Indian Journal of Surgery Medknow Publications on behalf of Association of Surgeons of India ISSN: 0972-2068 Vol. 65, Num. 1, 2003, pp. 38-40

Indian Journal of Surgery, Vol. 65, No. 1, Jan.-Feb. 2003, pp. 38-40

Perspectives of Rural Surgeons

Taking Newer Technologies to the Rural Patients

H. K. Ramakrishna

Lakshmi Surgical and Endoscopy Clinic, New Bridge Road, Bhadravati-577301
Address for correspondence: Dr H. K. Ramakrishna, Lakshmi Surgical and Endoscopy Clinic , New Bridge Road, Bhadravati-577301. E-mail: swarama@hotmail.com

Paper received: June 2002
Paper accepted: September 2002

Code Number: is03006

An oft-repeated question is "Are the newer technologies useful in rural surgery"? Some surgeons argue that these newer technologies are costly and not necessarily in the best interest of the patients, and that they have treated and are still treating patients with conventional techniques and procedures quite effectively, especially in rural practice. While others argue that these technologies should be used in rural practice and their benefits must be extended to the rural patients as well. Let us consider the pros and cons.

FAVOURABLE POINTS

Any procedure, investigative or therapeutic, if useful for an urban patient, should also be useful for a rural patient. All patients are human beings. I've witnessed the usefulness of lap-chole. It is less painful. Patients are discharged early and it has a lower complication rate vis-à-vis infection. ESWL is definitely superior to open surgery and serves the same purpose of clearing the kidney of stones with much less trauma. Now TURP has established its value in prostatectomy. The importance of a CT scan, endoscopy and ultrasonology cannot be overemphasized, if they are utilized judiciously. Likewise all so-called "Hi-tech" procedures have their own usefulness and advantages. Some of these are by now so familiar that we may not even call them newer technology any more. I call them "newer" because they were not available in medical colleges when we did post graduation. Now these are available sometimes even in a rural set-up or a centre nearby. It is a mistake not to explain to the patient about the usefulness of these procedures in the treatment of his condition. It is up to the patient to decide whether he can or cannot afford the treatment. Some of the rural patients are rich enough to afford these procedures.

PROBLEMS

Rural surgery merits special consideration because most of the patients are poor and facilities in the rural areas are limited. Newer technologies are essentially costly to establish and therefore, costly for the patient to utilize. So it is difficult to apply these techniques in a rural surgery set-up. Before setting up the unit we have to consider carefully whether the unit is economically viable. No surgeon can continue to provide the service if the unit is not giving back enough money to meet at least the expenses. To work this out we have to consider an approximate monthly expenditure of the unit, which includes salary of staff employed to run the unit, running cost of the procedure, interest payable on the loan taken to buy the equipment, surgeon's profit margin and any other unforeseen expenditure. A provision should also be made for the cost of repairs and periodic maintenance. Any premium paid for the insurance or annual maintenance contract also comes under "other expenses". A major repair can cost many thousands for high-tech equipment like endoscopes, ultrasound scanners, etc.

Training is also a costly affair. We will be practising whatever we have learnt at our medical college. A new technique or procedure is difficult to adopt as we have not been exposed to it and we feel less confident while using it. This also requires training before practising the technique on the patients. To get trained, a surgeon has to close his practice and go to a place where such a facility is available. This leads to loss of income for the surgeon and inconvenience to the patients in his practice, particularly as in the rural areas he may be the only surgeon available. In addition, the surgeon has to spend for the training fee, accommodation, food, travel etc. This may be a significant amount for a young surgeon who has started practice recently. Some laparoscopy training programmes charge about Rs. 4000/- to 7000/- per day.

Once the surgeon gets the training, he has the responsibility of training the paramedical staff. In the rural setting the doctor of the nursing home himself trains most of the paramedical staff. They do not have any idea about the new instruments. Mishandling of the instruments may lead to costly repairs. They also should be taught the new procedures. Their assisting capacity with the new procedure or new instrument may not be what is desired. This adds to the surgeon's frustration who himself is new to the procedure. For example, if the assistant does not know how to hold the telescope and zoom in and out at the appropriate time to give the operating surgeon optimum view of the critical area, operating time will be prolonged, the surgeon gets fatigued early and if the procedure is complicated, leads to frustration in the whole team. Prolonged anaesthesia has its own problems (I've seen laparoscopically assisted vaginal hysterectomy taking 5 to 6 hours in experienced hands while conventional surgery would have been over by an hour. If the surgeon and the team are new to the technique, you can imagine the situation).

Besides, if the existing infrastructure is not sufficient, that too has to be arranged. For some procedures like upper G.I. endoscopy, it doesn't cost much but for a laparoscopy unit, this is quite a significant amount.

When a new procedure is initiated, complications and other problems are high initially. We face many questions and come across many problems that aren't seen during the training period. We need some experienced person in the field who can guide us in times of trouble and complications. This is difficult to get in a rural set-up.

The more the number of cases, the lesser will be the cost per case. In a rural area, with its limited population, the surgeon of that area gets lesser number of cases whereas his urban colleague gets cases pooled and referred from many villages and taluks. Less number of cases also delays the "getting used to the procedure". For example, if the surgeon gets a cholecystectomy case in one or two months, it is not possible to start a lap-choly unit neither can he become reasonably adept in that procedure.

REMEDIES

If we bring down the cost, most of the procedures can fit into a rural set-up. The main reason for the high cost is that the equipment is imported. Fortunately, some of the products are now manufactured in India, and cost significantly less. Competition from Indian and other companies has also reduced the cost of some of the equipment. Most of the dealers give hiked quotations when we ask for one. They are open to negotiation and bargaining. So we should be willing and able to bargain. We should take quotations from multiple dealers and compare them. This also helps in the bargaining. We should acquire a thorough knowledge of the equipment we are buying. Otherwise, clever businessmen tell many stories of "unwanted advantages" of their equipment and overcharge. A visit to an already operational unit helps a lot in planning and avoiding wastage of money. At the same time we must pay attention to the quality, reputation of the dealer and after-sales services. Avoiding disposables wherever possible saves significant amounts of money (I am not talking about disposable syringes), for example, disposable cannula used in laparoscopy makes the procedure costly. We can buy a basic set and add the instruments later in a gradual manner, if we cannot afford the whole set at one time. Careful handling and maintenance prolongs the life of the instruments and reduces the cost of repair.

For learning a new technique various travelling fellowships are offered by both ASI and ARSI for its members. These are very useful for young surgeons wishing to learn a new technique. The amount varies from Rs. 5000/- to 10000/-. For some of the equipment (for example, upper G.I. endoscope, ultrasound scanner) the dealers offer training. (Of course, its cost is hidden in the cost of the equipment.) There are some senior surgeons who offer free observer-ship /fellowship (I had been to Dr. Krishna Rau, Chennai, for upper G.I. endoscopy and Dr. P.K. Chowbey, Sir Gangaram Hospital, New Delhi, for Minimal Access Surgery). However, the surgeon has to adapt to these new techniques gradually. In the beginning a very cautious approach is required to avoid complications. It is better if an experienced surgeon is available in a location nearby to guide the beginner. Also, it is better to have contact with a referral centre where the patient may be referred to in case of unmanageable complications.

In order to get more cases we should avoid duplication of facility in the same place. It is better to set up a mobile unit so that many rural areas are covered, benefiting more patients and giving the surgeon more cases. This will reduce the operating cost and make the procedure cheaper. The surgeon can be in touch with his colleagues in nearby places and can request them to pool the cases for a particular day, and the surgeon can then visit the place with his mobile unit. As a part of the service, every surgeon must be ready to help a needy poor patient with free service. This enhances the image of the surgeon and also the procedure. Free camps help in popularising the procedures (sometimes with the help of voluntary organizations).

Adequate training should be given to the postgraduate trainees in medical colleges who later take these technologies to the rural areas.

Last but not the least, we must never subject the patient to an unnecessary investigation or procedure. Already poor, the patient thus gets much more strained. The procedure itself falls into disrepute. We must ask ourselves the question, "If the patient were to be my own father or mother, will I advise the procedure under consideration?" If the answer is no, we must never advise it to the patient. If we knowingly do unnecessary investigations or procedures, it is akin to merchandising the practice of surgery which is our first love.

CONCLUSION

Rural surgery is not second grade surgery. It differs in no way from surgery practised in an urban area. The only difference being that it is made more affordable to the patient. Rural patients also need the benefits of newer technologies. With more and more thoughtful and service-minded rural surgeons, these newer technologies are coming to rural areas at an affordable cost benefiting rural patients, a welcome change. The next generation of surgeons will be trained in new technologies in their medical colleges during their post graduation courses. They will have less difficulty in establishing such centres. I wish a bright future for rural surgery.

Copyright 2003 - Indian Journal of Surgery. Also available online at http://www.indianjsurg.com