Great Equalization: Is MBBS From India Equal To M.D. In U.S.A?

AAPI Journal • March 2009
FEATURE
Crisis!
by Dr. M. P. Ravindra Nathan
M. P. Ravindra Nathan, M.D.
Brooksville, Florida
“Come to the office right away”,
Becky, my nurse, interrupted my
ICU rounds. “Sally fell in the
examining room. I think she has a
fractured hip,” her words exploded
in my ears. Knowing the patient
well, I panicked sensing this could
portend her end.
When Sally presented to me for
the first time, she looked like living
death; very frail and much older
than her age of 60 years. She was a
poor Medicaid patient from another
town where no cardiologist would
accept her. I was the new kid in
town and coming from a teaching
hospital, I was fascinated with the
challenge she offered, too naive to
think in terms of dollars and cents.
Boy, did she turn out to be some
challenge! Sally had chronic
rheumatic heart disease and already
had three mitral valve surgeries.
She currently had a dysfunctional
prosthesis with severe mitral
regurgitation and a baggy left
ventricle which looked more like
end stage cardiomyopathy. Type II
diabetes, peripheral and carotid
vascular disease were additional
burdens to cope with. As expected,
she developed severe heart failure
complicated by pleural effusion and
ascites. During the next several
months, Sally needed multiple
hospitalizations. I thought each one
would be her last, but her
indomitable will and undying
optimism pulled her out.
My nurse even delivered diuretics
and antibiotics to her home, as she
had no money or reliable
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transportation. I never saw or talked
to any of her relatives, including the
daughter who worked for a local
dentist, with whom she lived
sporadically. Her folks had
seemingly abandoned her, Sally
having become a big liability.
There was near pandemonium in
the office, by the time I reached
there. Sally was on the floor, quite
short of breath and pale. The nurse
was administering oxygen. The
ambulance promptly arrived to take
her to the ICU. I wanted to inform
the relatives but she gave me,
between short and difficult breaths,
her usual answer: “Oh, don't bother
to call my children, they don’t care.
You are my family, Dr. Nathan, I
trust your judgment”.
During the last few years, amidst
many critical care admissions, there
were no enquiries from the family.
Becky and I were her sole
guardians, literally. I liked and
respected her almost like my mother
and she, of course, was very grateful
for the attention we showered on
her. She used to become visibly
upset whenever we mentioned her
relatives. To make matters worse,
Sally developed carcinoma cervix
with pelvic metastasis, and I had to
use my wit and charms on one of
our radiation oncologists to accept
her as his patient. Initially, she
couldn't even lie down long enough
for radium implantation and I had to
readmit her to relieve her
pulmonary congestion before she
could complete a course of
radiation therapy.
Now Sally is in the intensive care
unit (ICU), with a fracture of the left
hip and was steadily going downhill
with full-blown heart failure, almost
into cardiogenic shock. An
emergency thoracentesis yielded a
liter of pleural fluid. Her diabetes
was out of control. She was in Atrial
Fibrillation with rapid ventricular
rate and a BP of 90/60 mm of Hg.
The orthopedic surgeon was
reluctant even to touch her and the
anesthesiologist didn't like the idea
of her dying in the operating room;
the risk was much too high, for
surgery. And without surgery, Sally
would never walk in the near future.
Just then, the ICU nurse
announced there is a bunch of
relatives waiting to see me. “Finally,
I get to see Sally's folks, it's about
time,” I thought. My enthusiasm was
very short lived. I saw a half a
dozen hostile, irate faces in the
conference room. The eldest
daughter, the self-appointed
spokesperson of the family, had only
one question for me:
“Doc, what is the name of your
insurance company?”
I was stunned and speechless for a
moment. Trying not to show my
rage, I politely replied, “But first,
don't you want to know how your
mother is doing?”
“Well, she fell in your office,
didn't she?”
Without mincing words, a clear
message was delivered. A barrage of
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