improved in this regard, and in actuality it is worst. Our Sliding Scale patients cannot be seen by any of the local private or “charity” hospitals, so they are left having to get their care at Cook County Hospital (CCH), the third largest public hospital in the United States. CCH gives wonderful care to the patients who are fortunate enough to get in the door. At present, CCH, due to the enormous number of patients without healthcare insurance in Chicago, is overtaxed and cannot keep up with the healthcare demands of the residents of Cook County. For example, there is an 18-month waiting period for a diagnostic colonoscopy at CCH. Invasive carcinoma of the colon does not wait 18 months to progress and kill our patients. Presently, there are several specialty clinics at CCH that will not even give an appointment date due to these clinics being so backed up; many other example of long waiting times for specialists at CCH exist. In addition, our Medicaid patients are regularly turned away from some of the specialists and hospitals in our area due to Medicaid’s poor reimbursement. This lack of healthcare options for our patients forces us to send them through the emergency rooms of our local hospital, which is an inefficient use of healthcare dollars, not to mention burdening the already overworked emergency room staff members. In short, the healthcare options for my uninsured and underinsured patients have dramatically worsened since my intern year.

    3. How did you end up going from inner city Chicago to Nepal?

    I have had a love of hiking and mountaineering ever since attending high school at Holderness School in the White Mountains of New Hampshire. Nepal, the Shangri La of wilderness travel, was always a place I wanted to visit. When I heard about Himalayan HealthCare’s medical treks in Nepal I realized that I could fulfill my desire to travel to Nepal and also use my medical skills to help the people of Nepal. I also have to admit that getting out of the inner city and traveling to a remote mountainous part of the world on a regular basis is a rejuvenating change of scenery for me!

    4. Your book describes two visits to Nepal. The first, in 2001, involved trekking many miles on foot to remote mountain villages where you and the medical team you were with were the only medical professionals the villagers had seen in a very long time. Medicines and other supplies were severely limited, yet you managed to provide pretty good care to the people you saw, although sometimes it did require airlifts to a Katmandu hospital. During another visit four years later, you were able to provide all of the care needed by the local populace at a hospital smaller than most found in the rural U.S.  Do you ever look at your experiences in Nepal and your experiences here in America and wonder if we don't suffer from an overabundance of medical choices that actually make providing affordable care more difficult? (Plavix vs. aspirin, the use of expensive brand name drugs instead of generics, the willingness to jump to procedures instead of using cheaper medical therapy, dialysis for elderly end-stage renal disease patients, SSRI's for every little mood disturbance, the list could go on.)

    At present, due to my work in FQHC’s, my patients do not have an over-abundance of medical choices. Some of my patients in Chicago even have less healthcare options than some of the patients in Nepal. And Nepal is a country that spends $4 (US dollars) per capita on healthcare compared to the roughly $6000 we spend per capita in the United States.

    There is something to be said, on a clinical diagnostic skill level, to working in Nepal verses the United States. In Nepal, I was continually impressed with the diagnostic skills of the Nepalese doctors. As you allude to, they have honed their diagnostic skills because they do not always have a laboratory value or radiological image to fall back on.

    There is no doubt that the many new and expensive drugs that are being produced by our pharmaceutical companies (many just “me too” drugs that have no real advantage over generics) have increased the cost of our healthcare in this country without increasing the quality of care. Nepal, thankfully, does not have to suffer from that, although, it would be advantageous to have more drugs and healthcare options available in Nepal.

    5. Inner city Chicago and rural Nepal are vastly different places. In rural Nepal, patients sometimes had to walk for days to see a doctor. In Chicago, patients can walk to a hospital or community health center with much less effort. Yet, in both situations, you often saw patients who only presented when their disease had reached extreme straights. In your book, you make it clear that it's been your experience that in Chicago it's because the patients can't pay for their healthcare. How would you answer those who suspect that there might be a cultural component at play as well? (Patients with substance abuse or mental health issues, for example, aren't likely to put healthcare needs to the forefront under any system of healthcare. Not to mention the universal capacity for denial in the face of largely asymptomatic disease.)

    Outside of mental health and substance abuse (two well documented disease states that can impede an individual from accessing timely healthcare), I do not see a cultural component that inhibits individuals from seeking care for themselves. The one universal inhibiting factor for individuals of all walks of life is the financial barriers that our healthcare system places before them. When Canada implemented it universal healthcare system, a plethora of individuals, who had previously been denied care due to economic hardship, went to the doctor for the first time, which was fortunate. We see this same type of response when a free clinic opens or a group of medical students set up a free medical exam day at a fair or cultural event; people who normally would not see the doctor for financial reasons come to these clinics and events to be examined. The perversity of the US healthcare system is that the wealthiest nation in the world, and a nation that spends close to two times as much on healthcare per capita as its closest competitor, has to rely on charitable healthcare to care for our citizens. It is understandable that a country like Nepal, where the majority of people live on $1 US dollar a day, needs charitable groups like HHC to administer healthcare. But, it does not make sense for a country like the US to do the same.

    6. Finally, could you explain a little more about Himalayan Health Care and its objectives? How are things going for the organization today?

    Himalayan HealthCare (HHC) is a not-for-profit, non-denominational, non-government organization that has started in 1992. HHC’s goal is to help the people in Nepal to help themselves. HHC started by running medical treks into the mountain village of Tipling, and over time its programs have expanded to other villages and now beyond healthcare, to include education and income generation. At present, due to the Maoist insurrection in Nepal, HHC has concentrated its efforts in the eastern part of Nepal in a large village called Ilam. One year ago, HHC, with the help of the Ilam community and international funds, built a small hospital in this village. At present, this hospital, with its three medical doctors, cares for the 400,000 Nepalese who live in northeastern Nepal. The Maoist insurrection has made it difficult for HHC to carry on all projects and treks, and, indeed it has had to scale back some projects in parts of Nepal that have a heavy Maoist presence. However, the Ilam hospital has been a real success story this past year. HHC, like many non-profits in developing countries, relies on contributions, both in-kind as well as financial. It also welcomes the assistance of volunteers who would like to work at the Ilam clinic. Please see our website for more information.

    Himalayan HealthCare seems to be a very noble cause. They go beyond medicine to providing educational opportunities and encouraging entrepeneurship. They can't be too popular with the Maoists, who have their own educational programs.

    posted by Sydney on 4/09/2006 10:58:00 PM 2 comments


    I visited the clinic in the Himalayan Mountains in 1998, before China decided to take over Nepal.

    Most of the health care in the remote villages was done by Nepalese nurse practitioners. These practitioners were trained by the doctors in the clinic. The system seems to work well. The clinic handles the severe cases.

    Nepal has two huge advantages over the US:
    1. There are no greedy trial lawyers in Nepal.
    2. The government has nothing to do with health care.

    The complaints McKersie has about Medicaid and medicare are exactly the complaints doctors have about every government healthcare system in the world they are forced to work in.

    By Blogger Jake, at 11:43 PM  

    Rebuttal to Jake’s comments:

    I appreciate your comments and also your work and interest in Nepal.

    My experience as a healthcare provider in the US has demonstrated to me the need for a national healthcare program. Preferably, a government financed, privately run, non-profit healthcare system. This healthcare system would need to ban investor-owned delivery systems and eliminate the multiple payers that our system now has. In other words, A Single Payer system. There is an abundance of data that shows that for-profit hospitals and clinics in the US offer inferior care and are costlier than their non-profit counterparts. One reason some of the US healthcare indices (infant mortality rate and number of uninsured to name two) have worsened is a result of the increasing percentage of our healthcare system that is now for-profit.

    I believe that government is not the problem to our healthcare woes, but government can be the solution.

    The criticisms I have with Medicaid are that some doctors and clinics, due to poor reimbursement, are refusing to accept it. A Single Payer system would alleviate this. Medicare, which I have only had good experiences with, is excellent healthcare insurance on many levels. The Veterans Administration is another example of a good government healthcare systems.

    Nepal is one of the poorest countries in the world. Per capita GDP is $1,500 per annum, compared to the US per capita GDP of $42,000 per annum. Nepal is also a country that only spends about $4 (US dollars) per capita on healthcare. A country this destitute cannot have very much influence on its healthcare system, and it is forced to rely inordinately on charitable care. However, the healthcare indices of Nepal are dismal, its infant mortality rate is ten times that of the US, its maternal mortality rate is 100 times that of the US. These Nepalese healthcare indices are averages for the whole country, the remote villages in Nepal have far worst healthcare indices than these averages. In sum, I do not believe that one can conclude that Nepal has an advantageous healthcare system because its government is not involved.

    Robert McKersie, MD
    Author of “In the Foothills of Medicine, A Young Doctor’s Journey from the Inner-City of Chicago to the Mountains of Nepal”

    By Anonymous Dr. Robert McKersie, at 11:14 PM  

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