Of Saints and Surgeons, Scalpels and Scale
Robert Graboyes interviews Dr. Devi Prasad Shetty, visionary surgeon and entrepreneur
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I often describe Dr. Devi Shetty as the most interesting, most important doctor on Earth. The following files include the complete transcript and audio from my 2021 webinar with Shetty, originally titled “The Narayana System and Innovations in Healthcare.”
What follows below are highlights from my discussion with Shetty.
ABOUT THE DOCTOR
Devi Prasad Shetty is founder, chairman, and executive director of Narayana Health—a privately owned group of roughly 30 surgical hospitals and heart centers in India and one in the Caribbean. A cardiac surgeon with more than 30 years’ experience, he has been a professor at Rajiv Gandhi University of Medical Sciences in Bengaluru, India, and at the University of Minnesota Medical School.
THE NARAYANA RIDDLES
In the United States, a heart bypass operation generally costs at least $100,000. At India’s Narayana hospitals, the cost is around $2,000. Yet, in terms of outcomes, Narayana’s performance is on par with the finest American hospitals.
For me, this cost differential is the single most important question in healthcare—something I call “the Narayana Riddles.” To understand this remarkable institution, one must understand the role Saint Teresa of Calcutta played in its founding, the drive and motivation of its founder, its Toyota-like scale economies and Walmart-like cost-cutting, and the light regulatory environment that allows Narayana to extemporize in ways impossible to replicate in Western countries. And, one must keep in mind that Narayana is a privately-owned, for-profit enterprise.
In 2014, Shetty and his colleagues 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 the sort of treatment offered in India. Together they built this hospital, not in America, but rather in the British-owned Cayman Islands, an hour or so south of Miami. At the time, he explained:
SHETTY: “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.”
BYE-BYE BEDSORES
Bedsores (pressure wounds) can be painful for recovering patients, and they can be pathways for lethal infections. Shetty said, worldwide, 7%-40% of cardiac surgery patients develop bedsores—a standard that Narayana found unacceptable:
SHETTY: “We told our nurses that something has to be done, and it has to be done fairly quickly. … 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. … [T]he nurses came up with a very innovative way of preventing bedsores. … [W]e have virtually eliminated bedsores to quite a large extent. Once in a while, we do get it but it’s very rare.”
THE SAINT AND THE SURGEON
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Netflix’s The Surgeon’s Cut profiled Shetty and stressed the role Mother Teresa (now Saint Teresa of Calcutta) played in his career and his stewardship of Narayana. Shetty told me:
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.”
FINDING GENIUS IN REMOTE PLACES
Another answer to the Narayana Riddles is the system’s ability to structure its labor force in ways that U.S. regulators would forbid. Narayana devised “critical care assistants” (CCAs)—essentially hyperspecialized nurses trained only in a very narrow area of medicine. Shetty recruited CCAs from impoverished villages, knowing that those snatched from hopeless poverty would be ferocious in their dedication:
“[W]e 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. … The training program is exactly like nurses, but they’re trained only to assist for heart operations, nothing else. …
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. …
Having escaped poverty, CCAs become equally ferocious in raising their own children to be high achievers.
SHETTY: “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.”
This philosophy, I told Shetty, reminds me of Mother Teresa’s philosophy.
SPECIALIZATION AND ECONOMIES OF SCALE
Scale economies are essential to Narayana’s achievements:
SHETTY: “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 … 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.
Specialization also matters:
SHETTY: “All of us as heart surgeons, we started off doing everything, but gradually we choose one or two areas. … 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.”
TECHNOLOGY AND HEALTHCARE QUALITY
Intensive use of technology is another answer to the riddles:
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. … 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.”
TOWARD AN AMAZON EXPERIENCE FOR PATIENTS
Future improvements will depend heavily upon mobile phones—with specific design principles in mind:
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. …
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.”
“[A]ny digital tool you build for the doctors should not have a keyboard because God did not create doctors to type.” … [A]ny digital tool you develop for doctors should not have an instruction manual, because doctors hate instruction manuals. … 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.”
DISSOCIATING HEALTH FROM WEALTH
Shetty suggested that India would become the first country to dissociate health from wealth, and he ventured that this could happen within ten years.
INDIA AS SUPPLIER OF MEDICAL PERSONNEL
Shetty suggested that in coming years, India would become the most important source of physicians practicing in the West and that India would have to vastly increase its medical education industry:
SHETTY: “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.”
FROM POVERTY COMES EXCELLENCE
Shetty said that, as with critical care assistants:
“[O]utstanding 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.”
IMPROVING MEDICAL EDUCATION
Shetty has harsh words for contemporary medical education:
SHETTY: “[I]f 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. … 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.”
THE PERILS OF EUROSLOTH
Shetty stressed the importance of intensive learning among young doctors—and the West’s urge to deprive young doctors of that resource:
“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.”
DOING THE WORK OF SAINTS
I noted in our conversation that Mother Teresa had specifically asked Dr. Shetty to bring care to the poor of India. I asked him how he had sought to fulfill that awesome charge from a future saint. He began by noting that:
SHETTY: “Technically speaking, the job of the doctor in a developing country is putting a price tag on human life.”
and then elaborated on what he meant by that remark. Among other things:
“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.
He then elaborated on how one combats the unacceptable reality of expensive procedures in a country with widespread poverty and describes—in particular a program called Yeshasvini Health Insurance and the promise of mobile telephone technology.
Devi Prasad Shetty is a surgeon, not a saint, but one can feel the presence of the saintly in his voice, his desires, his drives, his achievements … and in the knowledge that one is speaking to a protégé, caretaker, colleague, and friend of the legendary Saint Teresa of Calcutta.
Just read this again. So much for us to learn here in the way we education physicians in America. Indeed, in the way we practice medicine. Putting an honest price-tag on care is fair. What we do is say 'you need this to save your life,' they agree, and then the family is bankrupt because they had no idea the cost would run into six or seven figures. (All complicated by our nefarious malpractice system.) Great interview.
A very interesting interview, thank you. I think Shetty is 100% right about the importance of long hours during training, the importance of a certain level of dedication (which one finds more often in ambitious young people from scruffy backgrounds[1]), and the value of phone-based software[2]. The overall impression I get is that so-called medical tourism, which one might more charitably frame as the practice of visiting speciality clinics overseas, should be much more encouraged, even by regulatory agencies and the American medical establishment itself[3].
One observation, however: Shetty's approach seems extremely powerful when it comes to medicine that is well-established, what one might call medical engineering practice. But I doubt it will work as well for medical innovation, what one might call medical science. If you want to discover *new* ways of fixing this or that, or new combinations of therapies, then you actually need all the American inefficiency in the system[4]. You need bus drivers (physicians) who are indeed steeped in aerodynamics and how to fix the engine. Only generalists working within a system that has significant inefficiencies, which spends more time and money than it absolutely must, can come up with new paths to treatment. In part because you have to have a more general perspective along with your gobs of practical experience to try coloring outside the lines, and in part because most new paths investigated will *not* be better, that being the nature of the Second Law, one might say -- there are always far more ways to be plausibly wrong than right. You have to be working within a system where "wasting time and money" trying "dumb" (according to the conventional wisdom) stuff that couldn't possibly work better is tolerated.
Which leads me to conclude there should be more regional and national level specialization in medicine: there should be places where performing well-understood medicine as efficiently as possible is the priority, and other places that focus on innovation. (And yet more places in which rock-bottom price, even at some cost in skill and safety, is the priority, for the benefit of the very poorest for whom that tradeoff is worthwhile -- but that's another story.)
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[1] I don't think this is limited to medicine. Certainly in the sciences my experience is that the most creative individuals (cf. Feynman) come from scruffy backgrounds and are working to escape that, and will overshoot, to some extent -- become great in their ferocious attempt to escape sub-par. I think there's some truth to that in business and entrepreneurship, as well. We humans are not at our best when we are comfortable, alas.
[2] In defense of the software industry, part of the problem might be that phone-based software is inherently faster-changing and less reliable, because of the fast pace of phone hardware (and OS software). With desktop hardware, you can lock down some combination of hardware and software that meets the high reliability needs of medicine for a decade. For phones, not so much. And software developers may quail at the reliability needs of medicine for a platform that may change in 18 months with Apple's newest tweak to iOS or Samsung's new chipset. Or rather, they won't quail so much as shake their heads in astonishment at the price they're going to charge you for Apollo 11 level reliability in a Tik Tok video app world.
[3] I mean, BMW doesn't work to prevent you from buying a Hyundai, and Saks doesn't work to prevent you from shopping at Target. It's madness to insist that everyone buy the same kind of medical care, even for the same medical situation -- because all *else* in their lives will often be different. Restricting consumer choice rarely optimizes consumer utility, one would think.
[4] You also need a good regulatory regime, too, which encourages a certain level of innovation without exposing people to recklessness or charlatans. Something between the complete stultification of the nuclear industry by the NRC and the carelessness that gave us lobotomies and Elixir Sulfanilamide.