Before my mother’s recent surgery in India, she had one in the U.S. almost eight years ago. Back in late September 2011, my mother had to have emergency back surgery in Abbott Northwestern Hospital in Minnesota when she had come to the U.S. to welcome my second child into the world.
The laminectomy and partial discectomy surgery was successful, and she was impressed by the surgeon’s prowess, the dedication of the care team as well as the inpatient rehab she underwent before returning to India. But the incident also left a real bad taste in her mouth. Her back had been deteriorating for weeks in 2011 and Abbott specialists had initially sent her home without a steroid injection or surgery — things they had discussed after they saw her MRI – with just a recommendation for physiotherapy. Soon after, she suffered a major trauma when she suddenly couldn’t walk one fine morning and 911 had to be called, which finally led to surgery.
“I was appalled that the second time around, the doctor told me that ‘Your MRI is still as bad but now you have symptoms.’ ” “They waited until I collapsed to do the operation.”
Since that 2011 surgery, my mom has managed to live with her repaired but degenerating back until earlier this year when the near constant pain and fear of permanent debility made her decide to go under the knife again. This time she decided to undergo the spine stabilization surgery in India and leave her fate in the hands of Dr. Saumyajit Basu, a spine surgeon roundly revered as god in Kolkata.
Still, I flew to the city of my birth in June, apprehensive. I know the U.S. healthcare system, and between my mom and my brother (who died of cancer in 2017), I have spent enough time in the hospital and payer worlds here. India has changed rapidly in the past 20-odd years since I left, and while signs of progress are everywhere, it is a world where everyday life is very much a struggle and not within a person’s control. Nonetheless, what I came away with is that if you have copious amounts of patience and money, you encounter a mostly pleasant medical experience. Far more importantly, a dedicated, forward-thinking surgeon with a team of passionate, junior docs and a strong multi-discipline care team is a recipe for success anywhere in the world.
The surgery was scheduled at Kothari Medical Centre, a 10-story, slightly rundown, nondescript building, housing the multi-specialty hospital. There are other, more gleaming, American-style hospitals in the city but Dr. Basu chooses to be affiliated with Kothari and one other medical center. Based on anecdotal evidence and experience — an unnecessary pacemaker implantation in a beloved neighbor and observing my uncle’s care who needed dialysis and who was made to endure open heart surgery to place stents — my mother believes those hospitals are out to make money.
Kothari hospital and preserving female modesty
Before setting foot in Kothari, I convinced myself that I would go with the flow and not be the obnoxious foreigner finding fault with everything. So I didn’t bat an eyelid at the setup of the emergency room. There was no partition between administrative staff handling admissions and patients who were in the same long room with beds, separated by curtains with ER staff taking vitals. You generally cannot expect privacy in a nation of one billion. That I was prepared for, but not necessarily seeing sick patients exposed to people casually walking in from the outside.
Luckily, even before me insisting, my mom — who as a retired academic has great health insurance through her previous employer — had booked a private room up on the ninth floor. I had told her that I wanted to spend the nights with her and that wasn’t possible say on the sixth floor female ward that reportedly houses five patients per room.
The ninth floor room was bright and airy with a view, a television and a comfortable couch that I slept on. My mother was asked to check in two days before surgery, another point of difference with the U.S. where patients are encouraged to stay the least amount of time in the hospital.
Soon after checking into the ninth floor, a junior doctor on Dr. Basu’s team realized that my mom is 73 and doesn’t have a recent bone-density test. How porous her bones are would determine the kind of fixation devices Dr. Basu would use to stabilize her spine. Off we went to a nearby imaging center to get that done with both my dad and I grumbling to each other about why this wasn’t communicated earlier. But whatever annoyance we felt washed away when Dr. Indrajit Roy, the jocular neurosurgeon, noted that it’s a problem that my mother’s bone density is better than his.
The usual pre-operative MRIs and X-Rays occurred later, and here I encountered one of the most curious and regressive hospital policies. As soon as Ma checked in, she changed to standard patient garb — comfortable cotton shirt with pockets and loose cotton pants. Not the horrendous backless, tied with strings nonsense that qualifies as patient wear here in the U.S.
But there was a catch. Kothari seemed bent on preserving female modesty using an awkward twist on the traditional salwar kameez.
Widely worn in India, Pakistan and Bangladesh, the outfit usually comprises long pants called the salwar; a long, tapered shirt/blouse that is around knee-length or longer called the kameez and a chunni/dupatta meant to be worn over the kameez to cover the chest area. The chunni is of course eminently unsuitable for hospitals but Kothari has found a way to put women in shirts and pants — Western wear — and still maintain their Eastern modesty. This means that serving staff who wheel you around in the wheelchair to take you to imaging or surgery lovingly drape a white bedsheet on the torso of the female patient.
Yes, a bedsheet grabbed from the patient bed!
I found this so ludicrous that once when the attendant went to recover the bedsheet after an imaging session, I wheeled my mother onto the elevator and back to her room by myself, thereby flouting two hospital policies — ditching the bedsheet and not allowing the attendant to push the wheelchair. No one upbraided me of course except my mother, who made me apologize to the hapless attendant who was nervous to see his patient disappear when he was simply following the rules.
I humbly ask the Kothari administrators who have instituted the policy to walk around Kolkata. Despite Ma, who still dons the chunni, many Indian women of all ages, have largely cast it aside in daily wear.
Surgery Day: “Nothing ever goes awry with Dr. Basu”
Finally, it was d-day. I choke up —as is always my wont in these situations — as they wheel Ma away who promises that all will be OK. I barely manage a nod and join my dad and cousin in the waiting area. I expect to be in a room with family members of other patients all equally anxious and waiting for good news.
But I am greeted with a surprise.
The waiting area has a flat screen with the status of every patient and the name of the surgeons who are operating. There is even an expected duration of surgery — Ma’s is supposed to be 3 hours long, although Dr. Trinanjan Sarangi, the neuroanesthesiologist had earlier warned my dad that he will not be setting any such duration. I had not expected to have real-time status of Ma’s surgery so was most relieved to see the monitor.
But that relief turned into concern as the clock ticked by – three hours, four hours, four and a half. All other patients’ status had been updated to “surgery completed.” Only Anuradha Chanda continued to be “in surgery.” Being impatient, I walked up to the attendant manning the entrance of the operating area and asked him if he could get me some inside info on Ma’s status.
He dialed in but no nurse picked up inside. Worried, I said in Bengali, my mother tongue:
“I wonder if anything has gone awry,”
To which ever so calmly, he declared: “Nothing ever goes awry with Dr. Basu.”
The god reputation gets confirmed.
Soon enough Dr. Sarangi emerged to tell my dad that the surgery was successful. We were allowed to see my mom, and Dr. Basu signaled that all was well. She was cold and shivering but was soon going to be released back to her room. [Later, Ma told me that Dr. Sarangi while administering anesthesia before surgery stroked her head in a gesture of affection, which immensely soothed her.]
At 12 a.m., Dr. Basu and his team came to visit my mom after a full-day of surgery and seeing patients in the clinic. He asked my mom to flex and unflex her feet.
“You haven’t gone home yet?” my mother asked amazed at his energy.
Nursing, dietitian and serving staff – all smiles all the time
Nurses in the U.S., while warm and caring are almost always overwhelmed. I have noticed that patients need a strong advocate to ensure that care is happening according to plan. Nurses need to be reminded of things that need to be done. If you need anything, you have to ask for it.
Not so on the ninth floor of Kothari. Nurses and lower-rung staff were always around, always smiling and happy to fulfill your need. What’s more a smiling floor manager would take complaints and attempt to solve every problem — she even helped to pull up the Star Sports TV channel so we could watch the World Cup Cricket when we failed. [The demeanor of nurses and other staff on Kothari’s sixth floor with a reportedly worse ratio between nurses and patients is different, I was told by someone in the know.]
Dietitians would come daily to check on whether Ma liked the food — which she did initially and quickly tired of. However, unlike hospitals in the U.S. that have a menu that you can order from, there was never any menu available to see what was available.
On the other hand, because patient choice in general is limited, tea, lunch and dinner were generally delivered at a set time. No one was waiting for patients to decide that they were ready to eat. I appreciated that having observed my sick brother in the U.S. not have breakfast until I arrived at 8 a.m. or 9 a.m. simply because he was in no position to pick up the room phone and order food.
Remarkably, the doctors were able to control my mother’s pain without ever prescribing opioids like oxycodone or hydrocodone, a standard protocol here in the U.S. A junior doctor on Dr. Basu’s team declared that “we don’t prescribe any morphine-related” drugs.
European docs apparently also never got into the habit of prescribing opioids and this is clearly an area that U.S. physicians can learn from their brethren around the world.
Recovery, release and cashless insurance
The usual aches and pains after surgery aside, Ma seemed to recover well. The physiotherapist, Souvik Ghosh, passionate about his calling, knowledgeable about his subject and with a friendly, chatty demeanor, got her walking in the first 24 hours. Soon after, she was walking the corridor and climbing stairs one at a time.
The X-Ray after the surgery looked good, per Dr. Basu. Armed with this information, I begged him to order she be released from the hospital on the third day. So, I was very heartened to see that by mid-day on June 29 his discharge summary arrived.
However, that did not mean we were on our way out of the hospital.
In India, it appears you are either a cash patient, where you pay the hospital directly when you are discharged or a cashless patient, which means you have health insurance. Ma had insurance but because the hospital bill exceeded the initial insurance package, my father had to pay the remaining balance before she was allowed to leave. In other words, from the arrival of the discharge summary, to getting insurance to approve the package and then us paying the balance to get the green signal to leave took roughly seven to eight hours.
It seemed slightly mercenary that patients aren’t allowed to leave unless the hospital gets insurance approval and/or whatever payment is owed to them. But my mother explained that in India this is the only shot the hospital has of getting its share from patients and so if patients are allowed to leave without paying, many may not pay up later.
I am still not sure which system of discharge is better. Pay the balance upfront and try to get insurance to cover some parts of it after release as we planned to do in Kolkata or getting released from the hospital almost immediately after the doctor orders it in the U.S. and then getting surprise medical bills in the mail at home thereafter.
The wonderful nonHIPAA world
HIPAA has its detractors and while it was intended to protect patient privacy in the U.S., it has effectively become a stumbling block to share patient information.
In India, I communicated with the care team using Whatsapp and regular email and it was a liberating experience. Perhaps it is irresponsible of me to say the above, given the importance of patient privacy but when technology-related regulation hinders communication instead of aiding it, the policy — however well-intentioned like HIPAA is— needs a do-over.
Ma is continuing her physiotherapy at home under the care of Ghosh who has now gotten her to walk without using a walker or even a cane at times. That is sure to boost her confidence. She looks forward to leading a more active life.
As for me, I feel fortunate to have a better sense of the healthcare system in Kolkata, India. Bedsheets and female modesty aside, there are legions of caring professionals who are jumping through many a bureaucratic hoop and facing the day-to-day challenges of a populous nation with limited resources, to deliver the best care humanly possible.
What more can one ask for.
Photo: sezer ozger, Getty Images; Umanath Jha