REFLECTIONS

So, I have been back home two weeks now.  Though I am over my jet lag, I am not over my "re-entry shock".  After a month in a very different culture, questions arise about my own culture and my own life.  Two weeks ago I worked 6.5 hours a day.  I got up in the morning and had a leisurely breakfast and two cups of coffee while I read, watched BBC Asia or simply listened to the music at the Ambient Cafe.  I went into work at 9:00 and I believe accomplished some meaningful things (something I value), but got home by 4:00 PM and worked on this blog (It is 8:00 PM now!).  I then went out and spent 2 hours at dinner with friends (old and new).  The dinner conversation was some of the best I have had since college.  Now that I am back to working 12 to 15 hour days the question keeps arising - "Why am I doing this?"  Why, indeed.  I need to keep thinking on this and not just give in and become numb, which I believe is what was happening to me before I left.

So what do I think of Bhutan?  First of all, it is stunningly beautiful.  It truly is the last Himalayan Kingdom, shangri la if you will.  It is not everywhere that you can step on your balcony in the morning and see snow capped mountain peaks.  Second, Bhutan wears spirituality on it's sleeve.  You cannot walk the streets without passing red robed Buddhist monks.  I would challenge anyone to find any place where they could stop and stand and NOT see a prayer flag.  All of this serves as a constant reminder that there is more to this universe than what we see.  The world is not all about having "things".  There is meaning in the universe, and Gross National Happiness is more important than Gross National Product.  Third, there was a military presence I never did quite understand.  It is a country with very little crime and a kind and gentle people.  Why the police or army so prominent, literally on every other street corner?  Fourth, I was saddened by the lack of maintenance of buildings, streets, and the hospital.  Rubbish in the streets, dirty floors in the hospital, and dangerous holes in the streets all seemed out of place amidst such natural beauty.  Fifth, there is a lack of urgency in Bhutan.  Things happen at there own pace.  You do not see people in a hurry very often.  This is wonderful in day to day life, but not always a good thing in a hospital.

In thinking about the hospital and medical care, several observations come to mind.  I have developed a new respect for a free market system.  In Bhutan the government owns the hospital, employs the care givers. and serves as the payer.  The really great thing about the system is that all get care.  However, there is little accountability in the system and significant lack of systems and organization.  This is evidenced by the lack of outpatient charts and the lack of a centralized section for orders in the inpatient charts.  This lack of charts also led to a lack of information.  To me this made it more difficult to see patients than the limited hospital formulary.  Outpatient appointments are never scheduled.  Every one shows up at once.  In a very polite way the patients and there families are "pushy".  I believe they have to be to get seen.  Supplies see to have been purchased in bulk based upon what was available and well priced, rather than maintaining a short-lived inventory which is replaced as used.  Providers have little incentive to work past 3:30 PM - after all, they are salaried. 

To me the best allegory to the medical care system in Bhutan is their street traffic.  They have the technology (cars).  However, as near as I could determine there were few traffic rules - "Drive on the left and don't hit any one!"  No stop lights and no stop signs.  Use your horn liberally when going into curves.  That seems to be about it.  Needless to say they have plenty of motor vehicle accidents.  Unfortunately, the medical care system runs similarly - a good deal of technology is there, but it needs to be organized and used more efficiently.  As my friend Ed stated (paraphrasing), "Most of the significant advances in medicine in the Unites States over the last 10 years have been in the development of processes and systems of care rather than new technologies."  Bhutan needs standardized pathways and systems of care to ensure that they use their technologies in a standardized and consistent manner to deliver high quality medical care.  They have a wonderful opportunity to create a system without the "built in" waste which exists in the US system.

I loved my time in Bhutan and would never trade it away.   I went there to give western medicine to Bhutan.  Bhutan gave back much more to me.

As they say in Bhutan,

Tashi Delec
 (Roughly "May good fortune follow you until we meet again")