Is the United States the Core of the Health Care Universe? Reflections of the Recipient of the 2007–2008 E. J. Wylie Traveling Fellowship Award

One of my most vivid early childhood memories was driving through shantytowns in Peru, sitting on the back seat of our family's car. My father would always say while driving, pointing at one of the poorest shacks: “If you don't study, this is where you will end up living… If you do, you will become a surgeon in the United States.” This statement, arguably expected from a Latino surgeon addressing his first-born son, encouraged him to become the best he could possibly be.

Recently, I discovered that a person, specifically, a medical student living in a developing country, could develop a very distorted view of the world. Growing up in South America, I had the impression that US medicine was the most advanced in the world, that the United States was where the bar was set at the highest level, and that medical development and progress in the United States were always up-to-date. As a result, most of my classmates had one idea in mind throughout medical school: to ultimately migrate to the United States and, by being there, be the best we could be professionally and financially.

These thoughts came back to me while I was the recipient of the E. J. Wylie Traveling Fellowship Award of the American Vascular Association. ¹ Through this very generous support, I was able to visit several centers of vascular surgery excellence in Australia, the Netherlands, and Sweden. More than once, a nurse or radiology technologist from abroad would ask, “What are you doing here?” to which I answered, “I was given the chance to visit institutions anywhere in the world where interventions that are not routinely offered in the US are performed.” They invariably replied, “But I thought that the US is where progress starts. Why do you have to visit our country to see these things? Is it that you do not do these procedures?” I was never sure if those questions were sarcastic, truly naive, or sincere.

Somehow, the United States has been highly successful in making most of the world believe that, indeed, it is located at the core of the universe in terms of progress in most areas of life, including health care. Certainly, this was the case in a past era that I was not lucky enough to enjoy. I believe, however, that in 2010, this could not be further from the truth. In my opinion, the United States is currently going through a severe crisis in key aspects of medicine. As Dr. Frank Veith wrote in a recent editorial, ² the United States used to be the dominant force in medical development and progress. The rest of the world looked up to us in the United States for leadership. Then, in the 1980s, important changes occurred in medicine worldwide. For instance, in vascular surgery, endoluminal techniques to treat atherosclerotic disease and endovascular stent grafts to treat aortic diseases appeared and revolutionized the specialty. These advances often proceeded faster in other countries, in part because of less restrictive regulatory rules and in part because of a greater willingness to accept change.

Our medical crisis in the United States is based on three important issues. First, the United States is no longer in the forefront for medical advances. For instance, the use of fenestrated and branched stent graft technology has dramatically changed the management of aortic aneurysms. After the introduction of these devices in 1997, ³ about 100 cases were performed worldwide during the first 5 years of this experience. This quickly increased to over 1,660 by 2006. Currently, none of these devices are approved for use in the United States but are widely available in Europe, Australia, and elsewhere. This widespread use has been associated with good short- and midterm results with up to 5 years of follow-up. Yet I have been led to believe that these newer, more complex stent grafts will not be widely available in the United States for 5 years. I was shocked as these naive folks in the nations I visited asked me about the reasons for this seemingly nonsensical fact.

Fenestrated and branched technology has enormous potential to help patients in whom traditional open aneurysm repairs are contraindicated owing to their medical fragility and comorbidities. We had a distressing experience with a patient who underwent a so-called debranching procedure, ⁴ a method that allows patients to have their aneurysms repaired by using standard stent grafts, without aortic cross-clamping. After a long and complicated postoperative course following the debranching operation, the patient eventually improved. Sadly, he decided that he had enough of invasive treatment and refused any further procedures. He requested hospice care and eventually died from his aneurysm. I wish we could have offered this gentleman fenestrated technology to avoid this terrible outcome. Regrettably, this is currently common for many citizens of the richest country in the world.

A second issue is the reduction in the number of resident work-hours, which is dramatically important in a surgeon's education. I once felt that I got the best of both worlds in terms of medical education. By being taught in a school of a developing country, I was immersed in a very “hands-on” environment owing to the severe limitations in staff, acquiring a high degree of knowledge directly from the physician-patient relationship rather than from teachers or textbooks. In contrast, by receiving postgraduate education in the United States as we knew it (the halstedian model), I was exposed to progress in technology in an environment where learning was the most important factor, irrespective of the hours that proper education would require. Surgical training was a calling and not a lifestyle. We accepted these time demands without hesitation in exchange for a greater good.

Third, there is a great deal of discontent among the recipients of health care in the United States. The US health system spends a higher portion of its gross domestic product than any other country but ranks 37 of 191 countries in public perception of the quality and cost of the product, according to the World Health Organization (WHO). ⁵ These results were based on the analysis of five indicators: overall level of health; health inequalities within the population; patient satisfaction and how well the system functions; how well people of varying economic status find that they are served; and who pays the costs of health care within the population. On the contrary, European and Australian citizens enjoy levels of very high satisfaction with regard to health care, based on the same WHO results. I can anecdotally confirm those findings by the answers I obtained after surveying the cab driver or the regular pedestrian in the countries I visited about their perceptions. They feel that the high tax costs they are required to pay are well justified, in exchange for a highly efficient, high-quality medical care they and all their fellow citizens receive.

I agree with Dr. Veith that we must embrace the importance of overseas surgery by reading non-US journals and by becoming aware of material presented at non-US meetings and US meetings featuring non-US leaders in the surgical field. ² I have to add that relying on overseas education should be seen only as a temporary measure until a major change occurs within the United States. Our country must soon modify its severely restrictive development processes, reconsider its limitations on resident work-hours, and revisit its many misguided government-directed health care policies. Especially now, in the midst of major changes in the US health care system, our government cannot overlook the importance of taking lessons from foreign regimes that have successfully reformed their health care systems. ⁶

I concede that the centers I visited do not represent the average health care institution in Europe or Australasia but, rather, are widely recognized as worldwide leaders in vascular care. I also acknowledge that, in spite of all of the above, the United States still is probably the most common destination for migration because it truly is the land of opportunity. I am an example of this and will be forever grateful for the opportunity I have been given. However, I cannot refrain from expressing my concerns. There is no reason why the country with the most intellectual and financial potential on Earth should take a back seat, watching its health care advances depend on developments elsewhere and dissolving into mediocrity. This is the modest opinion of a partly foreign-trained surgeon who once from afar greatly admired the US health care model. This admiration has turned into disappointment, frustration, and a desire to learn more about the intricacies and dynamics of the US health care system and how it can be improved.