In this fourth installment of the Fortress and Frontier series on Discourse Magazine Podcast, Robert Graboyes, a senior research fellow at the Mercatus Center, speaks with Dr. Devi Prasad Shetty about the innovations of the Narayana hospital system, the ways in which technology can improve healthcare, how to fix medical education and much more. Shetty is the founder, chairman and executive director of Narayana Health, as well as a cardiac surgeon with more than 30 years’ experience. He is a professor at Rajiv Gandhi University of Medical Sciences in Bengaluru, India, and at the University of Minnesota Medical School. He has received several awards and honors, including the Padma Shri Award in 2003 and the Padma Bhushan Award in 2012, both conferred by the government of India for his contribution to the field of affordable healthcare.

Previous installments of the Fortress and Frontier series include two conversations between Robert Graboyes and Temple Grandin. The first can be found here, and the second can be found here. The third installment is a conversation with Pradheep Shanker on COVID-19 data. The fifth talk with Eric Topol is about medicine’s slow progress and machine learning in healthcare. The sixth with Keith Smith focuses on price transparency.

ROBERT GRABOYES: Welcome to all of our listeners, and a special welcome to our guest, Dr. Devi Shetty, who is among the most innovative and acclaimed physicians in the world. It’s wonderful to have you with us today, Dr. Shetty.

DEVI SHETTY: Thank you.

GRABOYES: For our listeners, the crucial facts about our guest are these: Narayana’s 31 hospitals in India and one in the Caribbean are famed for low cost and high quality. The system is also a pioneer in high-tech approaches to quality control and cost efficiency.

At the same time, Narayana has experienced some striking successes by way of very low-tech approaches. In the United States, a heart bypass operation generally costs at least $100,000. At Narayana’s hospitals in India, the cost is around $2,000—2% of the amount that Americans spend on the same surgery. Yet in terms of outcomes, Narayana’s performance is on par with the finest American hospitals.

In 2014, Narayana wished to offer their services to Americans and others in the western hemisphere. So, Narayana teamed up with Ascension, America’s largest Catholic hospital system, to build a hospital where Americans could receive treatment. Together they built this hospital, but they built it not in America but rather in the British-owned Cayman Islands, an hour or so south of Miami. At the time, Dr. Shetty explained, “The best place on the planet for a hospital to be built is on a ship parked outside U.S. waters. The United States charges maximum rates for procedures. U.S. regulations make it very difficult for hospitals to innovate and control cost.”

For seven years, I’ve spoken frequently about what I call the Narayana riddles. How does Narayana perform such excellent work at such low cost? And why is it that we cannot replicate in this country what Narayana does in India or in the Caymans? Today Dr. Shetty and I will explore these and other riddles, and we’ll discuss the role that Mother Teresa, now Saint Teresa of Calcutta, played in the founding of Narayana. Now I’ll ask some questions, and we’ll hear our guest’s answers. Again, Dr. Shetty, thank you so much for being on this podcast.

SHETTY: Thank you so much for the opportunity.

Healthcare as a Service Industry

GRABOYES: The first story I ever heard about Narayana was about a highly successful effort to reduce the incidence of pressure wounds or bedsores among patients. Could you tell us first what bedsores are, why they’re so terrible and how you worked to reduce the number of cases?

SHETTY: Across the world, about 7% to 40% of the heart patients after a major heart operation develop some degree of bedsore. It may be just a skin peeling, peeling at the back or at the heel, or it may be a full-thickness tissue loss at the pressure point. This is accepted by the global standards of 7% to 40%. That’s okay if a hospital is doing 200 heart operations a year. We do close to 700 heart surgeries a month. If, say, 10% of your patients develop bedsores after the heart operation, we will be producing about 70 people with a bedsore every month, and we need a separate hospital to take care of the bedsores.

We told our nurses that something has to be done, and it has to be done fairly quickly. As usual, we didn’t say that we have no money, but we strongly believe that anything you want to do in life, if you have too much money in the bank, your brain stops working. We tell our employees, all my colleagues, that we want to change the world but we have no money. So, as usual, they started thinking, and the nurses came up with a very innovative way of preventing bedsores. We have virtually eliminated—I’m not saying we have eliminated completely, but we have virtually eliminated bedsores to quite a large extent. Once in a while, we do get it but it’s very rare.

GRABOYES: It’s important to know that they can have very serious health ramifications as well. My mother nearly died of a pressure wound when she was 92. We barely saved her life. I understand that a key factor in this fight against bedsores was your corporate culture—that at Narayana the humblest nurse or technician is free to offer observations, opinions and criticism, even to the highest surgeons such as yourself, and that you, the top of the organization chart, will listen to the humblest of employees and their suggestions. Tell us about this part of your culture.

SHETTY: See, we are in a service industry. Every person working in the hospital potentially interacts with our customers. Everyone is customer-facing in the healthcare industry, unlike the automobile industry or the software industry, where employees really do not interact with the clients, other than the marketing people. Here, everyone working here is involved in interacting with the customers, as well as we have a very important mission—that is saving lives. You must understand that this industry is dramatically different than any other industry.

You take the example of any industry in the world. When there is an agreement or understanding between the client and the service provider, discussion is about the money or the legality—all those things involved in the regular contract. But discussion is never about death. In our business, whenever we interact with our customers—that is, patients—in the end, everything is revolving around death. Because if we make a mistake, somebody is going to die.

It’s a very, very serious business. So in this industry, unless everyone is passionately involved in your mission, you cannot give that kind of results. When I do a heart operation, I may be the most accomplished heart surgeon in the world, [but] all it requires is a perfusionist who’s running the heart-lung machine to be not attentive only for two minutes; then you have someone who’s brain dead. That’s it. Every person in the organization is very, very, very important. But we clearly articulate to all of our colleagues, to all our employees, our salary is paid by the patients. Salary is never paid by the management. Our salary is paid by the patients, so they are our customers.

GRABOYES: I would strongly urge listeners to watch the Netflix program on Dr. Shetty. It’s a beautifully made film, and the story it tells is compelling. In that program, Doctor, you talked extensively about your relationship with Mother Teresa and the role she played in Narayana’s mission. Could you please share a little bit of that history?

SHETTY: I was working in Calcutta [Kolkata] as a young heart surgeon, about nearly 30 years ago. In the middle of the operation, the telephone started ringing—at that time we didn’t have a mobile phone. The landline in the operating room started ringing, and my anesthetist took the call. And he talked to the caller, and he turned around and he said, “Devi, somebody wants you to make a home visit.” I told my anesthetist, “I’m a surgeon, I don’t make home visits.” Then the caller said, “If you make a visit to see this patient, it may perhaps change your life.” I said, “That’s a very interesting offer. I don’t mind.”

That’s exactly what I did, and as I was reaching the home, the address, I realized it was Mother Teresa’s address. She was not well, and I had the privilege of being involved with her care the last 7 or 8, 10 years of her life. That was perhaps the best part of my life. She dramatically changed my perception about what life is, whatever duties and responsibilities are, what is caring, what is compassion. And she really epitomizes the power of love, unconditional love. Many, many things happened in my life—I can go on and on—how she influenced every aspect of my way of thinking.

Critical Care Assistants

GRABOYES: In a conversation you and I had last week, you told me about a remarkable innovation that you implemented, and it sounds very much to me like something that would have been inspired by Mother Teresa, and that is critical care assistants. Could you please describe this job, how it came about and whom it is that you hire for these positions?

SHETTY: One of the problems we have running hospitals, doing high-end procedures, is the nurses who assist us for the operations. We do complex heart operations on children, on adults, and all types of procedures. These operations are very long procedures. It sometimes takes 8 hours, 10 hours, each operation. You cannot keep on telling your nurses what exactly you’re looking for, what exactly you want.

You want people around you to understand what you want and just help you, without you even talking about it. We had very well-trained nurses, but the problem with the nurses is that they are very, very career ambitious, especially nurses in India. The majority of them are dreaming of getting a job either in the Middle East or in England or the U.S. They all want better living conditions, better remuneration.

We actually became a training ground for nurses for the Middle East or England or the U.S. because our hospital is accredited by the Joint Commission of the U.S., so we follow the norms like an American hospital. So if a nurse worked in our hospital for two or three years, she will get a very attractive pay package outside India. We were actually churning out larger and larger numbers of these nurses. Then we realized it can’t go on because we can’t keep on teaching these girls.

So we started identifying girls from villages who couldn’t join the nursing college because they couldn’t afford it, but they have a great ambition to be nurses. We brought them onto that program called the Critical Care Assistant, CCA. The training program is exactly like nurses, but they’re trained only to assist for heart operations, nothing else. They’re not trained to assist for appendectomy or a brain operation. These nurses are trained for three years to assist for a heart operation.

Initially, they learn about sterility, human biology and human anatomy and these things, like any other nurse. Then we train them. At the end of three years, when these girls finish their training, now we have hundreds of them working and they are so smart in learning the trade. Today when I am operating, if I put my hand out and tell the nurse to assist, “Give me 6-0 Prolene”—that is a stitch we use for stitching—she knows that the step of the procedure I’m in, I need 7-0 Prolene, not 6-0 Prolene. She will hand me over 7-0 Prolene, but she wouldn’t say anything. She gives me what I need rather than what I asked for.

That is a level of knowledge, skill, presence of mind, passion they have. They may not have a degree as a nurse. Essentially, we believe, in a country like India, where there are not many opportunities for women from lower socioeconomic strata to climb up the ladder, if they are brought into the healthcare system and given a structured training program to do one particular type of job, and pay them like a regular nurse, do not treat them like cheap labor—if they are paid exactly like a nurse—but our idea of training them is the continuity.

These girls coming from a very poor family, once they start working in an organized institution like a hospital, they learn how the society runs. They get educated and they become assertive. These women, when they get married and when they have their own children, they teach them the art of making choices. Our whole idea is that if we can use the healthcare industry as a means for transforming society, other than making the world a healthy place, we can change the world.

Healthcare Costs and Economies of Scale

GRABOYES: It’s an inspiring story. You impressed upon me the last time we talked that some of these women come from deeply impoverished villages, and their options in life would have been extraordinarily limited without this chance.

Let’s get to the Narayana riddles that gave this podcast its title. In the United States, the cost of a cardiac bypass graft is generally around $100,000, which is 50 times the cost of the same surgery with the same quality outcomes at Narayana.

Now, whenever I tell Americans these statistics, their first impulse is to say, “Well, doctors in India don’t earn as much as American doctors, and that’s why it’s so cheap.” Of course, it’s true that your doctors, their salary levels are considerably lower. I don’t think that can explain a 50-fold difference in the price. Could you explain, why does a bypass cost so much here in America and so little at Narayana, aside from that one difference of physicians’ salaries?

SHETTY: First thing is the economy of scale. About 14% of the heart surgery done in India is done by our group. We naturally procure materials at significantly less cost than the others. Then, we use our infrastructure for at least 12 to 14 hours in a day, six days a week. We work for six days a week, unlike the European hospitals or an American hospital, which works only for five days a week. We set our infrastructure—like we buy a CT scan or MRI scan, and we try to run it virtually 24 hours, because you run it 24 hours or 2 hours, it only has a lifespan of five years to seven years. Then the new model comes in, to keep on changing. So, we keep on using the infrastructure a maximum number of times, as you do more operations.

And we also have surgeons who are trained to do a particular type of operation. All of us as heart surgeons, we started off doing everything, but gradually we choose one or two areas. Like my choice—as you mentioned, “The Surgeon’s Cut,” the Netflix documentary you talked about, is about a surgery called pulmonary endarterectomy, which is a very complex operation done by very few surgeons across the world, and we have very large experience in that. I concentrate on pulmonary endarterectomy. My colleagues, some of them concentrate on aneurysm surgery, some of them concentrate on pediatric surgery. People do only focused work. By doing one particular operation or two types of operation every day from morning till evening, our results get better. When the results get better, your cost goes down.

When the results get better, patients are happy. More patients will come. Essentially, it’s a virtuous cycle of economy of scale, maximum utilization of the infrastructure, and also we have mechanisms to run low-cost health insurance schemes for the poor. We do many, many things together to bring down the cost. It’s not like you can do one thing in an organization which makes a huge difference. You have to do thousands and thousands of little things to make a big change.

GRABOYES: We’ll talk about that insurance scheme a little bit later. I’m an economist, and my profession was founded by Adam Smith in 1776. In his great book “The Wealth of Nations,” he wrote about the importance of economies of scale, of specialization. Unfortunately, the news from that book in 1776 is only beginning to penetrate the medical profession. So I’m glad it has reached yours at least.

I’ve taught at a number of medical centers, and I’ve had some students who were nurses and doctors who had worked in hospitals in South Asia and Southeast Asia. They talked about lean manufacturing methods. In particular, I remember one nurse from either Malaysia or Singapore who had spoken of working in an operating room. She said they had a bell in the OR. At any point that anyone in the room thought that something was going awry, something was going wrong, they could ring that bell and bring the surgery to a stop, and the technician who was standing there holding a tray of implements could tell the chief surgeon, “I see a problem developing here.” Now, I don’t know if you have similar procedures, but I have some idea that perhaps you follow similar schemes.

SHETTY: Fortunately, the process of what you talked about has now become part of a Joint Commission protocol before starting any heart operation. Everyone should stop everything. Then it gets to talk of the situation, starting from identifying the patient to the procedure and the site. This is the standard procedure now across all Joint Commission accredited hospitals.

Essentially, quality parameter and documentation have become the buzzwords in the healthcare industry to prevent medical error. You’d be surprised to know that in the United States of America, medical error is the third leading cause of death. If 200 patients get admitted to an American hospital, spend just one night, 1 in 200 dies due to medical error, not medical negligence. Getting admitted to an American hospital is 10 times riskier than skydiving.

The error happens because protocol and processes are not followed. When people choose to treat the patient with their own style of treating, without looking at the protocol, problems happen. So our entire mission now is to have digital tools, which will smoothen the process, and everyone has to follow the protocol. When that happens, healthcare will become as safe as the aviation industry.

Technology and Healthcare Quality

GRABOYES: I often compare aviation and surgery. It’s interesting. I’ve got a paper, I’m working on that right now. I may consult with you on it. Just to reiterate for people who are not familiar with your system, your success rates are comparable to our best hospitals here, Mayo and Cleveland Clinic and those, I believe. Could you just tell us a little bit about the quality at your institutions?

SHETTY: Today we have technological tools to predict complications, predict cardiac arrest and predict mortality. In my mobile phone, I have all the parameters of the patients in the ICU to an extent that I stopped going to the ICU. In the last one year, I have hardly gone to the ICU. I go to bed at half past 11:00 at night, and I finish the ICU rounds in my house, and I am up at 4:30 in the morning and again do the ICU rounds.

Essentially, all these technological tools have put us in a phenomenal position to predict complications and prevent problems. One is the focus factory approach of doing a large number of operations in one building, rather than different, different types of specialties working together like in a typical general hospital, has definitely helped us to benchmark ourselves with the best in the world.

Also, you see, the whole philosophy of how a hospital is built and managed in developing countries is dramatically changing. I’ll give you an example. In the U.S., if a hospital is doing about 200 heart operations a year, it is recognized as a training institution. In India, the number of surgeries is so high that . . . in the U.S., an average heart surgeon, when he retires, in his entire life he would have done not more than 2,000, 3,000 heart surgeries in his whole life as a heart surgeon. We have surgeons who have done more than 3,000 surgeries, and they are still in their late 30s or early 40s. Essentially, because of the sheer volume, our doctors have become very, very good in skill.

Also, in the good old days, we had no access to those high-end machines like the CT scan, MRIs, and all these fancy gadgets. Today these machines are made by companies on a large-scale commercial basis, so we have access to buy those gadgets.

Essentially, healthcare is nothing but the interaction between man and the machine. If you have the same gadgets as the First World countries, and you have people sitting behind the machine with 10 times more experience than our counterparts in the Western part of the world, naturally the outcome will be very good.

GRABOYES: I want to get back to the technology aspect, but first I’d like to ask a question. In 2014, you and America’s Ascension hospital system, the largest Catholic system in the U.S., created Health City Cayman Islands, 90 minutes south of Miami. And its purpose, as I understand it, was in large part to serve American patients. I’d like to ask about that hospital. Tell us a little bit about the hospital, and also why you and your American partners decided to build it in the Caymans rather than to build it in, say, Florida.

SHETTY: Why we decided to build outside the United States is obvious—I may not to have to state it. The Cayman Islands is a fantastic place for a project like this, mainly because it’s a First World country infrastructure, very safe and wonderful environment, very stable government. It’s a British protectorate, very friendly people. And they provided, gave us everything to build a hospital.

Our idea is to build a different model of hospital, which learns a lot from the Western healthcare system, and also we have our own knowledge from running hospitals in a country like India, and merge the two entities and give a better experience to the patients at an affordable price. That’s the whole philosophy.

The Cayman Island government was very forthcoming, and the Ascension group, we learned so much from them, and they are one of the most progressive healthcare groups in the United States. They have been extremely nice to us in giving us the freedom to build our dream project in the Cayman Islands, and we learned a lot. Our desire now is to reproduce the same model in the Caribbean region, which desperately requires a different model of delivering healthcare, and try to produce a model which others can replicate. That’s the whole purpose.

GRABOYES: Yes, I’ve met some of the Ascension people, and I can say that they learned as much from you as you learned from them, so it was a good partnership.

SHETTY: We learned a lot from them indeed.

Updating Healthcare Technology

GRABOYES: A lot of people are very critical of the American healthcare system. I’m very high on it. There’s an awful lot to praise about America’s healthcare system. We do some wonderful things. We have some wonderful institutions. But perhaps the single most embarrassing fact is that our hospitals and our medical offices are still heavily dependent upon handwritten notes and fax machines.

You mentioned that Narayana is investing heavily in a digital revolution in healthcare. Your Atma system is aimed at creating a truly paperless hospital, something that we talk about here, but we never get there. Could you please tell us about Atma and about your vision for virtual healthcare and its role in serving the people of India?

SHETTY: We believe that if we can take away the pen and paper from the hands of doctors, nurses and medical technicians, we can bring down the mortality and morbidity in hospitals to quite a large extent. Significantly, we can reduce mortality and morbidity in the hospital. But, unfortunately, the tools available to make it happen are totally disjointed. One aspect of the electronic medical records doesn’t communicate with the lab system; the lab system doesn’t communicate with the EMR. So they’re all disjointed.

There are very major powerful payers who are already established who are doing a wonderful job, but unfortunately most of the electronic medical records—what is currently established—have converted paper into a digital form, but they have not given the intelligence that software can give to those electronic medical records. Our intention is that, fundamentally, all the electronic medical records should be built for the mobile phone, not for the desktop.

Now, why mobile phones? Because doctors look at their desktop five to six times in a day, but they look at their mobile phone 200 times in a day. If you want their attention on their patients, all the applications you have built should be built on a mobile phone. That’s the first criterion.

The second criterion is, any digital tool you build for the doctors should not have a keyboard because God did not create doctors to type. They simply cannot type. We have designed the entire electronic medical records just with the touch screen.

And the third thing is, any digital tool you develop for doctors should not have an instruction manual, because doctors hate instruction manuals. Doctors hate someone telling them what to do. And it should be so intuitive that the doctors should embrace it.

If you can give a fantastic experience on a mobile phone in buying stuff through Amazon or watching a movie on Netflix, why can’t we have the same thing in healthcare? Why do people not see a doctor when they have symptoms? Why do they keep on postponing the clinic visit? Because the experience is horrible. It is like, if somebody has a chest pain, he only wishes that it goes away. He doesn’t have a wish to see the doctor. Why can’t we have an option where the moment the patient gets chest pain at two o’clock at night or a headache, with just the touch of a button he will get through to the nurse from the emergency room, he talks to the nurse, and in five minutes he talks to the doctor.

And you have all your medical records in your own phone, and the doctor has a copy of your electronic medical record in his phone, and they go through all the records, and they talk to each other in a meaningful manner, not talking to the patient at two o’clock at night about the family history. And straightaway, they come to a conclusion within two minutes of discussion that, “Okay, this pain that you’re getting in the chest is not cardiac. Don’t worry, I have seen your ECGs, I’ve seen all the annual reports in the past. You cannot develop a heart attack, go back to sleep.” Or alternatively say, “Look, you have to see, go to the emergency room and get yourself admitted.”

This can be done. We have to give an Amazon experience to the patients. I keep buying stuff on Amazon—stuff I never use—because of the joy of buying things. I want the same experience to be given to the patient. And when we develop this digital tool, we want this to be available to every hospital on the planet, at whatever price they can afford to pay. We can afford to do it because this is the beauty of converting atoms into bytes.

If I have got one kilo of rice and I give you half a kilo of rice, I’ve lost half a kilo of rice. If I have developed the software to treat my patients with our money and my patients are happy, our doctors are happy, if another hospital wants the software, I can technically give it to them free of cost without losing what I have, and they will have what I have. This is the beauty of converting atoms into bytes. Our mission is to ensure that these technologies are available to every hospital on the planet.

GRABOYES: Right now I’m writing a paper on virtual health with two very fine doctors. One of them, Dr. Lyle Berkowitz, gave a lecture—it’s on YouTube—about 10 years ago, in which he said, “We doctors are the reason that electronic medical records are so terrible.” The software people came and said, “What do you want?” And the doctors said, “We want paper. We want you to put paper onto the screen.” And he said, “It just simply does not transfer well.” His conclusion was we don’t have the shortage of physicians that we talk about. We have a shortage of using physicians efficiently, and a virtual revolution is what we really need, and that’s what we’re writing about.

Dissociating Health from Wealth

GRABOYES: I’ll mention a story I often tell; I’ve already alluded to it today. My mother, when she was 92, was sitting on an iPad, eight o’clock in the evening in her apartment, talking to her grandson, my nephew, who’s a physician. She said she felt good; she said she had a little sore that was hurting her, and she was going to call the doctor in two or three days and check into it because it wasn’t getting better.

My nephew started looking at her through the screen, going closely, and said, “Would you mind showing me the wound?” She swung her iPad around and showed him and he watched her breathing and looked at her skin and whatever. Ultimately he concluded that she was in the early stages of a MRSA infection and sent her to the hospital immediately, where she nearly died anyway. They were able to save her life, and she got a wonderful extra year, a year and a half of life.

What I’ve always taken from that is just how miraculous the ability to use these screens is and also the fact that you should not have to have a doctor in your family to enjoy that sort of life-saving treatment. It should be available to anyone.

SHETTY: Everyone, yes.

GRABOYES: Now, you made an astonishing claim last time that I hope will come true. You said you anticipated that India would become the first country in history to dissociate health from wealth, to separate these two.

By itself, that’s a profound observation and quite a noble ambition, but you added that you thought it could happen in, I believe, the next 10 years. I wanted to find out, did I hear it correctly? And, if so, please tell us about that vision and how it will come about.

SHETTY: Interestingly, healthcare is not limited by any finite components. Like, tomorrow, if the Indian government decides to give a car free of cost to every citizen, it is not possible because making cars requires finite components like steel and various metals and the oil—they’re all finite. God doesn’t create them anymore. Healthcare is delivered by people. People are infinite.

When I get old, when I retire or when I die, somebody else is going to take over. We produce 24 million babies a year. We can potentially train the entire global requirement of doctors, nurses, medical technicians. We have that capability and we also have the desire. If we can produce large numbers of passionate doctors, if we can produce large number of passionate nurses, medical technicians, we already have virtually the pharmacy of the world. We make all the medicines.

Now, thanks to government policies, we are rapidly emerging as the medical technology hub, wherein, as an organization, we have decided that all of our cardiac monitors, ventilators, x-rays, everything has to be replaced with very, very advanced machines made in India. We have all the machines, all the medicines, and all the people. Naturally we will be in a position to make healthcare affordable to everyone at a price, what they can afford. It is just a matter of time, mainly because of the position that the country’s development is in.

So our desire is to ensure. . . When I was a kid, I could hear all the policymakers say that healthcare is expensive, and it will always remain expensive, but one day India will become a rich country and everyone can afford healthcare, and we all believed them. But when I grew up, I looked at the richest countries in the world struggling to offer healthcare to the citizens. So then I realized that becoming rich and then offering healthcare to everyone is not going to work.

We have to dissociate healthcare from affluence. This is the trend I’m watching in India, which has clear policies to produce—we already have over 500 medical colleges. I wouldn’t be surprised in the next few years we’ll have about 1,000 medical colleges, and we will produce that many doctors, nurses, and we will be able to dramatically change the way healthcare is delivered.

India as Supplier of Medical Personnel

GRABOYES: In fact, you told me two things that at first glance almost seemed to conflict, but I know they don’t. You said first of all that in India your biggest problem is you have a critical shortage of the number of medical personnel that you need to do the sorts of things that Narayana does, and that needs to be fixed. But also you mentioned, and you just alluded to it, that India could become the world’s major supplier of medical personnel, that you could export doctors, nurses, others to fill the gaps all over the world. So tell me, how do you end up filling that gap in India first, and then what do you do to fill the gap for the rest of the world?

SHETTY: The World Bank predicted that in about 10 years’ time, there will be a need for nearly 80.3 million health workforce across the world, both in developing and developed countries. Interestingly, I don’t think any country has plans to build that technical manpower for the healthcare industry, and this process of bringing health workforce for healthcare takes a long time. It takes 14 years to train someone to operate on the hand.

When no country has a plan, our fear is that when they face a shortage, which they will, with increasing life expectancy and also when families become wealthy, the medical profession doesn’t become attractive for the children of the family. When a country becomes wealthy, the medical profession doesn’t become very attractive for the young people with the passion to embrace. This is a natural phenomenon.

So we expect the developed countries to have a shortage in the next 7, 10 years’ time when the aging population virtually skyrockets. So they need large numbers of medical specialists. When that happens, we are afraid they will open the doors for Indian doctors and nurses, and there is nothing we can do to prevent the exodus of these medical professionals.

The only option we have is to produce them in abundance, rather than preventing them from leaving the country. You cannot technically prevent people from seeking a better fortune or a better life outside. So this is the whole purpose, that we need to invest right now in producing very, very large numbers of health workforce.

Do Less Wealthy Students Become Better Doctors?

GRABOYES: You remind me of a story from my teaching days. I was a professor of economics at a school, University of Richmond, that catered very heavily to very wealthy students, and we had a career day where people, graduates of the university, would come back and talk about their careers. I had a young man who came back. He was a medical resident at the local medical school—he had been the first person in his family ever to go to college.

Initially he didn’t have the money for medical school, so he worked as a lab technician, and in his late twenties he said, “I have enough money. I’m going to go to medical school now,” so he became this rather elderly med student. And the students asked questions, and it turns out he worked extremely long hours, his pay was nothing like what these students were hoping to make when they graduated, but he said, “This was my dream. This is what I wanted as a child. It’s what I wanted to be.”

He was an inspiring speaker. And then the next Monday morning I asked the students, “So what did you learn from hearing from him?” And one student raised his hand and said, “Don’t go to medical school.” [laughter]

I think that was the embodiment of exactly what you said. Had he been one of the wealthy students there, he wouldn’t have considered it. And he explained that his classmates, whom he had gone as a college student with, were earning 10 times what he earned and were living a good life with mansions and fast cars, and he was still living in an apartment with roommates.

SHETTY: I have a very interesting observation. You see, with the escalating cost of medical education in India and other parts of the world, children from poor families have stopped dreaming of becoming doctors. This will have serious, serious consequences in the future because outstanding doctors across the world with magic in their fingers generally come from deprived backgrounds because these are the kids with fire in the belly, who are willing to work for 20, 24, 25 hours a day and change the way healthcare is delivered.

I’ll give my experience as a young surgeon at Guy’s Hospital. One day I was—twelve o’clock at night, patient was unstable after the bypass grafting—I was sitting on a chair, dozing off, looking at the urine bottle where urine started trickling, and when the urine started trickling . . . because the patient wasn’t passing urine three hours before that point of time when I arrived because of what we call a low cardiac output.

I changed the medicines and did a lot of things. When the urine started trickling, I was so happy and I said, “Oh, hooray!” Then the nurse in charge, she looked at me, she said, “You must be the only person in the world who’s so happy looking at somebody else passing urine.” Right? We need to be differently tuned to doing what we are doing.

In my experience, generally, I’m not saying . . . there are exceptions; kids from very wealthy families have become outstanding doctors. Generally, my observation is that you should really identify the doctors with truly magic in their fingers. Most of them come from deprived backgrounds, and we need to encourage these kids to become doctors, to change the way healthcare is delivered.

How to Improve Medical Education

GRABOYES: That’s fascinating. I’ve never heard that observation before, but it rings very true. Which brings us to medical education. I’ve written in the past the argument that really the way that American medical education is structured came from a 1910 report called the Flexner Report that set the standards for medical education. It all had to be very standardized, every student had to arrive with precisely the same undergraduate background of chemistry and whatever, and they had to follow the same list of courses.

And it had its virtues. There was certainly a quality control element to it. But there’s also an argument that it stifled innovation in medical education, that we couldn’t get the specialization, the economies of scale. Everyone had to be a complete generalist—the exact opposite of what you’ve done with your critical care assistants—so that someone who wants to be a psychiatrist needs to have studied every single aspect of medicine.

I suspect that given the role of the Joint Commission, this has some application, not only in the United States, but feeds over into the rest of the world. Do you see needs in changing the way we actually educate doctors and nurses?

SHETTY: Medical education requires a dramatic transformation to suit the current requirements. The first thing is my observation about universities, how they function, especially medical and nursing and paramedical universities.

My observation is, if you want to train someone to drive a bus safely, if you go to your university and ask them to create a curriculum to train bus drivers, they will make a curriculum with maybe 300, 500 pages explaining how the bus engine works, aerodynamic works, and every detail about how the bus works, but they never make a serious attempt to put him on the driver’s seat and teach him how to drive the bus safely. Instead of sending him to a university, you send him to a driving school. They do not teach him about aerodynamics or the engine or how to fix the bus, but they will put him on the driver’s seat and teach him how to drive the bus safely.

That is what is required from the bus driver. The problem of our medical education is we are taught about things we virtually never encounter in our life. I’ll give you one example. There is a syndrome called carcinoid syndrome. I read about it when I was in first year, second year, third year, fourth year, fifth year. Then I prepared for the entrance exam. It was a standard question.

I finished my MS and appeared for FRCS many times, and every time they asked the question. But in my entire life as a heart surgeon I would have seen not more than one or two carcinoid syndromes in my life. The diagnosis was not made by me, and I’m not expected to make the diagnosis.

Essentially, medical education should be like an apprenticeship. A student, the first day after medical school, should be made to work as a nurse’s assistant and then gradually become the doctor’s assistant.

You cannot teach someone to swim in a library or a classroom. You want to learn swimming, you have to get into water. You learn about all the art of swimming in the library, you get into water, you drown. This is exactly how medical education, nursing education should happen. They have to be at the bedside, and that is the best place to learn medical education.

Unfortunately, today the curriculum and the syllabus, and the way they are trained and the way they are evaluated, is all dependent on how many hours they have sat on a chair and started marking about various things—it’s what they need to do. I’m not saying these things are not important. These are very, very important. But all this knowledge is available with click of a button on Google on your mobile phone.

You don’t need to spend endless hours trying to remember these things. We need to relook at medical education completely, and it has to be made attractive. People should love working and becoming doctors, not get put off by looking at those thick books from which any question can be asked, and if they are not able to produce the sequence of the syndrome they fail. Something has to be done.

Time Spent Learning and Working

GRABOYES: And another aspect of that is that it takes so many years of undergraduate education, medical school, residency, internships, etc., that by the time anyone is actually a serious practicing doctor, they’re well into their 30s, which in many technological fields, the really creative years are in your early to mid-20s. We’re, I think, wasting the years of innovation by dragging things out too long.

SHETTY: The other disturbing trend in medical education is European regulations, which makes the young doctors work only 48 hours a week. When I was a young resident in Guy’s Hospital, I used to work nearly 20 hours a day. I could become a very experienced surgeon because I was working every day from morning till late evening. In the process, I learned all the tricks I needed to learn to be a good heart surgeon.

Today, with 48-hours regulation, when a young person becomes an experienced surgeon, it’s the time for him to retire. That long it takes. You have to respect nature’s law. When God makes someone young, they’re expected to work long hours. When you grow old, you work less hours. You can’t say that a person who’s about to retire also works 48 hours a week, and a young person trying to learn the skill also works only 48 hours a week.

You’re defying God’s, nature’s law. In the process, these days, doctors who come out after training, they’re too substandard compared to in the past. Something has to be done.

GRABOYES: The doctor I mentioned earlier, who’s a young resident who spoke to my class, he asked the students—now, this was a university where their standardized tests were on par with Harvard or Yale, and the students were extremely hardworking and very competitive. He asked them to estimate, “How much time do you spend a week on class, and study, and study groups, and whatever?” And they all wrote numbers, and we averaged it. And it came to . . .

He said, “You’re very serious students.” They said, “Yes.” He said, “The average here is 25 hours a week of studies.” He said, “I do 120 hours. One hundred twenty is the legal limit for me in medical school, but I actually do more because they don’t care if I’m reading journals on the side.” He said, “In my field, even though you think you’re working very hard, you can’t imagine what it is for a doctor.”

Bringing Healthcare to the Poor

GRABOYES: One more question. We’re running close on time. Let’s return again to that mission that Mother Teresa gave you.

Recently I was talking with an American public official, and I mentioned Narayana, and I was describing it. She was interested but somewhat dismissive. She said, “Well, high-level healthcare in India is only for wealthy people, so I don’t really want to talk about it.” I know that’s not the case with Narayana, but I’d like to hear some specifics from you. In particular, could you discuss the Yeshasvini micro-health insurance programs? I know Mother Teresa asked you to bring care to the poor of India. Tell us a bit about how you’re doing it and, in particular, that insurance program.

SHETTY: When you’re practicing as a heart surgeon in India, or as a doctor in developing countries, the reality is dramatically different than what a doctor in other parts of the world thinks about it. I’ll just give an example. Technically speaking, the job of the doctor in a developing country is putting a price tag on human life. I’ll explain how it works.

I see 50 to 100 patients every day, and I do at least one or two heart operations. The typical patient of mine is a little baby sitting on the mother’s lap. I examine the kid, and I look at the mother, and I tell her that her child has a hole in the heart, and he requires a heart operation. She has only one question. She will not ask me about how safe is the surgery, and how many days the kid will be in the hospital, or what is the length of the scar, and the cosmetics about the scar. She has only one question: “How much is it going to cost?”

If I tell the mother that it is going to cost $1,000, which she doesn’t have invariably, that is a price tag on the kid’s life. If she comes up with $1,000, she can save the child. If she doesn’t have $1,000, she’s going to lose the child. This is what I do as a heart surgeon, morning till evening, putting price tags on human life. This is what most of the doctors in all the developing countries do from morning till evening, putting price tags on human life.

This is unacceptable. How long are we going to let it happen? Essentially, we are in a situation wherein we can’t just talk about what amazing things healthcare has offered to the citizens. For us, if the solution is not affordable, it is not a solution. It’s pointless talking about all the fantastic outcomes of cardiac surgery if 90% of the country’s population cannot afford. How do you make them afford? This is why we come up with innovative schemes like Yeshasvini.

Around 18 years ago, there was a drought in the state of Karnataka, where I’m living currently. Farmers lost their capacity to pay for healthcare, because our government spends about 1.1% of the GDP on healthcare. I talked to all my colleagues, who are friends who are running hospitals in different parts of the state, that “Look, you guys have enough operating space in your operating rooms because not many patients are coming. We will launch a health insurance with the government, and we will get what it costs to do the operation. You won’t make any profit, but it will keep the show going.”

They all agreed. Then we came with a proposal to the government, that if every farmer in the state of Karnataka one day, he doesn’t smoke, and that money, which is 5 rupees, about 11 cents, he gives it to the government scheme as a health insurance premium, and everyone contributes, and government agrees to become a reinsurer—and we had a very progressive government at that point of time, and they agreed.

And this scheme, called Yeshasvini Health Insurance, was born with a premium of 11 cents per month, and about 1.7 million farmers enlisted in the first year. Eventually, there are over 4 million farmers, and the insurance covers only for the surgeries of any type—there are about 650 varieties of commonly performed surgeries we’re covering, including heart operation, brain operation, kidney operation.

They could choose any hospital; they didn’t need to come to my hospital. There are over 600 hospitals which are recognized. They could go anywhere, get the operation done, and the insurance pays. At the end of I think 12, 14 years, we ran the scheme. About 1.3 million farmers had varieties of surgeries, and 130,000, 150,000 farmers had a heart operation just by paying 11 cents per month.

Imagine a situation, if we have close to 900 million mobile phone subscribers who spend about 300 to 400 rupees every month to speak on a mobile phone, if they pay 30 rupees [roughly U.S. $0.40] every month for health insurance, we can actually cover the surgical cost of the entire 900 million people. It is possible. Four people in isolation are very weak, but together they are very strong. Today, internet and mobile communication has brought all of them together. We have to bundle them together and offer a service, and that will be a game changer.

GRABOYES: Those are some pretty amazing statistics. I think our time is just about up. Do you have any final thoughts that you would like to share with the audience?

SHETTY: I just want to say that the future is going to be fantastic. I know we are all going through hell, but all pandemics come to an end. It is a matter of time. No pandemic has lasted forever. So we have to take care of ourselves and be very positive, and encourage your government to change the way healthcare is delivered. Use the modern tools, and working together, let’s make this world a better place to live. Thank you so much for the opportunity.

GRABOYES: Thank you, Doctor. It’s been such a pleasure talking with you.

SHETTY: Thank you.