Ah July 1st... the transition point between non-clinical and clinical years in medical school, between being a student and intern, and also between being a trainee and being 'in charge.' As a student- you're no longer carrying books (or iPads), and now have to interact with sick humans. As an intern- you go immediately from hot-shot-test-taker to having to respond to actual emergencies. As an attending- you now have seemingly fewer people to question at every decision point. I remember my first night call as an intern in 2008 very well, and now I've been an attending Hospitalist for three years: my brief tenure full of transitions. The same same simple rules seem to apply to thriving in any new healthcare work environment.

I ASK YOU!

I - Be interested in others, and introduce yourself. This obviously starts with the patient; Mrs S is not just some GOMER in bed 3 with failure to thrive. Taking 2 minutes to truly learn about her as a person will help you maintain empathy, and get you through the brutal paperwork, bureaucracy and scut that is omnipresent. This should extend to your coworkers, nurses, techs, all non-physician types that make patient care possible. You'll have to interact with these nice folks for at least a year, and (maybe 7 if you're a Neurosurgery trainee). Learn people's names. As Dale Carnegie once said- 'a person's name is the sweetest sound to that person.' Don't do as my anatomy lab partner did during medical school and address his cadaver buddies as 'hey boss,' 'dude,' and 'yo!' for four months. People will notice.

A - Ask others for advice. This one is obvious. People that have walked your path know more than you, and they can save you some time. Someone once said to me; you can open your mouth and seem like a fool for one moment, or stay silent and certainly be one when preventable stuff goes wrong. Remember, it's also okay for this advice to come from other non-physician-types; senior nurses definitely know more than you on day 1 of internship, and perhaps still something useful on day 1095.

S - Systems, learn them! You can't function effectively if you don't know how to reach people, how your EMR works, whether your attending prefers direct communication or a hierarchy of secure texts through your senior resident. This is an actual prerequisite to doing good work, so pay attention and develop a method to tame the madness. First step is learning how to function in your new environment.

K - Knowledge. Realize it takes time to acquire, and it's not easy to retain. As a Critical Care attending once barked at me - "reading UpToDate is not the only form of required learning." I scoffed at the time, but he was right. Making a sincere consistent effort to learn no matter how crappy your day is a challenge. You did great on Step 1 and 2 (and maybe 3)? Congratulations, but now that means very little. Having a baseline knowledge is a prerequisite but not the end point. You're judged on patient outcomes now, and against 10 other interns, rather than a multiple choice test. Malcolm Gladwell reminds us that 10,000 hour of "deliberate practice" are needed to become world-class in any field. (No wonder you were in school until you were 30).

Y - Focus on you (and your well-being). I don't mean be selfish and neglect patient care responsibilities to slip out to an early happy hour, or neglecting your partner, or ignoring your parents (if you haven't already). I mean take care of yourself; that you're eating and sleeping well, scheduling time for 'fun,' and exercising. Don't preach to your patients what you don't practice yourself.

O – Remember your oath. It may have been conceived in a time of togas and violence, but it is still sacred. Every year the media is flooded by some inconceivable story of doctors doing bad: sex scandals, billing fraud, unnecessary procedures... the list is endless. Please strive hard to not to become one of these people. It's bad for your career, it's horrible for your family, and it's a waste of your talents.

U – Understand that everyone needs their own system for thriving at work. Like anything in life, you need to be purposeful about it. Strive to develop your own, and then hold yourself to it.

So I ask you... what will your system be to survive the July transition?

Varun Verma, M.D. is an internal medicine Hospitalist who helps develop The Magic of Medicine  podcast about mentoring in medicine. He can be reached on Twitter @VarunVermaMD

Medicine has undoubtedly come a long way. Paternalism has been ditched in favor of a shared decision making approach, diagnoses and treatments are (largely) based on scientific evidence, and information is not outright withheld from patients out of some misplaced belief that they are not capable of handling the truth. Some of the modern pain points that patients now face involve access to specialists, skyrocketing cost, misinformation and miseducation surrounding prognosis, and confusion about end-of-life care. In addition to all of this (and much more)– one thing that has not improved for hospitalized patients is the uncertainty of their day.

A typical day unfolds as follows: Provider-X sees the patient once at the start of the day, while nurses diligently attend to the moment-to-moment care, and various departments work to execute the plans that have been ‘ordered.’ Throughout the day, a handful of other providers walk in consulting on the patient, and inevitably at some point plans change. The poor patient sits around, while their providers attend to their many other patients, duties, boxes to check, forms to fill, and other distractions. At some point the patient or family member voices concern because they feel they’ve been forgotten. After some delay, the provider walks in and sheepishly apologizes for events that are largely out of their control. Welcome to inpatient medicine in 2015. The majority of the 5600 hospitals in the US are not flawless assembly lines of medical care that we would imagine them to be based on $3 trillion of annual healthcare spending.

It’s frustrating to see advances in medicine constantly weighed down by ancient inefficiencies in the system. Quite often, hospitalized patients have little sense of what will get done, when, and for what purpose. This is drastically different to their out-of-hospital experiences where technology has ensured that people are well aware of weather, transportation delays, and possible variations in price, quality and quantity. The problem doesn’t just extend to when exactly diagnostic tests or invasive procedures will be performed. Patients often don’t know which specialist consultants will examine them, when physical therapy will work with them, or whether a social worker is available to talk. The sad fact is — as their doctor — I am in many cases equally in the dark. It is not unusual that I spend a significant part of my day chasing around my colleagues (and they in turn page, text, call and email me to find out what my plan of action is for our patients).

If you’ve been to a hospital recently, you’ll notice that the truly ‘innovative’ ones have a display on the wall facing the patient that contains useful information like the date, the names of the doctor and nurse, and what the diagnostic plan is for the day. What is shocking about this potentially revolutionary communication tool in 2015 is at the majority of institutions this is actually a whiteboard. Unsurprisingly, I often see inaccurate and outdated information that is less than helpful for a patient attempting to discern the big picture surrounding their care.

When a patient endures the torture of being kept hungry and thirsty, only to have a scheduled test canceled, they’re often told that it was because “emergent cases take precedence.” Of course protocols about which patient should get first priority do make sense. In most places though, the ‘system’ doesn’t seem to provide continuous feedback of care-flow inside of hospitals. If it does, the information is certainly not shared effectively with healthcare team members or the patients themselves. Individual patients and their families suffer in the ensuing uncertainty as they’re the last ones to find out about whats going on, and often with some delay. Imagine how patients may feel if their whiteboard were electronic and resembled an airport departure screen to actually update them in real time them with useful information about delays, cancellations, and perhaps even (gasp!) ETAs of providers.

Some may argue that giving approximate or expected times for anything in the hospital is ridiculous, pandering to a concierge approach to medicine, and ultimately does not change the outcome for the patient. I disagree. Patients deserve better while in their most vulnerable state; with illness, pain and anxiety. Perhaps a good motivator for change is the indisputable fact — that we will all be patients one day. We surely would not accept the existing level of chaos in care coordination for ourselves or for loved ones, and we clearly have the technology to enact change. So why don’t we?

Its irrefutable that crowdfunding does good for thousands who otherwise could not afford their medical treatment. Internationally, many companies have formed alliances with not-for-profits to provide access to lifesaving surgery and medical care that would otherwise be unaffordable. Increasingly they have strived for financial transparency including metrics like number of cases treated, cost per surgery, and percentage of funds spent on overhead. Domestically in the US; family members and friends have also had varying degrees of success on sites where you can raise money for anything related to healthcare costs (think of the medical equivalent of Kickstarter/Indigogo). In places like the US we are also lucky to have the safety net of government protection and institutions like teaching hospitals were some services are available for free. Despite these opportunities- plenty of people globally fall through the cracks and find themselves helpless – not meeting the strict inclusion criteria for formal crowdfunding organizations or simply unable to crowdfund on their own.

Consider a patient from remote rural Nepal who falls into both cases. Our patient B. had just returned from Southeast Asia where he was working. Chief complaint: Traumatic brain injury. I wondered how they had got him on the plane in his condition (he reminded me of the dead migrant workers in Qatar being sent back to Nepal in coffins). We were looking at a young 30-something year old gaunt male. He stared up into space from the stretcher, unable to speak, and responding only to painful stimuli. From his belly protruded a feeding tube (I hadn't seen one of those in rural Nepal the past few months), and dark yellow urine flowed through a catheter inserted up his urethra. I read his typed out reports – hit by a car two months ago, 2 week intensive care unit stay after he was intubated, intracranial hemorrhage – no midline shift (and no surgical intervention), some type of arm fracture, feeding tube, and being sent back to Nepal since patient was 'stable' and off the breathing machine. His sister S., who had been a nurse at our hospital previously, held up one can of almost empty Ensure (powdered feeding supplement) that had been sent back with him. I discussed the difficult reality with my colleagues that we had little to offer the patient. No CT scanner for repeat brain imaging, no Neurosurgeon (likely wouldn't have helped anyway), and no on site physical therapy. I commented aloud about how terrible the situation was- and then didn't think much about it the next two days. Misery was in no short supply around here- and there were many other patients to help.

Two nights later I felt embarrassed when S. came and found me. I hadn't realized they were still in the hospital (the staff had carved out a private corner in the ER for B. rather than transferring him to the busy inpatient unit). I was on the hospital campus at the canteen getting my dinner and she sat beside me. 'Do you speak Nepali?' She looked hopeful (probably given my brown skin and dark hair). I didn't. However, I did speak Hindi fairly well and she seemed like she could get by. She asked me if I thought he would get better. I cringed and then discussed his slight improvement; she had mentioned he was drinking a little bit now and sometimes intermittently speaking one/two words. Yet he remained disoriented and unable to support his own body weight or control his bodily functions. I emphasized that the prognosis for traumatic brain injury was often poor but unpredictable. She understood. She apologized for interrupting my dinner... and then kept talking.

S. now worked at a nearby government health-post. She was a single parent with an infant daughter, and she also took care of her mother who lived with them (in what barely met the definition of a house). She started to cry as she told me her husband had divorced her, how she was in chronic pain from a leg injury, and how she now found herself completely responsible for her brother's care. She had raised B. since he was six months old and their father had passed away (I wondered how much older she could have possibly been at that time). Apparently he hadn't been able to send any money back while working- and in fact she had to pay some of his expenses while he was abroad. It's hard enough coming up with the right words in English to console grieving family members – it's even worse when you're trying to make a difference in another language. I had stopped eating – but S. motioned for me to continue – she even asked if I needed more roti. I could tell all she wanted was some concrete solutions and direction. She expressed unlimited gratitude that the hospital director had sent an ambulance to pick up her brother for free and the care we had provided thus far (not much to be honest). Now she was worried about three things: 1) How to get him a wheelchair 2) Whether we could write a letter stating B. was disabled that she could present to some Government disability program for migrant workers and 3) How she would get him the physical therapy he would need.

Non-government organizations (and governments for that matter) rarely have a discretionary fund to cover things like durable medical equipment, physical therapy and home-care. Clearly there are exceptions to this rule – some organizations do provide walkers, wheelchairs and the like upon discharge from the hospital (Partners in Health has been especially deliberate about figuring out what is needed for the complete care of a patient). There are also many groups devoted to donating specific supplies to where they are needed. For the most part though, worldwide– it is easier getting patients free vaccines, antibiotics, anti-retrovirals and anti-TB drugs, other lifesaving medications and even world class visiting surgeons than to get them 'stuff' or ongoing out-of-hospital services. We the donors are mainly to blame. We appreciate pictures of patients before-and-after surgery, we like our names/brands stamped on physical structures, but sometimes we forget the 1000 other things that are needed to ensure the well-being of a patient (such as food, housing, and supplies – not to mention the salaries of local staff or community health workers). Overall- it's not a stretch to say that all of us are reluctant to contribute our hard earned savings to such 'peripheral' interventions – fearing that our money will be squandered (interestingly Bill Gates pointed out in his 2014 annual letter that corruption or diversion of resources is an irrational fear). After a few brief years in Haiti and Nepal – I can honestly say that other supplies and services are often those that often matter most for patients and their families. We cannot hope to provide complete care without them since medical and surgical interventions are often just step one.

I have no idea what will happen to S. and her brother. We can certainly write her a letter about her brother's disability in a few days (since he most likely will not recover to be able to work again). Somehow she will take more time off work and present this piece of paper to the Government in the capital – but whether she actually gets any financial support is an entirely different matter. We will also figure out a way to get her a wheelchair (generous friends have helped me many times in the past when I've shared similar experiences of hitting roadblocks). For the physical therapy I suspect we will end up teaching her what needs to be done daily, so she doesn’t have to worry about the how, when or where to get him services. I'm less certain about the bigger issue though – the long term financial outlook for S. and how she will take care of her dependent family. As I prepare to part ways with her at the end of my meal, she has finally stopped crying. She asks me where I'm from and how long I've got left in Nepal. 'I feel like you were sent here for me.' I'd like to hope so, but in reality all I see is a woman at the start of another set of struggles. Plus, as my time in Nepal comes to an end – the important durable component of the entire healthcare system remains intact – the local staff who sacrifice to be in such a remote location, and continue to serve in the face of tremendous resource limitations. Perhaps not for B. - but for many of our other patients, their presence makes the world of difference.

2/17/2015
Varun Verma, M.D. is a board-certified Internal Medicine physician who splits his time as a Hospitalist at Brigham and Women’s Hospital (Boston) and as a Senior Clinical Advisor to Possible (Nepal) 

@VarunVermaMD

Countless others have written of the injustices faced by those lucky enough to be patients in the developed world in 2014 (as opposed places like West Africa where hospital systems are severely lacking). Some of the pain points for patients surround access to care in the first place, being asked to answer/fill out the same questions repeatedly, insanely high out-of-pocket expenses, abyssal coordination between providers, misinformation on prognosis, and confusion about end-of-life care. In addition to all of this (and much more)– as an internal medicine doctor who works mainly night shifts in a hospital – I have noticed one thing that has not improved for patients is the uncertainty of their day. I try my best not to cringe when patients ask me what time exactly they will be going for their CT scan (or other test/procedure, or when will Doctor A. see them in the morning). Unfortunately, in the majority of cases I have no idea.

It pains me most to see patients awaiting a diagnostic test or invasive procedure who are kept NPO (nil-per-os; not allowed to eat or drink). Hunger and thirst aside, even the ones that aren't NPO are understandably anxious. Sometimes they endure this torture; only to have the test canceled at the last moment. “You know that emergent cases take precedence” is the variation of response that is often barked at me when I call other departments for answers. Every employee in the hospital is bound by their duties and protocols about which patient should get first priority for things like MRI (e.g. strokes are evaluated before cancer patients with suspected metastasis who are stable overnight). Obviously this is the most rational approach for the system as a whole (for the greater good!) What about the individual patients though? They suffer. Families suffer with them, as do the nurses and doctors taking care of them.

The purported amazing advances in medicine are constantly weighed down by ancient inefficiencies in the system. Whole genome sequencing in 2014 matters to a handful of patients (yes, I realize the tremendous potential), but uncoordinated care affects everyone. Unlike in many subways stations in New York, where we now have a 'next train approaching' notification, patients have zero sense of what will get done and when. The problem doesn't just extend to diagnostic tests or invasive -procedures. From the moment they walk in the E.R. door; patients don't know when their bed will be ready, when their specialist consultants will examine them, when physical therapy will work with them, or when a social worker is available to talk with their family. The sad fact is – as their doctor – I am equally in the dark. I often spend a significant part of my day chasing around my colleagues (and they in turn page, text, call and email me).

Some may argue that giving an approximate-expected-time for anything in the hospital is ridiculous, and ultimately does not change the outcome for the patient. If there is a delay, it may be equally frustrating for the patient as not knowing in the first place. I disagree. The situation right now is the equivalent of being asked to show up to the airport at midnight, and not knowing whether you'll have a flight for the next 24 hours. Surely with billions spent on healthcare IT we must be able to do better? Patients deserve more. In their most vulnerable state; with illness, pain and anxiety – our hospital system piles on greater and greater uncertainty.

The challenge remains; how do we recruit brilliant minds engaged in building yet another social network, the next best mobile game, or a fitness tracker (as if we need more of these) to start solving the many problems in hospitals. Secondly- how to fund something innovative? V.C.s may not be able to see beyond R.O.I (hence more likely to fund a dating app than something truly lifesaving). Perhaps a good motivator to back healthcare innovation is the indisputable fact — that we will all be patients one day.

12/16/2014

Varun Verma, M.D. is a board-certified Internal Medicine physician who splits his time as a Hospitalist at Brigham and Women’s Hospital (Boston) and as a Senior Clinical Advisor to Possible (Nepal) 

@VarunVermaMD

Recently I experienced one of the most terrifying nights of my professional life. Having worked in six different hospitals since finishing my residency training, I am well aware of variations in work load. I've worked in a 700 bed hospital, and a 40 bed rural setting. Chaos in healthcare inevitably ensues  when more patients show up. Sometimes it is the hospital setting (urban vs rural), other times the day of the week (people avoid coming in during holidays), and sometimes simply the weather (patients don't like traveling during snow). This particular night captured how much harder my job is given that providers still don't have the correct healthcare I.T. tools to optimize their own work flow.

In the first half of my night- I received so many pages, phone calls, and admissions from the emergency room that I could barely scribble them down quickly enough on the printed sign-out document in my white coat pocket. Writing things down to relay back to the morning team was one thing; however the true challenge was efficiently executing a diagnostic or treatment plan with all the interruptions. I was on the verge of committing multiple medical errors as my pager rang non-stop, I navigated through four different computer systems (lab ordering, radiology, billing and patient charts themselves), and attempted to coordinate care with nurses other colleagues in different specialties.

My own momentary mental misery aside (12 hours go by fast) – I couldn't help but think of the care that patients receive. Put aside the tremendous delays in getting from ER bed to hospital bed once you are admitted (sometimes patients are 'boarded' downstairs for 24 hours). Forget the fact that you had to answer the same questions at least 4 times; to an ER nurse, ER provider (doctor, physician assistant or nurse practitioner), then to the Hospitalist/admitting provider when you reach your room, and then finally to your unit nurse. On top of all this - imagine a night filled with delays because your nurse, doctor, pharmacist and others are still relying on archaic communication methods.

A common scenario unfolds. You have severe abdominal pain, nausea and vomiting and you press your call button (yes, that tiny button on the end of a cord next to your bed). Now you wait. Your nurse arrives 1-5 minutes later (no idea whether you've fallen and hit your head or whether you're just hungry), pages your doctor (who is in the middle of something else), and they call back 1-15 minutes later. Either they come to assess you, or order something to treat empirically in the computer order entry system. The treatment must be released by the pharmacy, somehow arrive to the floor, and finally your nurse can administer it. Really.

It easier for me to reach a friend or family member using a variety of escalating techniques such as email, text message, phone call (and when I am really desperate Facebook) - than it is for me to coordinate with colleagues to provide life saving and efficient care. Simply replacing pagers and telephone call back with something 'digital' (like secure messaging)  is a really low bar to set ourselves. We should have surpassed that level of mediocrity a decade ago. Admitting that we're failing is a start. What we need is a complete overhaul of communication, coordination and work flow optimization in the hospital. Using existing technologies available in 2014, we should be able to pivot and rectify the chaos. We're just not doing it. This is despite knowing that chaos leads to decreased provider satisfaction, delays in care, medical errors and death. We don't need more studies. We need action. What more will it take? 

11/26/2014

Varun Verma, M.D. is a board-certified Internal Medicine physician who splits his time as a Hospitalist at Brigham and Women’s Hospital (Boston) and as a Senior Clinical Advisor to Possible (Nepal) 

@VarunVermaMD

One would expect that in an era where smartphones are more powerful than our computers were 5 years ago, healthcare providers would have an arsenal of healthcare IT solutions to enhance patient care but also optimize their own work-flow. Shockingly, in 2014 most healthcare IT solutions (such as EHR systems) are incapable of basic functions that we take for granted in other aspects of our digital lives (this is despite the fact that hundreds of millions of dollars have been invested by institutions). We have made information electronic, but continue to work with it as if all we had was an abacus. This is problematic since many providers are now involved in taking care of patients (physicians, nurses, physician assistants, clinical pharmacists, therapists, and trainees), and there is greater turnover of team members due to the shift work nature of inpatient care. Rather than having optimal information available – we have data chaos.

The situation is in stark contrast to my out-of-hospital life. In my Gmail I can (usually) easily find a specific message using a combination of ‘has,’ ‘to,’ ‘from,’ and ‘subject’ statements. Most EHRs on the other hand have me scrolling through consultation and progress notes in size 10 text, stacked one on top of each other, which are about as search-able as a Where’s Waldo scene. As a Hospital Medicine doctor who needs to rapidly assimilate information often in the middle of the night – EHR is my last resort. When I receive an emergent page, I rely on my examination, the patient interview (if they’re able to talk), and then a quick glance at a rudimentary ‘sign out’ document handed to me from the day-team. EHR is neither optimized for mobile in most cases, nor can I find anything I am looking for when I actually need it. This is true irrespective of whether I am working at a rural hospital in Maine with a 10 year old EHR, or at a major academic center with a ‘cutting edge’ EHR.

Despite heavy investment in healthcare IT from institutions – providers like myself still find ourselves carrying around printed patient lists with scribbled check boxes and to do lists. The sign out document – a purportedly succinct summary of the patient problems and suggested plan of action quite obviously has pitfalls. One night last week I counted 42 patients I was covering overnight on five different sub-specialty services; and some basic math revealed that in my 12 hour shift I was in charge of more than 120 active medical problems, and at least 1000 years of medical history (conservatively). All of this was summarized for me by other providers in a neatly typed word document extracted from copy-pasted snippets of EHR notes, printed, stapled, and then folded – ready in my white coat pocket for me to peruse while I bolted through corridors or took the elevator to where a patient was crashing.

On discussing the shortfalls of modern healthcare IT solutions; I often hear colleagues stating that change is coming ‘soon’ (read; 2–5 years). Given that medical errors now kill more than 400 000 Americans and are the number three cause of death in the United States – we need a greater sense of urgency about how broken IT systems are, and how we can fix them immediately. Infinitely more thought, investment and energy goes into social networking endeavors than how patient information is presented and made available to healthcare team members. (It is irrefutably easier for me to find out where you went to college – using LinkedIn, Google, or Facebook — than to find out who my patient’s primary care doctor is).

It makes little sense that modern medicine offer us marvels like whole genome sequencing, while simultaneously providing ridiculous solutions such as mnemonics to reduce errors during change of shift. Surely the bar must be set higher, and we must harness the technology we carry in our pockets.

11/4/2014 

Varun Verma, M.D. is a board-certified Internal Medicine physician who splits his time as a Hospitalist at Brigham and Women’s Hospital (Boston) and as a Senior Clinical Advisor to Possible (Nepal) 

@VarunVermaMD

Trying to persuade people to care about strangers in far away lands is always tiring. Perhaps the saddest part about human suffering is that it is infinite. Every week there is some new disaster in the headlines; an earthquake in Haiti, floods in Pakistan, typhoon in the Philippines, civil wars, dictators in Syria, insurgents still in Afghanistan and Iraq, and a new entity called ISIS. The list of things making human beings endangered is literally endless (I forgot global warming). Last month when I commented to friends that we shouldn’t just reminisce about disasters (like 9/11) on anniversaries — I was promptly advised to not dwell on things because it’s depressing.

In the midst of all of this carnage, somehow all of us still carve out time for the FIFA world cup, another celebrity picture leak, sexy Halloween-costumes, and social media memes involving ice buckets. There seems to be an entitlement that despite the collective suffering of billions, we somehow owe it to ourselves to go on having a jolly good time. To do anything less would be giving in to evil. Unfortunately, I think that this has bred a culture of superficial activism actually hiding apathy and leading to a collective inaction. ‘The problems are so big, that what else can I do but donate $50 to my friend running the NYC marathon?’ Despite having worked in Haiti and rural Nepal the last two years, I find myself equally as guilty of forgetting other peoples’ problems the moment I land on American soil. My biggest concerns in the middle of a stretch of night shifts in the hospital are me, my food, and I.

Currently #Ebola is trending like wildfire (ie. like Ebola itself) on the internet. The American public is being fed a very different message from the reality facing Africans; that everything is going to be fine. This is despite thelatest figures that reveal 9000 cases and the death toll surpassing 4500. The response from American officials is essentially ‘keep calm and carry on’ — that polar icecaps melting, or another aviation disaster will kill you before that rare and remember-it’s-not-airborne virus (after all it’s only one dead patient and 2 American nurses that were infected from direct bodily fluid contact). A perfect example of this was a recent article on Bellevue Hospitalin NYC (where I happened to train in Internal Medicine) that revealed it ‘could treat up to four patients with confirmed cases of Ebola in isolation units.’ Prepared! With four isolation rooms? The WHO has calculated that by December in West Africa there could be 10 000 new cases per WEEK. If… and I am not saying when, there were to be more cases in America — it would be magnitudes more than four.

Potential American apocalypse aside, what we really need is the world coordinating its help around African nations to contain the chaos, and to ensure this does not happen again. The media has been abuzz with reports that a certain billionaire had given $25 million to the CDC foundation to stem the fallout, but no one bothered to question — for what purpose? In reality when the on-the-ground forces taking care of patients in West Africa are actually MSF (Doctors Without Borders), Partners in Health, Last Mile Health, and major needs are to get an adequate number of local health professionals working, what good is it giving more money to an organization that already has a $6.9 billion budget (and is US-based)? In any case, money by itself clearly doesn’t solve problems. However, before seeingdisorganization first hand in post-Earthquake Haiti, I never realized that getting money into the right hands in a timely manner is more complex than quantum mechanics. All the Ebola Czars, committees, subcommittees and specialty groups aren’t going to solve that. We already know where to send the money, and yet we consistently fail to deliver.

It’s becoming apparent with every major disaster that those in charge of protecting the most vulnerable in society have little clue of how to actually coordinate care. ‘Experts’ are a dime a dozen, and few with actual real world training in matters of mass mayhem. What is also apparent (in the words of PIH co-founder Dr. Paul Farmer) is that some lives matter less than others. Look at what we as a society value in 2014. A computer company churns out a new cellphone and 20 million people make a purchase within 1 month. A disease kills 9000 Africans, and ten months later agencies are still debating what is the best course of action. Investors are more rattled by bad video-on-demand sales figures, wearable fitness trackers (useless), and a Chinese company IPO than they are interested in investing in R&D efforts for things that actually could save lives. There has been an outpouring of volunteers (PIH reported thousands of applications for field staff immediately on request), but there have been little promises of better capital investment (build better infrastructure). Gloves and masks are easy to scrounge together from donors and funds- but it’s always an issue when governments in peril ask for assistance to build stable hospitals (not tents), or train more workers and actually pay them (and not rely on expat volunteers). Clearly there are many groups that realize the tremendous importance of this-but they are vastly outgunned by the problem at large. Larger groups in a position to help instead keep holding meetings.

I am not suggesting that everyone drop everything and start working on Ebola, but the slow response to the epidemic is a symptom of a malignant disease in our society. It’s interesting to look back at history and see that the world canceled the Olympics twice during World War II. Yes, war is different from infection, but in the end it’s devastation all around. We actually don’t even respond to war in the same way anymore (how many multi-year conflicts are still burning bright?) Instead now we talk in awe about how Twitter helped the Arab Spring (what exactly happened with that again?), click thumbs-up on links, and re-post videos of harrowing experiences of those in the middle of the action. We observe, applaud, and do little. No matter where or from what the end comes for any of us — warming, wars, or wildfire (Ebola) — the fundamental lack of concern for ‘other’ people across imaginary geopolitical borders has always been the problem. The good intentions of a select few are not enough. We all need to start not only being thankful for what we have (as the ubiquitous self-help gurus teach us), but figure out how we can also get others some relief from their misery.

We should be terrified of Ebola. It requires no vector except infected bodily fluids (unlike Malaria and mosquitos which kill 600 000 people per year), there is no specific treatment so far (only ‘supportive care’ which amounts to fluids, rest and monitoring), and even when we get a vaccine — the work of Edward Jenner 200 years ago, and more-recently the Gates Foundation pouring billions of dollars into health has shown that even when you make prevention free — you still fall short. The so-called experts are correct though; since American medicine is littered with doctors, nurses, PAs, NPs, naturopaths, chiropractors, reiki healers and billion dollar healthcare facilities — we lucky few in the United States — are probably going to be fine. Though we should be terrified for our fellow humans facing endless suffering in environments where they have nothing close to the resources that they need. Lets put aside our $700 cell phones for a second and figure out what concrete steps we can take. Doing nothing is certainly not an option — clearly that has not worked out very well for anyone in the past.

Varun Verma, M.D. is a board-certified Internal Medicine physician who splits his time as a Hospitalist at Brigham and Women’s Hospital (Boston) and as a Senior Clinical Advisor to Possible (Nepal) 

@VarunVermaMD

‘Statistics are human beings with the tears wiped off.’

“I won’t be here next month.” Ten years ago I walked into my very first patient’s room as part of my medical school physical diagnosis course. I was momentarily confused- but thankfully I did not naively blurt out “why?” I noticed her pale skin and her bald head and felt like I had intruded because she was sitting upright in the hospital bed with her legs crossed and hands in her lap, almost as though she was meditating. She continued — “sometimes I go to the mall and I sit there eating and watch other people and think: I won’t be here next month… but they still will.” I’ve thought about her often during the past decade- not only because that brief encounter with her taught me a lot, and not because I have had many patients with cancer since then… On my flight from New York to Kathmandu it occurred to me that I am now the age that she was when she died a few months later… 32.

Illness is a burden we must all someday face. My young American patient had access to a tertiary care hospital with the latest diagnostics, treatments and the expert knowledge of sub specialists, and yet she still died. In stark contrast to this- many sick people throughout the world do not even have the illusion of adequate access to healthcare, and subsequently no hope. There are of course exceptions; and while I was in Haiti I learned that Project Medishare is organizing chemotherapy for patients with cancer (as has Partners in Health an organization that believes health is a human right). Based on current WHO statistics, residents of Sierra Leone have the shortest life expectancy at birth – and at around 47 years, this is a shocking four decades less than Monaco (supposedly the country on top of the list). Of course figures do not capture the lives cut short of people trapped in the midst of dozens of serious armed conflicts worldwide. Essentially, people endure a tremendous amount of suffering due to the misfortune of the place of their birth. In rural Nepal where I now work, the primary culprit of misery is how far away people live from the care they need. A close runner up is whether or not adequate resources are on hand once they finally arrive…

Those of us lucky enough to live in places where we do not face moment-to-moment struggles for survival sometimes forget that people cannot just will themselves into better conditions. This is as much the case for homeless people in New York City as it is for poor people worldwide. Contrary to beliefs that simply ‘working hard’ will lead eventually to a better life, most people are trapped so deep in vicious poverty that climbing out is infinitely more impossible than the rags-to-riches stories that we are all fed by Hollywood. In desperate situations the prerequisites for change simply do not exist, nor are their options to just start over by escaping to another reality. Although global health statistics may widely show things are improving for the worlds’ most vulnerable (in terms of metrics like under-5 mortality), they fail to capture individual stories of tragedy. In the drowning propaganda of social media these stories rarely ever reach us, unless of course a minimum threshold of death and destruction is met to make it interesting (think 300 000 dead during the 2010 earthquake in Haiti).

Anyone that has worked in resource poor settings realizes quickly that a fundamental problem is the absolute lack of lifesaving technologies – some of which have existed for more than half a century (for instance the mechanical ventilator or ‘breathing machine’ for patients with respiratory failure). Another major factor is the limited skill set of local providers (we face the same deficit of specialists in undeserved parts of the United States). All of this leads to astonishingly high levels of horrific endings for people that have little joy to begin with. As a physician, it is never any less jarring to face a family member when their loved dies, or to hear statements escape lips such as ‘she lived a long life’ referencing 40-year olds.

Recently, I walked into the ER and saw a Nepali health assistant working on a 11-year old boy who had fallen fifteen feet (out of a tree apparently). By the time I saw him. his pupils were dilated and barely reactive to light, and his breathing was getting worse. The tremendous coordinated response we enjoy in the U.S. is not the norm in most parts of the world- from the ambulance actually showing up, the ER providers waiting, and the trauma team of surgeons on call. Were the boy not in rural Nepal he may have had access to a stat CT-scan allowing 3D visualization of his skull and brain. In reality, it took the family half a day to travel to the hospital. After this, the patient received a thorough neurological exam by our team (a group of generalists) and xrays of his C-spine and shattered left leg. What followed was debate among our team as to whether there was any ‘point’ in sending him for the grueling 12 hour jeep ride to the next hospital where there was a CT scanner (yet no Neurosurgeon to do anything about whatever catastrophe resulted inside his head). Given his clinical condition, he wouldn’t have survived the journey anyway.

Things will not change by themselves. We must have greater aspirations in healthcare delivery in impossible places, and strive to augment vaccinations, antibiotics and preventative measures such as mosquito nets with a focus on modern marvels that can safe life and limb. The knee jerk response to investing in healthcare in undeserved areas is often ‘we can’t afford to pay for it,’ or in other words to label it unrealistic. Yet consider the world we live in now where ‘poor people’ who barely have access to safe water or a toilet may in fact carry cell phones. This dichotomy has shaped aspirations of companies like Internet.org (Facebook) that think it more important to bring free internet to the bottom billion than free healthcare. They would be wise in worrying less about creating customers, and doing more to keep existing ones alive. Every young person that dies due to lack of access to healthcare sends a powerful message to our fellow human beings- that some lives really do matter less than others.

Varun Verma, M.D. is a board-certified Internal Medicine physician who splits his time as a Hospitalist at Brigham and Women’s Hospital (Boston) and as a Senior Clinical Advisor to Possible (Nepal) 

@VarunVermaMD

After my 23-hour New York-Doha-Kathmandu flight, I was lucky enough to have two days to decompress in Nepal’s capital. It reminded me of Delhi with its traffic congestion; where scooters and bicycles make 6 lanes where 3 should exist, and the unavoidable baseline level of smog. It does have magnificent historical sites though, and I managed to visit an ancient Hindu temple dedicated to the lord Shiva, as well as a Buddhist stupa called Boddnath. I fortunately also ate lots of momos — a Nepalese dish that looks and tastes like Chinese dumplings — my diet since then has consisted of rice, lentils and vegetable mash.

On day three, I began my travel to Achham, where Possible is based (it was called Nyaya Health previously: after the Sanskrit word for justice). One must fly from Katmandu to Dhanghadi (only about an hour away), and then take a jeep ride the rest of the way to Achham (which is in the far western region). Locals told me the name originated from Achha Aam ‘good mango’ in Hindi, and I can confirm that they are great. The domestic flight on Buddha Air treated me to sweeping views of the Himalayas (not Everest though, which is in the opposite direction). Though only a few hundred miles, the drive from Dhanghadi to Achham ended up taking 10 hours. The roads were fine for three quarters of the way, despite consisting of blind turns on un-barricaded sheer cliff-fronts. The final stretch was tremendously muddy, unpaved and bumpy; with semitrailers screeching down winding mountain roads in the opposite direction to us. Arriving in Achham at midnight I was greeted with modest accommodation consisting of a mat on a concrete floor (but thankfully with a ceiling fan). I was also somewhat agitated that standing in the bathroom/toilet was impossible because the ceiling was 5'5. I was annoyed at myself because my temporary ‘problems’ were clearly trivial compared to the struggles of the patients we serve. Welcome to Achham, where we are making ‘healthcare possible in the world’s most remote places’ (that is Possible Health’s philosophy).

Bayalpata hospital sits atop a hill (mountain by my standards). It was a government facility that was closed for many years, until Nyaya Health and it’s young founders rehabilitated it six years ago. It now operates as a partnership with the Nepal Government- has a coverage area of 45 000 patients, an inpatient ward that has 30 beds, and sees around 250 patients a day in outpatient clinic. The hospital has treated more than 170 000 patients since it opened. Health assistants (the mid-level providers in Nepal) do the majority of outpatient clinic, with the MBBS doctors doing the ER and inpatient wards, and two MD-GP docs doing amazing things like C-sections, skin grafts, toe amputations, and anything else that is thrown at them. We do not have general surgeons here, and complex cases are referred to a larger tertiary center back in Dhangadhi.

One of my first days here I decided to join one of the American co-founders of Possible on a walk back to my room down the mountain. He assured me it was shorter than the 5km road, only 20 minutes and ‘through the jungle.’ It ended up taking nearly an hour, in 38-degree Celsius heat (100F for you Yankees), down a challenging rocky incline (both of us in business attire and entirely incorrect footwear). I definitely was not keen to do that again, but being a motorcycle passenger the next day going down the mountain without a helmet was terrifying. I requested to be moved on campus and the Possible Health team graciously agreed. I now live in a dorm with the three young M.B.B.S. doctors who I serve as supervisor, clinical adviser, coach and educator for. The freshly minted MBBS docs look like they’re 16, but have a far superior book-knowledge than I did at their stage of training. They lack experience in real-life medicine though, so this is similar to July 1st in the U.S. when interns take over the old guard every year.

Patients here share in the misery of millions of others around the world. They have inadequate access to healthcare facilities, and are forced travel far across mountainous terrain to get any sort of medical attention. Two days ago I wandered into the ER and saw a health assistant suturing the hand of an infant. As I approached closer I realized what he was really doing. He was removing 10-15 writhing maggots from the remnants of the poor child’s limb — which was black and had been scalded by hot cooking oil eight days ago (sadly a common accident in remote areas where cooking is done in single room abodes). The parents had tried herbal remedies at home for two days, then gone to a health post where they were told nothing could be done. After this, they walked 10 hours to a bus stop, and took the half day journey to get to Achham. Now that we had disinfected the mangled limb, bandaged it, given the child pain medicine and antibiotics, there was nothing to do but arrange transport to a larger center. There was no escape from the harsh reality that the hand would have be amputated. As if the child had not been born into enough challenges…

Much remains to be done to ensure people around the world have access to the healthcare they deserve. In the end, the success of organizations such as Possible relies on local professionals providing this important service. There can be no global health without local staff. Possible has so far done an excellent job of employing and retaining Nepalese physicians, health assistants, nurses, and community healthcare workers. The system definitely does not rely on the presence of outsiders such as myself. Locals have options too, and could have found higher paying jobs in Kathmandu. Instead, they are here — where their patients need them, doing their job, and living in modesty. No matter how much ‘hardship’ outsiders experience in working outside our comfort zone, the reality is that eventually we get to go back to privileged lives back home. ‘More action, less applause’ — that will be my mantra over the next 12 months — much remains to be done.


CLICK HERE FOR PICTURES BY VARUN VERMA

Varun Verma, M.D. is a board-certified Internal Medicine physician who splits his time as a Hospitalist at Brigham and Women’s Hospital (Boston) and as a Senior Clinical Advisor to Possible (Nepal) 

@VarunVermaMD

“There is no hope for me here anymore.” It had been a month since I had spoken to J.D. and I felt guilty because working hospital night shifts in San Francisco had temporarily removed me from the world of daily Haitian struggles. He sounded more despondent than usual and went on to report that his wife was now (accidentally) pregnant with their third child. Last year she had started a five-year nursing school program, and he seemed ashamed, probably because he knew how challenging it had been to raise donations for her tuition from a small group of my friends. He also lamented that he was still without work, 14 months and counting, with only a few days of employment in between.

I had first met J.D. two years after the 2010 earthquake – he had been my assigned interpreter when I worked in Port-au-Prince as a physician volunteer. He never spoke of the event that that killed hundreds of thousands and left a million people homeless including his family. I was immediately struck by how his clothes were immaculate despite still living in a tent (where did he wash and how did he iron them I wondered). What impressed me more though was the quiet genius of the gaunt young man who studied chess strategy in his free time. While I managed my email inbox or surfed the web during breaks, he would pull out a photocopied textbook from his backpack and read intently. He was fluent in Kreyol, French, English, and was even teaching himself Spanish. One day he had casually mentioned to me that he dreamed of being a physician, and I in turn pretended to not hear him. In reality, my heart sank and I was speechless. I could envision no situation in which he could return to school and continue on to university and medical studies while simultaneously being responsible for his two young daughters.

Long before the earthquake, fate had cursed J.D. when he was forced to drop out of school in 9th grade because his father could not afford school fees and needed him to contribute to the household. Unsurprisingly, opportunities had been limited since then due to his lack of formal education. When the Haitian capital was flattened on January 12, 2010 he was already struggling financially, having to live apart from his wife and two daughters who had moved in with his in-laws. Miraculously no one was hurt. The more time that elapsed since the disaster, as not-for-profits no longer required many interpreters, the more infrequent work became. Sadly, I learned quickly in Port-au-Prince and in rural areas alike that many Haitians shared in his misery. Talented multilingual Haitians would consistently approach us and implore us to hire them as their interpreters, drivers or “fixers.”

While jobs are being created in Haiti (eg. TOMS shoes has opened a new factory) they are a small fraction of what is required to address the raging 70% unemployment rate that is estimated in the country. Even though so called free trade zones with clothing factories have sprouted up in select locations, families often cannot uproot themselves and move from what little social support or security they may have. Additionally, debate continues as to whether such jobs are anything more than sweat shops where workers cannot earn a livable wage.

Speaking to Haitians it becomes clear that although charity, support from not-for-profits, and the work of well meaning volunteers are all imperative in protecting endangered people, what Haiti really need is jobs. Haitians are ready, able and eager to work and desire a sustainable means to support their loved ones. Haitian President Martelly has attempted to lure foreign investment by stating that Haiti is “open for business,” and Bill Clinton, a staunch advocate for Haiti said he envisions it “building back better.” There are mantras – and then there is the reality four years after the tragedy faced by many everyday Haitians who have again somehow been left out and left behind. It remains to be seen if Haiti can truly capitalize on its proximity to the US, a “cheap” labor force, and an untapped tourism industry hinging on the same magnificent Caribbean coastline that its neighbors have exploited. What is certain though is the tremendous stress faced by ordinary people like J.D. who are left to navigate with uncertainty, negotiate constant challenges, and overcome daily hurdles unimaginable to those of us living elsewhere.

Varun Verma, St Marc Haiti 3/2014