Peter: I have the pleasure of sitting down with Vishal Khetpal, a second-year student at Alpert who’s currently completing the Physician as Communicator scholarly concentration. He has become a regular contributor for top national media publications, most recently reporting for VICE on free-market medicine in Oklahoma and for Slate on rationing healthcare and Medicare-for-all. The former is based on novel findings from his summer project in his home state, which I look forward to discussing further with Vishal. So, without further ado, Vishal, tell us about yourself and a bit about your path to medicine.
Vishal: I was born in St. Louis and moved to Oklahoma when I was three, and then lived in Oklahoma until I was 15. Growing up in Oklahoma wasn’t something I appreciated until after I left. I grew up in a small town, of about 15,000 people, so it was very much a tight knit community. Both my parents were doctors in town. It had this typical theme of Americana– high school football, the band, and that whole culture. Increasingly, I think the world’s becoming more and more similar but places like that kind of remind you of different priorities. There were cases where maybe I’d felt a bit different, but most of the time I think that difference is met with some openness, because when you’re in a town that small, you’re kind of forced to know everybody as a person. It’s really difficult to start stereotyping when you know you can attach a name to a face, a whole story, and I think that’s something that’s often misunderstood.
Peter: What would you say that motivates you to do what you do? What are you most excited or passionate about and what do you most want to accomplish in your work and in pieces like your VICE story on free-market medicine?
Vishal: I think that many of the problems in our world today or in our country – they’re results of the fact that we’ve missed a lot of aspects of the story. I love how other writers can do this. They can really examine some oddity, or they can examine a series of events, and try to make meaning out of those events. And I think that’s been my main motivation for writing. I think it’s really interesting just to uncover stories and engage with stories, which is what I’m increasingly moving into.
In terms of medicine, I think it’s a very similar concept. There’s a reason why we take the history first. It’s really to get some context into what’s going on, to try to understand the bigger picture before we look at quantified data, objective measurements. It’s interest in the story that underlies all of that. I’ve had an interest in just looking at things which are not well understood or on the periphery; to try to better understand it and make meaning of “why is this happening?”, or “why does this exist?”. With my recent article on free-market medicine, I found that this movement really just is a rebuke by physicians and administrators about the increasing role of data entry and money-crunching in medicine. It’s not motivated so much by ideology, but by people who are trying to get back to some older practice of medicine, however good or bad that was. So, with my writing, what I really try to do is just unpack loaded concepts, things that are often misinterpreted or misunderstood.
Peter: What life changing experiences put you on the path that led to what you’re doing today?
Vishal: Well I was a terrible writer in high school. I transferred to a boarding school in New Hampshire my sophomore year. Back in Oklahoma, we really didn’t have much of an English department; our public schools had pretty severe budget cuts. I think I had written maybe one essay: my admissions essay to go to that boarding school. So, I was a terrible writer, and in high school that really bothered me and I wanted to get better at it. So, that’s initially why I started writing – to try and get better – and then I kind of stumbled into this. I slowly developed a knack for it. I found that initially I was overcomplicating writing, and it was just going back to the basics, really just trying to go back and tell a story, which ended up being more important.
In terms of what got me started in my writing career, my first essay was published for the Huffington Post about my cousin’s high school graduation. It was based on how that whole graduation ceremony focused on the goal of getting into college. I remember there were honors just for getting a high SAT score or high ACT score, which I thought was kind of silly because the point of those is to apply for college. It’s not really an honor in and of itself. But it just made me reflect more about my freshmen year of college and how misplaced a lot of our efforts, back in high school, could be sometimes. I really enjoyed writing about that. Writing became something to slowly grow into during college. I wrote a few more essays, across freshman and sophomore year, and then I think my writing really started to pick up my last year of college and into graduate school. Long term, I want to do some work in policy and hopefully keep writing in a more permanent role alongside a career in medicine.
Peter: I want to understand how you’ve taken your passion for writing and translated it into the skills you now have, writing for VICE, STAT, and others. You’ve already spoken a bit about your path in terms of first starting with that piece for the Huffington Post, but what tools did you use to refine your writing?
Vishal: It’s all about getting a lot of feedback. A lot of sending my work to very patient people. To very patient friends. I think at first, the tough thing about writing these days is that it’s difficult to find good editors. So, you have to get really good at being very self-critical. And the best way to get better at writing is to just read as much as you can. I try to read every issue of the New Yorker. I try to read or at least to try to look at the perspectives of JAMA, NEJM and I think that’s absolutely essential if you’re interested in writing. You have to read. Now I’m starting to interact with editors from that world more and now I’m getting critiques that are more substantive, within an ongoing dialogue. But when you start off, you’re on your own. and maybe that’s not the case for places like VICE, Slate and STAT, where you do get editors, but when you’re starting off it’s really difficult.
What I would say is it’s just a matter of reading as much as you can, and not being afraid to show your work to people when you write. You really have to put yourself out there and practice. I look at some of the stuff I wrote a long time ago and know it’s terrible. The language is too complicated, points could be fleshed out better, but you get better as you go on. It’s like anything else. You just have to put in time and practice. Here at AMS, the Physician as Communicator scholarly concentration is really interesting. My advisor, Dr. Schraeder, has been really helpful with developing my writing more – she used to be a journalist and is now a practicing physician. My classmates in that concentration have been great editors too.
Peter: So, for our readers who saw your piece in VICE and work in Oklahoma, or even for those who do not know so much about it, can you tell us what you learned about your state this summer with regards to how it compared to your experience growing up there?
Vishal: I think I learned more about Oklahoma this summer than I had in my twelve years of living there. It was just an incredible contrast to a lot of conversations about health policy we’ve had here, not only at Brown, but also like in my past, in St. Louis at WashU, as well as in London when I was studying at LSE. The contrast is just remarkable in terms of what people are thinking, what their priorities are. Not only politically, but just logistically. Your day-to-day thinking and your priorities about what to reform in healthcare really become totally different.
I’m really glad I went back, because I personally felt a lot of confusion about the number of people back home that voted for Trump and got swept up in the election, even though Oklahoma is quite conservative politically. It was fascinating to go back and get some more perspective on what people were and are actually thinking about healthcare. It was also interesting because of the whole ACA repeal process that was going on the whole summer. I was getting updates, and actually my interviewees were getting updates, on the progress of ACA legislation during our interviews. Things were literally turning on a dime, and I got to see unfiltered, in-the-moment reactions to the news.
I drove about 2,500 miles this summer, and I also think that the history of Oklahoma itself was so fascinating to learn more about as I traveled on the road. As a kid, I went to the building in Oklahoma City where the ‘93 bombing, and it was very impactful, but I don’t think I ever quite grasped just how much that still shapes the ethos of Oklahoma. With events like that, and the oil boom and bust from last century, it was clear to me that states like Oklahoma can often feel left behind in the national conversation.
Peter: Can you tell us firsthand how your summer experience went with your project on rationing care?
Vishal: My whole project is about how we ration care; I think the biggest surprise is just how many ways health care is rationed in the US. We often talk about price and maybe insurance status, and while those are the common refrains, we also ration healthcare through so many others ways.
We ration healthcare even by cultural stigma. There was an HIV clinic I visited in Oklahoma City. Many of them are funded by the federal government through grant funding arranged by the Ryan White CARES Act. A few years back, that clinic tried to send out case workers to a lot of rural communities in state, since they have so many patients from them. When they send out these case workers, they realize that people didn’t want to go to the county health departments in their own communities, because they were afraid of somebody else watching who goes in at a particular time, when they knew that the HIV case worker would be in. Those towns are so small. If they see Susie go in on Tuesday morning, the guy watching her walk in from across the street could run into Susie’s mom at the grocery store later that week, and say “hey, I saw Susie going in on Tuesday morning. That’s when the HIV person’s there. Something might be going on.” A given person, in many cases, has to overcome that stigma to get care from that clinic and infrastructure, even if it’s free. And there’s so much stigma around issues like hospice care, mental health, and abortion in Oklahoma. We also ration healthcare by transportation, and by geography. I think that’s something we don’t think nearly enough about. Those stories really informed my thinking about this issue and health reform.
Peter: How did your hospital visits remind you of the status of healthcare in Rhode Island?
Vishal: For my work, I visited a critical-access hospital with about 20 beds, in a town of about 2,000. That town has had only two doctors since 1950. The current doctor’s now been practicing for about 38 years and getting ready to retire, so they’ll have to find another doctor from somewhere. In that part of the country, it’s incredibly hard just to get one person to come out and live and practice in those places. And it was fascinating to hear some stories from there. That hospital actually was going to close down in the 80’s since a for-profit hospital backed out of a sale at the last minute – similar to what’s going on with Memorial in Pawtucket now – and the local businesses in that town actually banded together to buy back the hospital and keep it open. Events like that still really affect the way people think there. That private involvement can fix a lot of community problems. And you can kind of see why: the bigger corporations back out, leaving these towns behind in the dust, and it’s them picking up the pieces, fixing their own problems.
Peter: What was the most rewarding component of your experience this summer?
Vishal: I think it great to learn more about the different ways in which healthcare is segmented in the US. In the UK’s NHS [National Health Service] for example, there are very specific ways and specific policies that ration healthcare there and it’s a cultural entity. While I was studying there, I found that it is generally respected and left alone politically. You can compare that to the US, where we have this highly segmented system; If you’re Native American, if you’re a veteran, if you have HIV, if you’re on dialysis, if you are an active military personnel, if you’re a federal employee, or if you’re disabled, there are different categories of healthcare. The range in quality within that is huge. Our arrangements with each of those groups of people is incredibly different. But each of those groups has different rules of the game. If you look at something like abortion care in America, that’s on a whole other spectrum, but that still varies from state to state.
First, I think forcing myself to learn about each of these components made me realize just how big our healthcare system is, and how it’s virtually impossible to learn everything there is to learn about American healthcare. But, second, it made me realize just how different the rules of the game are. And, I think that’s going to be valuable, hopefully as a physician, to kind of understand the underlying politics of the decisions that we’re making in different clinical settings. It’s something we don’t talk about nearly enough in medical school.
And, maybe we shouldn’t. Maybe the focus should be on clinical medicine. That’s what we’re here to learn after all, right? We’re first and foremost here to learn physical exams, learn the various clinical appearances of diseases like CKD. But maybe we should be talking more about these weird habits that we acquire once we go out there. It’s crazy just how much I talked about issues like money and barriers to when I was in these hospitals and clinics, with hospital administrators, doctors and nurses. When none of us – especially doctors and nurses – went to medical school where we talked about these things. And yet here we are, talking about these things. It’s something that runs our lives and they confront us every day.
Peter: How did your project inform you about the central benefits and challenges of health care reform moving forward?
Vishal: In terms of this project, it made me think that whatever we (as communities) decide, we have to be consistent. And by consistent, I mean consistent within probably a state level. The rules of the game, or the rationing of healthcare, need to be stricter and more transparent. What ends up happening is the uninsured person’s experience with health insurance and care, compared to the veteran’s experience, compared to the person who has a great private plan, compared to the person who lives in a healthcare desert – is invariably different. And, I think it ultimately informs different approaches to health reform. There’s just so much dissonance.
I also think the interesting thing is that, at the same time, there’s a lot of common values that people have. I think there recently has been more support for some minimum standard of healthcare. I talked to people all across the political spectrum: People who wanted to get rid of health insurance and just move everything to an open free market; Other people who wanted to just start the NHS [National Health Service] in the US tomorrow. And, really, I think there is this increasing agreement that we have to provide some minimum standard.
I think there’s a lot to be said about what that minimum standard is; There’s so many different services that are entailed in healthcare. Does a minimum standard mean that everybody gets liposuction who wants it? That’s maybe an easy no. But then there’s stuff in the middle. I mean, we can talk about plastic surgery. We can’t just ban all plastic surgery because a lot of is really important, fixing things like cleft palette. Shouldn’t that be allowed? Or take the issue of growth hormone, which we talked about in class this past week. When are growth hormone supplements indicated for a person? When is it clinically necessary, and when is it just clinically desirable? So, it starts to get really, really messy in the middle. But, I think there is increasing support for some minimum floor and it’s going to be tough to decide what that minimum floor is.
It made me think that history and culture play a huge role in how people think about healthcare and about what health reform should look like. And, maybe the solution for Oklahoma is going to be different from the solution for Rhode Island. Not only because of logistical reasons, because Rhode Island’s much more centralized, we have more providers here, things are smaller and more controllable, versus in Oklahoma, the population isn’t much bigger but you’re dealing with a much bigger land mass. You’re end up rolling out a health program that’s going to encounter a different process, with a totally different cultural context.
Peter: As you’ve alluded to, it seems like healthcare is changing at an increasingly dramatic rate, from Oklahoma to Providence and everywhere in between. When you think of the future of the kind of work you’ve talked about here, what gives you a sense of hope? What makes you concerned or worried?
Vishal: Well, I think we’re going to reach a breaking point. This dissonance, it can’t go on forever. This summer, I thought about American healthcare as like a bunch of wrinkles in a rug; Each of those wrinkles to me represents an inefficiency in the system. And the problem with each of those wrinkles is that it’s not so easy to iron them out because, for one, you will just get another wrinkle somewhere else and, secondly, those wrinkles are protected by various lobbying groups, corporate bodies, the medical community, even patients, and many other actors. There’s somebody protecting the inefficiencies with dialysis, for example, right? As we discussed in class a few weeks back, dialysis is this massive for-profit activity that’s paid for by Medicare for the most part. If you have end stage renal disease, you’re entitled to dialysis. During the Nixon administration, this is the policy they passed. But they likely didn’t envision that quality for dialysis treatment would go down, rather than up, over time, or that hemodialysis services would be provided by a cartel made up of DaVita, Fresenius, a few smaller companies. Or take the physician shortage. We, as doctors, are arguably protecting that because it keeps our salaries up, thanks to the AMA.
But there’s tons of examples like that – and that concerns me, because really, I think if health reforms are going to happen, it has to happen in 500 different ways. Those wrinkles in the rug, again, they’re really difficult to just iron out. Serious health reform is not just going to be, like, a single-payer system. It’s not just going to be a free-market system or whatever. It is really going to take this boring work of eliminating each of these wrinkles, you know, each of these small inefficiencies in the grand scheme of things.
Vishal Khetpal is a second-year medical student at AMS. When he’s not writing or thinking about health reform, he loves to play squash and keep up with Premier League soccer. Check out more of his work at https://vishalkhetpal.com.
Peter Mattson is a second-year medical student at AMS and serves as editor in chief of Murmur.