By Evan Falchuk

With Angel Cabrera’s dramatic win yesterday at the Masters, Argentina is in the news.

Coincidentally, I just returned from a trip there.   On many of my trips, I do my best to visit local medical centers and meet with leading physicians, especially those that have been involved in Best Doctors over the years.  This time, in Buenos Aires, several physicians gave me in-depth tours of three medical centers, two public and one private.

Every country is different.  But I have learned that a couple of things are consistent:

• No matter how a country pays for its health care, in terms of patient care, all systems are riddled with strange contradictions, inefficiencies and limitations.

• Doctors are incredibly resilient and creative, and are especially adept at working around these obstacles in the service of their patients.

Let me share a sense of what I saw in Argentina, and you’ll have a sense of what I mean.

Argentina has a first-world system of medical education, and some outstanding private hospitals.  People who can afford it, or who are members of a union or other organization, belong to a series of HMOs that provide comprehensive health services.  Everyone else has free care, but must get it at a public hospital.  As one doctor told me “health care doesn’t pay” for the government, and so it doesn’t for doctors, either:  typical salaries at public hospitals are only a few hundred dollars a month.  And so doctors spend the morning at public hospitals, and the afternoons practicing privately — which means that if you visit a public hospital in the afternoon, you will find it largely deserted.

Me with Dr. Grubissich and her colleague at Hospital Ramos Mejilla.

My first visit was at the Hospital Ramos Mejilla, which is a city-funded hospital in a working class neighborhood of Buenos Aires, where I met Dr. Kristina Bruno de Grubissich, PhD, an endocrinologist and psychiatrist who is the Chief of one of the departments.  As demand for health care has not kept up with the supply of space, doctors at Ramos Mejilla have divided up exam rooms and waiting areas of the hospital into ever-smaller sections using temporary walls that don’t reach up to the ceiling.  One doctor doing intakes of patients in a room no bigger than 5 feet on each end told me for what he does all he really needs is a table and two chairs.  Patients wait for their appointments leaning against walls in the hallways or sitting on the floor.  But the doctors were enthusiastic and proud of what they were doing.  They treat thousands of low-income patients, often dealing with complicated and unusual medical conditions.

But there are more obstacles than just space.  The hospital has one CT scanner and no MRI.   To get an MRI, you have to be referred to a nearby public hospital, but that can take many weeks.  So the doctors discovered a loophole:  admitted patients get an MRI in only a few days.   And so if a doctor wants an MRI on a patient more quickly, it is common to simply admit the patient.  While this uses up a hospital bed for those days, it means that patients who need MRIs can get them.

Dr. Grubissich is certain that the hospital represents an extraordinary learning environment for her residents and a daily clinical challenge for her.  “We do what we can with what we have,” she told me, in her understated way.

I next visited the biggest and most famous public hospital in Argentina, the Hospital de Clínicas.  This teaching hospital, founded in the 1880s, now operates out of a massive building constructed more than 50 years ago.  The structure, once a showpiece of contemporary design, is in a state of disrepair. Less than a half-dozen of the 18 elevators work, so there are long lines at those that do.  Parts of the ceiling have collapsed in places, with the rubble neatly swept into piles in corners. Large sections of the hospital are abandoned, and there were stories that homeless people had taken up residence in parts of the upper floors.  In the United States, the building might be condemned.

But it’s not all like that.  Doctors performing ground-breaking research have been able to get sponsorship from major pharmaceutical companies and have used those funds to build out sections of the hospital.  One half of one abandoned floor had been rebuilt into an ultra-modern surgical amphitheater.  Behind a set of doors on another crumbling floor was a clean and modern pulmonary care unit, complete with artwork and modern equipment.   One part of the intensive care unit boasted modern technology, while another was half-abandoned and partially used to store old beds.  “It’s a privilege to work here,” said Dr. Sergio Sarkis of the other, half-abandoned unit, “but this is reality.”  The almost surreal combination of old and new is disorienting, but is really reflective of the incredible ingenuity of the doctors who practice there and their amazing imperturbaility.

Dr. Sarkis, me and Dr. doBarro

One of them is Dr. Martin doBarro, an internist.  Dr. doBarro, along with other doctors, created a specialized ambulatory care clinic in one section of the hospital.  For reasons that no one really understood, the process of getting many ambulatory services, like a biopsy, involves many days of appointments at different public hospitals.  These doctors decided they would try to create a division within Hospital de Clínicas that did all of this at one time in one place.  Located behind a locked door on one of the upper floors of the hospital, it’s an oasis of cleanliness and efficiency.  “We realized we couldn’t change the system,” said Dr. doBarro,  “so we decided to change the part of it we could.”  Dr. doBarro and his colleagues have created their clinic without any resources from the government, and without any personal gain for themselves, other than the satisfaction of being able to help the patients they serve.  “I love this hospital,” says Dr. doBarro.

It’s a completely different experience to visit the Sanatorio Otamendi (pictured right).  This private clinic is across the street from Hospital de Clínicas but might as well be on another planet.  The ICU and in-patient floors looked more like something you would expect to see at the Augusta National Golf Club rather than at a hospital.  Patients and their families wait for their appointments in beautiful lounges, surrounded by an impressive collection of art and antiques.  Surgeons working there — some of whom make the walk across the street from Hospital de Clínicas each day — are greeted by an attendant in the locker room, where they are able to relax and unwind either before or after surgery.  The funding for this hospital is entirely private, made up of the fees paid by members of this exclusive HMO.

One doctor I spoke with there is a plastic surgeon, who works in the mornings at a hospital for members of the police force.  He takes care of officers injured in the line of duty, but is paid, like other doctors in the public system, only a few hundred dollars a month for his important work.  “I work two months at the public hospital and make the same amount of money doing one breast implant,” he said.

If you absolutely must be sick, this is the place to be

Health care is a strange business all over the world.  Doctors work under rules and systems they didn’t create, and which they often don’t understand.  And yet the tremendous energy and dedication to patient care that helped them become doctors in the first place drives them to fight to help their patients, even under the most challenging circumstances.