My American Trip
As most of you know, I spent the first three weeks of this July in the USA, invited by several members of the List and visiting their hospitals and homes. The report is below. After a few tries I finally abandoned the initially planned travelogue form which bored even myself to death and decided to present you with scattered impressions and experiences from my trip here, which, I hope, should not be too long or too tedious: just what caught my eye and stroke me as something different and unusual. These notes are absolutely superficial as could be expected from a 21 day stay, so please feel free to correct me, where I blundered too much, or add your comments – they will be most welcome.
The trip started in New York City. After 24-hour flight I alighted at JFK and was welcomed by an immigration officer with the same routine: usual questions, usual answers… It was not my first visit to the US, but they are still suspicious. Apparently, my red Russian passport is like a red flag – I can see why, but I don’t like it – so they channeled me to an adjacent room for “further investigation”. Just before me the immigration caught a couple of Chinese with fake passports. “Good beginning”, flashed through my mind.
My passport was authentic, though. I got my tourist visa fighting with Johannesburg US consulate as a trooper. I had no family, no property, no ties anywhere, I had a good steady job and earned as an American middle-classer, but who cares? They were still certain that I would exchange my comfortable life in SA for a respectable position of a bartender or dishwasher in “the promised land”. So whatever they asked I delivered: in three months after the rejection, a house in South Africa and an apartment in Russia were bought – sorry, I did not have time to start a family for them – and the longed-for right to enter this country was finally granted.
Well, I already braced myself to fly back to South Africa, but investigation was quick.
- Purpose of your visit?
- Taking an exam and visiting friends.
- What kind of exam.
- A medical licensing one.
- Aha! Who is sponsoring you for a visa?
- Nobody. I already have one.
- Who is sponsoring you for a work visa?
- Oh, I see. I am still busy with all these exams. Work visa is a completely different kettle of fish. I haven’t even thought about applying yet.
At this point he shrugged, obviously not understanding why I was shortlisted as an illegal immigrant, and stamped my passport for three months.
Russians are everywhere. When I just arrived at the hotel I was met with female receptionist who after having a look at my passport gaily chattered away in Russian with heavy Ukrainian accent. Even black guys at the security greeted me with "dObroye Utro". By then I already stopped wondering why. Somebody told me that New York has the biggest community - slightly less than 1 million, in Cleveland of 2 million, they are about 80000. I heard Russian and Ukrainian everywhere: in streets, at hotels, at airports. When I flew from New York to Cleveland I was seated near a Russian lady working at the Cleveland Clinics as a sonographist. Was it a coincidence? Probably yes... to some extent. In every hospital I visited I met Russians: doctors, nurses, technicians, receptionists. It was a surprise: in South Africa they are still very few and far between.
Half of New York speaks a language other than English: mostly it is Chinese or Spanish. All other languages are less common. Half of the medical and paramedical personal at hospitals are Chinese, Indian, Middle Eastern or African. New York, Cleveland, Los Angeles and, I suspect, any other large costal or near-costal city is a Babylon: all the languages, colors and hues are there. Not so with smaller inland cities such as Lexington or towns in Northern Wisconsin: they are mostly white, traditional and "American". Though, I must say, after a few days of my visit I had some difficulty defining the word "American" in terms of nationality, language and even cuisine, but about this later.
The first day of the exam went smoothly: I finished the day an hour earlier and still had time. So I took a bus trip around Manhattan.
New York is overcrowded. I know there are many people who love this city, have lived there all their lives and for them it is "the greatest city in the world" as the guide constantly reminded us, but for me it was a bit overwhelming. I felt the same way every time I visited Moscow: crowds of busy people milling around, everything is extremely fast-paced, steel and stone jungle... New York, specifically, has little vegetation. There are parks, but they are tiny comparing to the surroundings. Even the famous Central Park is small beside the size and population of the city. The architecture is impressive. A lot of high-risers. It IS impressive, but not necessarily beautiful. Definitely there is not so much beauty as in Europe. It’s a new world. Everything is purely functional: subway is just a means of transportation, not a luxury (those who saw the Moscow palaces of metro stations would understand what I am trying to say).
The subway and city in general is much safer now than it was 10 – 20 years ago: crime rate fell considerably. The ranks of NYPD were multiplied, the police force was given cart blanche even for petty crime, drug dealing was controlled, black and colored neighborhoods became more prosperous – a few factors were named, probably all of them played theirs roles, but the fact is that now you can stroll through the streets at night and use the subway without fear to be robbed. Dozens of stalls, booths, hawkers, heaps of litter – as if I found myself back in the streets of my home Samara City or black Pietersburg downtown – and I thought before that these were the costs of Wild West capitalism which befell the modern Russia. It proved to be not the case. It seems the only way to feed and serve the multitude of active people milling around. It is not attractive, but it is convenient and functional, serves its purpose, and it’s the only rational way of existence of a gigantic human anthill.
And as in any anthill there is some human attrition: it was not that different from any other multimillion city I visited, though.
A few words about “the Melting Pot”: never before did I see so many mixed couples and different ethnicities mingling together. Blacks with whites, whites with Hispanics, Hispanics with Asians – it was a striking diversity after the relatively monoethnic Russia and even South Africa, which is rightfully called a rainbow nation and its communities do live peacefully together, but I almost never saw mixed marriages there – it happens, but usually looks as a funny dislocation. Oh, yeah… How did it happen that there are so many beautiful women in NYC – unusually high concentration of them – that I could not grasp and would only wonder. Is it heterosis? Does New York simply attract the best female specimens from all over the world or I’ve just gone wild in my rural capital of the glorious Limpopo Province?
The next few days went uneventfully. The exam was finished I was free to see some attractions, which I did, but I am not going to bore you to tears with facts about the Statue of Liberty, Ellis Island or Empire State Building. I saw enough. On Monday when I was supposed to visit the Mount Sinai Hospital with George Bock, it turned out that I cannot do it. Before my coming to the States George sent me a list of documents which I had to submit to be an observer. It was long: somewhere about ten items. I sent most of them, but it was not possible to find certificates of my immunity to measles, mumps, rubella and TB. How could I? All this was about 30 year ago. I needed only 2 days, but my implied contagiosity became a serious obstacle – I couldn’t get in. So instead of Mount Sinai, I visited the Central Park.
Eventually I got there – thanks to George – but it was not easy. Most other hospitals were less strict, but we did have to ask every patient to sign a consent form for my presence. And if I were them I would have never signed it, not for the world. Look, would you sign something that reads like: “I release the hospital of any responsibility for any damages to my health which can ensue from the presence of the above observer, including death”.
After a barbeque at George's house
Life in NYC is exciting, but it may be difficult. Real estate is expensive. Most people spend 1/2 - 2/3 of their incomes only on housing. To live in the downtown is very expensive, so they prefer to live in more affordable suburbs and have to commute and spend a few hours just to get to work and back home. For the same money one will be able to afford a small apartment in Manhattan or a palace in Mayfield Heights off Cleveland. Most of the money I spent in the US I spent in NYC. I cannot complain, though. Did you know that on the list of world costliest cities New York ranks only No. 10, after Hong Kong, Osaka, Seoul, Tokyo, Geneva, London, Copenhagen, Zurich and… which city is the No. 1? Right, Moscow: the vodka may be cheap, but in Moscow, the apartment will run you $3,000, the coffee $5.27, the paper $3.40, and the burger with fries $3.87. Who could imagine that?
Times Square (a crossroads of Broadway and 7th Ave with plenty of neon adverts, theaters and movies)
The hospitals I visited were well-oiled machines. Efficiency is the rule: computers everywhere, you can access any information on your patient trough the net in a moment. Any blood work, consults, imaging studies, etc. are immediately available on a PC at any work station. Most of routine referrals (lumps and bumps) are done electronically and it saves time considerably. From hospital PSs you have access to all the journals you may need to update yourself, full-text articles, books, everything is there. Only short notes are written in patient’s files, anything longer than a few sentences is going for dictation and later being transcribed and filed. All the routine work which is usually done in South African public hospitals by junior doctors (interns, community service, MOs) is done by physician assistants here. Pre-operative assessment and preparation, routine follow-up, any menial tasks… They will ask you for advice if the situation is non-standard, but usually PAs are quite capable and manage most routine tasks by themselves. There are phlebotomists to draw blood, a nurse first assistant will assist you during surgery so there is no need to tie up another surgeon for routine cases, a nurse anesthetists will give anesthesia from the beginning to the end (5 of them are supervised by an anesthesiologist). So the role of an attending boils down to supervision and surgery (and, yes, occasionally they see patients too :)). I trust that not everywhere the system is so smooth and in teaching hospitals all these tasks are done by residents, but what I could see was pretty impressive.
It is a typical suburban America.
Housing landscape is different from South Africa in two things: there are no shacklands (haven’t seen any), and there no fences. “Affluent society”, large middle-class population… Crime exists, but it is negligible in residential suburbs (at least, comparing to South Africa). Otherwise, in big cities the layout is the same: high-risers in the relatively small downtown (New York is an exception, of course) and spreading expanse of one-storied suburbs.
Personal life of an American surgeon… He is so busy that marrying another busy professional may become a problem. If he marries a doctor, she is a pathologist, dermatologist, i.e. a doctor in a “lifestyle” specialty with regular hours. More commonly, he is married to a nurse. In one of the practices I visited, five out of seven surgeons were married to nurses while only other two – to doctors. It must be typical and means essentially two things: first, it hints that surgeons have no social life outside their hospitals and, second, someone in the family must have at least a little time to raise the children, while the husband/wife works long hours and makes all the money.
American patients are something special. Every second one intended for surgery asked the same question: “Are you familiar with this procedure, Doctor? How many cases a year do you do?” They are knowledgeable and demanding. They request special attention and it may be difficult to satisfy them. Communication is usually extensive and relatively long. The patient must be happy; otherwise, he will not come back – if you are a solo surgeon, or will rate you low – if you work for a HMO. So HMOs have their own control system. Patients may not only sue you for mistakes or alleged mistakes, after every visit they fill in questionnaires sent to them by the hospital and those questionnaires form the overall physician’s rating, together with scores from your colleagues and nursing staff. A surgeon lives in the public gaze and under constant pressure. The Big Brother is watching you. If your rating is less then, say, 90%, it may jeopardize your salary. If it is consistently good, in due time, you will get an incentive. Another nightmare is malpractice: premiums alone will eat up to one third of your gross income. Everyone is getting sued at a certain point of his career. You may be a perfect surgeon, solid academic, brilliant technician, but you will get sued anyway. It has nothing to do with your professionalism, it is all about money.
America is different. Different and diverse… From the concrete, steel, glass, and rush of New York to the rural green bliss of the agricultural Wisconsin; from the typical central Russian landscapes of Ohio and Kentucky to the subtropical South African paradise of the Southern California; mountains and deserts, lakes and forests, boondocks and megalopolises – it seems everyone can find here a corner after his heart. So what is the typical American climate or landscape? There is no such thing. There are hundreds of different climates and sceneries (sorry for a platitude, but I just want to drive the point home). What is the American cuisine? There is no such thing. I tried the Italian, Creole and Hungarian one in NYC, the Chinese, Japanese and Russian food in Cleveland, the French, Mexican and Indian cookery in Lexington, scads of Middle Eastern dishes in Wisconsin and California; I tasted all kinds of liquors, wines and cocktails (as you can see, I had a lot of fun, generally), but I still have a great difficulty in defining such a thing as the traditional American cuisine or booze (Bourbon, probably?). Please don’t tell me about hamburgers, Big Macs or hot dogs – it is not a cuisine, it is what it is – a stuff that keeps Josh very busy. So what is the American nation? Is there such a thing? Or it is a multitude of separate nations still melting in their common Pot?
Redlands, Southern California
The Buffalo Trace, the oldest bourbon distillery in the world.
Tasting wine at the Ferrante vinery in Ohio.
I am still amazed at the reception I got from the fellow Surginetters. What made them to invite me at the first place (I received eleven invitations in and out of the List)? No-one of them ever met me in person before. What made them to bend over backwards to arrange my visiting their hospitals with the respective authorities – which was not always easy as you could read above, to introduce me to every patient they saw, to every single hospital employee they met? It was not a small hassle, but they did it. What made them to spend their evenings on my entertainment, on showing me around their cities or taking me to local restaurants and attractions? What made them to ask me to stay at their homes, to introduce me to their friends and families, to travel for two hours to an airport to pick me up and then bring me back?
An attraction highly recommended for visiting, especially with children. Adult children will find it highly enjoyable as well.
The hospitable Assyrian house.
The world is small, indeed. The Surginet is not a virtual community – the fact we had an occasion to witness not once before. This trip was very useful for me, socially and professionally. I had the opportunity to see a lot. I heard not a few exciting and sometimes exotic personal stories. It was a good experience: enriching and unforgettable. I admit, at the stage of the planning I was very apprehensive: it was a leap in the dark, but it worked out beautifully. Thank you all.
Alex Oparin, MD
Pietersburg, South Africa
© Copyright: Alex Oparin, 2006