Another status update from over yonder...

It's August. It's still hot and humid. The Ramoray family have all packed up and gone. No Tornado warnings for a week now, but still occasional thunderstorms.

We've managed 4 months now - a third of our year, so I thought it would be a good time to reflect on what I've learnt so far.

My objectives when I came here were:

To experience working in a totally different health care system

To have more experience of supervising junior colleagues

To develop my teaching skills further

To do more challenging cases (eg transplants, bariatric surgery, challenging airways) (I was actually hoping to do some liver transplants, but that hasn't worked out)

To see a different way of organising the whole process of surgery, and see if they were more efficient than how we do things in the NHS.

To see different methods of anaesthesia.

To see a bit of America, and live a bit of American culture.

To enjoy it!

So far I think I can safely say that I've ticked all the boxes (especially the last two), but there's still loads more to see, do and learn about the way of life and the way things are done here.

My log book is filling up - when I remember to keep it up to date...

For anyone who is interested in what kind of experience we get here:- So far in my 4 months I've logged 350 cases - but I know I've not logged a lot of my on-call cases. The break down according to specialty so far has been:

ENT 56
General 88
Gynae 45
Max fax 11
Neuro 14
Orthopaedics 28
Plastics 29
Trauma 18
Urology 47
Vascular 2
plus a few miscellaneous

173 have been ASA 3 or 4.
78 have been with CRNAs
The others with residents.

Only 41 have had an LMA, 264 have been intubated. 28 have had "sedation" (which can roughly translate to a general anaesthetic without an airway... but that's another story), 11 have had a spinal. 11 have had an epidural. Only 16 have had TIVA.

I've done 8 awake fibreoptic intubations and 3 cases using the jet ventilator. 38 patients have had arterial lines, but only 3 have had CVP lines.

I've run some teaching sessions with the residents, a couple of tutorials with medical students (on cardiovascular physiology), I have run a journal club, and when I'm working with a resident I try to cover one topic each day with them (although it's often hard to fit it in if you have 2 busy lists). I'm also working on a project that will hopefully result in a publication at the end.

It's been.... intense - and it still is. It's easier after the first month, cos you adapt to the system here, but then you start getting harder cases, and then the residents change and you are supervising novices - so there's always new challenges around the corner.

In terms of learning about another health care system... I still don't really understand the health system here. It may sound odd, but it isn't really relevant to my job. I just make sure that I electronically sign the right documents so that the hospital can bill for my services, but I have no idea what happens about funding. I know some patients are insured, and some are insured via medicare or medicaid (Medicaid is government funded health care for those who are poor enough to qualify - as long as you fall into one of the eligibility categories. It is means tested. I don't really understand what it will and won't cover. Medicare is government funded health care for those over 65 - and is not necessarily free and has a very complicated set of rules about what is and is not included.) There is also a significant size of the population that fall into "none of the above" - ie they don't get insurance from their employers, and they can't afford their own, but they are not poor or old enough for government funded health care, yet ironically their tax is funding it. I don't really know which patients who I see are insured, and who are on medicaid - although it is in the documentation if you look for it. You can often guess, but everyone gets treated the same - you do your best for everyone - just like at home. It's not like - Patient A is on premium insurance so we'll crack open the expensive drugs.

Health care is expensive and it's big business. Luckily we get insurance mostly paid for by the University of Michigan employee benefits office. For me, my wife and 2 children it costs $1200 per month. I pay nearly one third of that, the university pays the rest. To many who don't have such a generous employer the choice must be to either pay for a mortgage / rent or pay for health insurance. $1200 a month is more than my mortgage at home.

It's not hard to see why health care is so expensive either. Nearly everyone is on a drug to treat something or other (OK - admittedly I am seeing a very skewed population who are all the least fit in Michigan, which is one of the least healthy states in the US), but even seemingly fit and healthy 18 year olds can be on 5-6 drugs for asthma, depression, high blood pressure, migraines. Drugs are nearly always prescribed by brand rather than the generic drug name (much to my irritation - everyone always use brand names rather than generic drug names).

As technology has become more and more advanced, it has been possible to keep people alive when pretty much every organ has failed. It's not uncommon to have a patient come to theatre who has a left ventricular assist device (basically an electric pump that supports a heart that has failed) or someone who has had multiple organ transplants. This is great, but it all adds to the rising health care costs. It's the same pretty much everywhere in the Western world. Medicine is a self fulfilling profitable business. The more successful you are - the more patients you have - and they will keep getting older and sicker. The hard facts are that if there were no restraints at all, health care costs would spiral up and out of control.

It's not just immediate costs of health care either. Patients who are surviving are going in to long term nursing home care, lawyers are making a fortune on medical negligence claims, there is also a big industry of specialist lawyers here who will help people become eligible for medicaid. There must be a whole army of administrators who deal with the billing. The insurance companies will go through every detail of a medical bill and contest anything they deem unnecessary, so all the paperwork has to be perfect. (I say paperwork - but everything here is electronic records.)

I can see now why there is such opposition to Obama's health care reform - it will affect a lot of these other industries that have built themselves around this current system. A lot of people are making lots of money from it at present. Also, if they introduce government funded insurance for all, but do nothing to reduce the costs, the country will be even more bankrupt than it is already.

I came here very open minded - generally fed up with the inefficiencies and bureaucracy of the NHS; the government interference and micromanagement. I expected things to be very different in the states - and don't get me wrong, things are significantly different - but there are just as many debates about health care costs and inefficiencies here. Some criticisms of the NHS could be just as applicable here. I can't say either system is better or worse. They are both flawed, and I don't think there is any health care system that isn't.

I am if anything more grateful for the NHS. For one, at least you can be confident when you go to the doctor they are not going to profit from prescribing a drug or operating on you. The NHS is something worth saving, as long as we can keep some restraint on it. I hope there'll be something of it left by the time I return please Mr Cameregg.

Till next time,

Stay Healthy,

Drake.