Medical Care a World Away

Regular readers may have noted a hiatus in my writings over the past few weeks.  Well, I am back-having returned from a two week period of volunteering at the Jigme Dorji Wangchuck National Referral Hospital (JDWNRH) in Thimphu, Bhutan.  Situated on the southern slopes of the Himalayas, and surrounded by India to the south, Nepal to the west, and China to the north, Bhutan is a small, largely Buddhist nation trying to upgrade its health system. I spent my time in observing hospital systems, care delivery and patient safety.  In so many ways Bhutan is a world away (actually ten time zones), and in other ways they struggle with the same issues as we do.

Instead of measuring the Gross National Product, the Bhutanese measure the Gross National Happiness (I’m not kidding-you can check it out on Wikipedia at www.en.wikipedia.org/wiki/Gross_national_happiness), a reflection of spiritual, environmental, educational and physical well being. Along those lines, the government has been working to improve the health system, initially starting with enhanced public health, childhood immunization, and primary care. There are a series of local primary care clinics which feed into regional hospitals.  The JDWNRH is the national specialty center, housing the country’s only CT and MRI machines, as well as being the home base of the only cardiologist, neurosurgeon and other specialists.

The county’s medical challenges are an interesting blend of the third world and the “modern” society. I was shocked to see the rampant nature of tuberculosis (TB), with daily cases of both pulmonary TB and  TB affecting the bones, brain, abdomen and other areas. On the other hand, there is an early epidemic of NCDs (non-communicable diseases) such as obesity, hypertension and type 2 diabetes (sound familiar??).

Among the observations I shared with the hospital leadership included 1) long, long wait lines at every clinic because of  lack of appointment system (it’s first come first serve) 2) the lack of triage system in the emergency room (so non acute patients are seen in order of arrival and seriously ill patients with chest pain sit and wait 3) the need to begin the development of a quality measurement system (we are only about a decade ahead of them on this issue) and 4) the need to better manage patient information (there are no outpatient records, so patients are expected to bring a notebook with them so the physician can enter a note to be read at the next outpatient appointment by the next physician).

Historically a monarchy, Bhutan elected its first parliament in 2008 after the King decided a democracy was in the best interest of his people.   After he yielded his power, he abdicated the throne in favor of his son, who still maintains influence and respect.  My favorite example of this occurred one day in the clinic. We saw a patient with chronic kidney failure who was an excellent candidate for a transplant (the county will pay for citizens to go to India for a transplant if a donor is available), and who had a donor identified. However, during the approval process it was discovered that his parents were born in Nepal, and therefore he did not have full citizen rights. The committee in charge of approving overseas care denied the transplant.  Anguished, the patient’s wife petitioned for an audience with the King, a right of every citizen. It was granted, she had a personal audience with the King, pleaded her case, and at the clinic visit she had an official letter from the King’s secretary granting support for the transplant. I guess it’s always good to be King!!