By Amita Rastogi, MD, MHA, MS
Medical Director, Cost of Care Programs
I initially trained as a cardiothoracic surgeon in India, in one of the apex institutions of Southeast Asia. When I moved to this country in 1988, I retrained by doing a fellowship in cardiothoracic surgery at the Mayo Clinic in Rochester, Minnesota, and then a transplant fellowship to get certified in heart and lung transplants. My experience at both institutions was superb. Patient care was the central focus., processes of care were well established and there were quality control checks all along the way. Discharge planning, care coordination, and patient engagement were the norm. And so I assumed that this was the norm for heart surgery across the world.
I then moved into an assistant professor role at the University of Kentucky and its affiliated VA medical center at Lexington, KY. It became rapidly apparent to me that there was a gaping chasm between the quality of care that I had seen in my institutions of training and the quality of care at the VAMC. Where I had trained, all open-heart surgery patients were transferred to a dedicated cardiac surgical ICU for their postoperative care. At the VA, the open-heart patients were transferred to the general surgical ICU instead, where they were exposed to patients who had undergone other kinds of surgery. This meant that my patients were under the care of nurses who were also looking after bowel surgery patients who often were sources of dangerous infections like E. coli and Pseudomonas. Any lapse in sanitation protocols by healthcare providers could and often did spread such infections to heart patients, leading to devastating consequences such as sternal
dehiscence, pneumonias, and even death.
Even the ordinary surgical protocols were not well established. Nurses failed to bathe patients in Hibiclens before surgeries. Patient beds were often not cleaned, even if they were soiled. Needless to say, infection rates were high, affecting roughly one in three heart patients. It was to the point where I began to come in and bathe my patients in the cleansing salve myself the night before operations. Postoperative complications were high, and patients in general had suboptimal outcomes.
I realized that in such a suboptimal environment, the complications that followed what should have been beneficial procedures were so harmful that they overshadowed the good that the surgery should have provided in the first place.
I worked hard to try and improve the status quo. But I was just one individual trying to effect change across an entire institution. I faced stiff opposition from the chief of staff and other infection control officials who wanted to preserve their turf. As my patients continued to needlessly suffer in spite of my struggle to protect them, it occurred to me that there may be several other institutions across the country with similar problems. Even if I won this local battle, it would not improve the status quo everywhere else. At that point I realized that national rather than merely institutional benchmarks needed to be created, and that processes of care must be standardized across the entire country, so that we could have favorable outcomes. That’s when I made the decision to earn a masters degree in Health Administration and move into health policy.
I also realized that from the patient’s perspective, health care was fragmented. For a patient to shuttle between doctors and receive healthcare bills for slippers that they had never used or equipment that was ordered on their behalf but was trashed was not only wasteful but also demoralizing. At that point I realized that we need to bring transparency to the system at the national level. At every healthcare conference I attended, I questioned the leaders, the presenters, and the keynote speakers, particularly to ask them why we don’t see healthcare costs as transparently in the U.S. as I could see them in India. Physicians did not know what a given service cost, let alone the patients. And nobody seemed to care. All that mattered was that the money was not coming from their pockets. But somebody was paying for it. It was the employers through their healthcare plans, and indirectly the patients themselves through their decreased salaries.
As a cardiac surgeon, I thought I could touch many lives and improve the wellbeing of many heart patients. But after seeing the appalling conditions under which heart surgery was being performed, I realized that I may be able to serve a bigger role through health policy and pushing for more transparency, care coordination, and patient centered approaches, leading me to transition from a provider to an advocate.