Knowing Who to Call

Sep 1

We were three hours into dinner and well past the point of politeness. We had shared a room in our first year at Georgia Tech, and he has spent the decades since abroad. He was not having it.

I had been telling him about the weeks after my mother's stroke this summer. How our general physician, the neurologist and the imaging center worked beyond their normal hours so she could be diagnosed that same evening, and how she was treated with a drug developed in India and licensed so far only here, for exactly her condition.

His answer was immediate. In America you call an ambulance. She gets the care she needs because that is what the system does, rather than because of who her son happens to know. What I was describing, he said, only works if you have money and the right phone numbers.

His wife thought that was too clean. Care in America also depends on which city you live in and what you can afford.

Where the four of us landed is the thing I have not stopped thinking about since. India is full of doctors who should not be practicing. American medicine has a floor that Indian medicine does not. Walk in off the street there and you are far less likely to meet somebody with no idea what they are doing. Here, the range from worst to best is enormous, and nothing about the building will tell you which one you have found.

So, the whole thing rests on one skill. Knowing how to find the right person.

I wrote in the companion piece to this one about a pattern I carried for sixteen years, and about how little discipline had to do with breaking it. What finally moved it was a doctor who explained the thing nobody had explained before. That piece ends with a question it does not answer. If change needs the right person, how do you find one from a standing start, in a city where your address book is twenty years out of date?

This is my honest attempt at an answer, including the parts that do not flatter me.

Three countries, and what each one charges

That dinner argument did not finish at the table. It carried on afterwards in a group thread with old friends and went somewhere I had not expected.

My friend made the case for Switzerland, where he spent six of his years abroad: universal coverage in the British style, emergency care faster than anything America manages, and more spent per person than either of the other two countries. Then he named the flaw in his own example before anyone else could. Switzerland is a rich cocoon, and his comparison was to the wealthy pockets of Andheri.

His wife had lived the fine print. Pregnant with their daughter in a small Swiss town, she found the prenatal appointments going badly, almost entirely because of the language, and an obstetrician who chain-smoked and kept disappearing partway through a session. She went back to Atlanta to give birth.

Every system has this in common. Each one sets a threshold for the newcomer and charges something to cross it. In Switzerland it is the language and the postcode. In America it is the city you live in and what your cover pays for. In India it is knowing who to call. The Indian threshold is higher and the drop behind it steeper, which is a real difference rather than a rhetorical one. But none of us was describing a country where arriving new and unconnected costs you nothing.

What the same weeks look like from two countries

Two others in that thread had been somewhere none of the rest of us had.

They lived here as expatriates, and their daughter was born two months early in Delhi and spent her first weeks in intensive care. Their second child spent time in intensive care too, in America, which makes them the only people I know who can set the two countries side by side across the same weeks of their own lives.

India was extraordinary in the ways I would have guessed. Two months of neonatal intensive care cost about a third of what a single month cost in America, and their doctors were reachable by phone and text at any hour, which they describe as having changed everything. Though their doctors had been pre-vetted by their employer, which means the work I have been describing had already been done for them.

Then they told me the rest.

In Delhi she was not allowed to hold her own daughter until the child was a month old. No kangaroo care, the skin-to-skin contact premature babies need, and fifteen minutes of visiting. The doctor, trained in Britain, judged that infection risk here made it unsafe. In the American unit, both parents could stay as long as they liked and hold her.

Earlier, on the day she was born, the monitor stopped finding her heartbeat, and the nurses worked through one machine and then another on the assumption that the equipment was failing. Her father left the room, found the neonatologist himself, and brought him back. The doctor understood immediately and delivered her there and then, rather than waiting the hours they had planned to let steroids work on her lungs. She is alive because a parent went and fetched a doctor.

The deference between nurses and doctors in Indian hospitals is real, and it means nurses who know exactly what they are looking at can be reluctant to escalate past it. In America they trusted the nursing staff for precisely the opposite reason, because those nurses were expected to speak up for their patient.

That is a system at its most extreme, on the worst morning of a family's life. The everyday version is far milder and built exactly the same way. Janvi found the same trade as a resident rather than a visitor. The gynecologist she trusted through her pregnancy meant three and four hour waits in the clinic, and a phone answered at ten or eleven at night. The pediatrician afterwards was the same bargain. She would also tell you that consultations here run as instruction more than explanation, so formula feeding or the purpose of a vaccination tended to arrive as decisions already taken. Her advice to any woman doing this in India is a single line. Choose the doctor you can trust, on somebody's personal recommendation, and let that doctor lead you to the hospital.

It is the same arrangement producing opposite results. Indian medicine concentrates authority in the doctor, and that is why you can text yours at midnight and why nobody below him will move until he says so. American medicine distributes it through procedure, and that is why a nurse will challenge a physician and why you will never once get your own doctor on the phone. I wrote a few weeks ago about hierarchy in Indian workplaces, and how the newest voice in the room carries less weight than it should even when it is right. In an office, that costs you a good idea and a slow afternoon. In a hospital, the same silence costs more.

That is the thing worth carrying out of all of it. In a system that concentrates everything in one person, who that person is decides almost everything that happens to you.

What it looks like when you get it right

I have seen the good end of that too, in a much smaller way, through my knee.

A hip and knee problem had crept up on me, the kind that removes small ordinary things before you notice they are going. I could no longer sit cross-legged, which in this country is not a minor loss. Since moving back, I have seen eight or ten physiotherapists. For this problem, Dr Shivam Chopra is the third. He trained at KEM and has worked with a Pro Kabaddi League side, an IPL team and a string of international cricketers. He is also the brother of Dr Trishala Chopra, the doctor I wrote about in the companion piece, which I have decided to read as an argument about families.

I am writing about him because he shows most clearly what the difference actually looks like. It is not warmth. It is competence, applied consistently.

He built my mother's rehabilitation program alongside mine after the stroke. She had seen two other physiotherapists before him, and the pattern in both was the same, and common enough to be worth naming. The first sessions are excellent, the senior person present and attentive throughout. Then you find yourself with somebody junior from the team. Then the hour thins into fifteen minutes of needling while your physiotherapist moves between rooms, seeing two patients at once. The fee never changes. None of that makes anybody a bad clinician, and a busy practice has real pressures. But you learn what a practice values by what session six looks like.

Shivam comes to us. One person at a time, and past the hour when either of us needs it that day. He reads the imaging properly, explains what he is doing and why, and adjusts as we actually progress. He turns up when he says he will. And he is building us both something to use without him, a routine my mother and I can each run on our own once the sessions stop, taught properly and corrected until we get it right. Not every practice has an interest in that.

What my friend was right about

All of which is where my friend at dinner gets his due, because he was right.

None of what I have described came to me by simply existing in India.

My brother trained at medical school here, and his closest friend from those years is an anesthesiologist in this city. Over more than a decade he has found the right doctors for my parents again and again, across whatever the problem turned out to be.

The reason he is so good at it is worth understanding, because it points at something useful. An anesthesiologist stands in theatre next to surgeons and specialists from every department, day after day, for years. He sees which of them are careful and which are hurried, and whose judgment holds when a case turns. That is not information a patient can get. There is no version of it on a website, and the doctor with the best reputation in the city is not reliably the one his own colleagues would send their mother to. He has never once been our treating doctor. What he does is know who should be, which turns out to be the harder and more valuable thing.

He should be our first call every time. He is not always. When my mother had her stroke this summer we did not call him at all. We moved on instinct, and the first call went to a general physician we have known for years who happens to live in our building. That worked, and it worked because she was already a known quantity to us. But the better version of that morning would have started with the person whose whole value is knowing who to send you to, and in a genuine emergency the difference between those two calls is time you do not have.

Every other name in my life here arrived the same way, through somebody who knew somebody. And I could afford to keep looking when the first physiotherapist did not work, and the second. Replace me with somebody who landed last month, knows nobody, and cannot absorb the cost of being wrong twice, and this essay tells a different story.

That is the honest condition of healthcare here. The ceiling is extraordinary and the floor is frightening, and where you land between them depends on what you can pay, who you know, how long you can keep looking, and how well you can tell the difference.

What I will not concede is the conclusion people draw from it, that you should therefore expect less here. The talent in this country is world class. It is simply not evenly spread, and nothing will point you to it. The system will not protect you, and it will not sort you. What it will do, once you find the right person, is give you that person more completely than almost anywhere else on earth.

How to actually do this

So the finding is the work, and it is less mysterious than it looks.

Ask the people whose judgment you already trust and keep asking until a name comes back twice. In the first appointment, notice whether you are being told or taught, because that distinction predicts almost everything that follows. And be willing to leave. I stayed too long with the wrong physiotherapist twice out of politeness, which is a very expensive way to be polite.

If you are arriving without any of that, the most valuable person to find is not a specialist. It is one doctor, any doctor, who knows the city and is willing to point. A cousin's husband who practices here, or a colleague's family physician, or whoever turns out to be two conversations away. Ask them to route you rather than treat you. And if you have a choice, the people worth asking are the ones who watch other clinicians work rather than the ones with the largest practices. Anesthesiologists, radiologists, physiotherapists, nurses who have been in the same hospital for fifteen years. They see the work rather than the reputation. Half of what makes this system hard is not knowing which door you are supposed to knock on, and that is the part somebody can solve for you in a single phone call.

Start before you need it. Everybody I know who found the right person in a crisis had begun looking in an ordinary week, months earlier, when nothing was wrong.

Something to sit with, and the rest of the territory

The companion piece to this one ends with the Health Transformation Mirror, and it is the right place to start here too, because the pattern you want to work on determines the kind of person you need to find. It is a short set of reflective prompts with nothing to score, and it opens with the question worth answering slowly: What is the health pattern in your life right now that you have been trying to change for years?

Module 7 of the India Life Blueprint is where the finding becomes a plan. It sets out how the system is actually organized, and why the freedom to walk into a specialist here without a referral costs you as many wasted appointments as it saves you. It deals with the emergency you hope never happens, including who to call and in what order and what to have written down before you need it. And it covers the parts of your care that are easiest to let lapse in a move, from medication continuity to the insurance gaps that catch people who have been away for years.

And if you would rather work out your own version of this with somebody, that is the conversation I have with people most weeks. The first one costs nothing.

Next week we turn to citizenship, and to the trade-off most people put off naming for as long as they possibly can. Until then, a question to carry with you: Who would you call here, tonight, if something went wrong?

In honest company,

— Rumit

Rumit Kanakia