Vikram Madireddy reflects on his medical training in rural Tennessee and the uncomfortable questions provoked when he encountered alternative systems of care.
As an American physician born and raised in New York City, trained in Tennessee, and now a doctoral researcher in Japan, I have long grappled with the contradictions of my country’s healthcare system. It was not until I began a five-month global journey—crossing Japan, the United Kingdom, Germany, and Australia—that I fully appreciated how the moral, structural, and cultural dimensions of medicine shift from one country to another. My travels were not simply educational; they became a mirror through which I could critically examine the ideological scaffolding of American healthcare and how it shapes our profession, our patients, and ourselves.
Growing up in the U.S., the healthcare system was a backdrop I took for granted: one where innovation thrives, but access falters; where the rhetoric of choice masks systemic exclusion; where physicians are caught between their Hippocratic ideals and standardised numerical codes. The U.S. system, defined by its market orientation, often champions autonomy—of doctors, of patients—but at what cost?
That question crystallized as I trained in Tennessee, deep in the so-called “Stroke Belt,” where rural hospitals are underfunded, preventive care is inconsistent, and comorbidities cluster like storm clouds (Garcia, 2020). It became evident that American medicine is unequally distributed, dictated not only by insurance coverage but also by geography, race, and socioeconomic status. In a country that touts individualism and freedom, many are left with too little choice and too much risk.
In Japan, I witnessed a strikingly different model. There, I was invited to study endovascular neurology (a medical specialty that deals with the blood vessels supplying the brain and nervous system) in a system that blends advanced imaging with a deep sense of relational ethics. The concept of shinmi—a physician’s emotional and moral connection to the patient—felt, to me, worlds away from the often-transactional ethos of American care. Japanese doctors do not outsource tasks lightly; they interpret scans, perform bedside exams, and invest deeply in the patient narrative (Ozeki-Hayashi, 2023). This sense of being embedded in the clinical process fosters not just competence, but compassion—an ideal increasingly elusive in U.S. settings where physicians are pressured to see more and more patients in less time.
Such experiences meant I could not ignore how professional identity is constructed through cultural values. In Tokyo, I saw how bushido—the samurai code—still undergirds medical professionalism, urging doctors to act with discipline, humility, and reverence (Nishigori and Hiroshi, 2014). I witnessed an example of this devotion to duty , where an entire group of trainee doctors in Tokyo performed their own nerve conduction studies on individual patients, a task that would be relegated to a technician in America. In the U.S., burnout and moral injury have surged partly because these virtues are hard to sustain in a system that rewards volume over presence.
My subsequent rotation in the U.K. highlighted yet another dissonance. Under the National Health Service (NHS), the constraints of a single-payer system demand clinical rigour and resource stewardship. While American hospitals order Computed Tomography (CT) scans at the first hint of uncertainty, British physicians dig deeper into the patient’s story. In one memorable case of suspected multiple sclerosis, a detailed history and careful neurological exam led to the unexpected diagnosis of a rare mitochondrial disorder—without a battery of redundant tests. There is a kind of clinical poetry in such encounters: the body speaks, and the doctor listens.
Yet, the NHS is not without flaws. Resources are stretched, waiting times are long, and bureaucracy is palpable. But what it offers—universal access—challenges American assumptions that scarcity is inevitable unless someone pays dearly for it. In the U.K., healthcare is not a commodity; it is a civic good (Gorsky, 2010). And therein lies the moral divergence. Where America sees patients as consumers, Britain sees them as citizens.
In Germany, I encountered echoes of this ethic in a system that traces its roots to Otto von Bismarck’s 19th-century reforms. Birthed to neutralise socialism, his social health insurance model now undergirds a form of solidaristic care that the U.S. has never quite embraced. What began as political pragmatism evolved into an ethical commitment: people should not go bankrupt to stay alive (Tulchinsky, 2018).
Australia offered perhaps the starkest contrast yet. There, working with the Royal Flying Doctor Service (RFDS), I saw how medicine adapts to extreme geography and isolation (Langford, 1994). Treating cases like Murray Valley encephalitis in the outback, challenged my assumptions about accessibility. In the U.S., rural populations face similar barriers, but without the coordinated lifeline that Australian medicine provides through Outback Clinics and the RFDS. Our neglect of rural health is not a logistical failure—it is a moral one.
As I boarded my final flight home, I carried more than new diagnostic skills or procedural experience. I carried a renewed conviction that the practice of medicine is inseparable from the systems that shape it. The U.S. excels in innovation, but too often neglects inclusion. It trains brilliant doctors, but burdens them with administrative fatigue and moral compromise. We celebrate choice but deliver it unevenly.
Such experiences have provoked uncomfortable questions: What kind of system are we sustaining? Whose stories are privileged in our policies? Where does empathy live in an Electronic Health Record? My global travels were not an escape from American medicine but a confrontation with its blind spots (Yamey, 2020). To improve, we must be willing to see ourselves through the eyes of other nations—and more importantly, through the eyes of our patients.
In every patient I now encounter—whether in New York, Tokyo, or London—I carry not only my stethoscope but also the stories, systems, and souls I met across the world. I am no longer just a physician trained in America. I have been a witness to what medicine can be when it remembers its shared humanity.
About the author
Vikram Madireddy received his medical degree (MD) from the University of Tennessee. He is currently working on his PhD in neuroscience at the University of Tokyo School of Medicine in Japan, focusing on neural circuits and language plasticity after learning Japanese whilst in medical school. He has published both peer-reviewed scientific and humanities articles worldwide, including for BBC Health and Sage Journals.
References
Garcia, M. B., J. C. Homan, and M. C. Richardson. 2020. “The Southern Rural Health and Mortality Penalty: A Review of Regional Health Inequities in the United States.” Social Science & Medicine 268: 113040. https://doi.org/10.1016/j.socscimed.2020.113040.
Gorsky, Martin. “The NHS: The Story So Far (1948–2010).” 2010. British Medical Bulletin 96, no. 1: 1–15. https://doi.org/10.1093/bmb/ldq039.
Langford, S. A. “The Royal Flying Doctor Service of Australia: Its Foundation and Early Development.” 1994. The Medical Journal of Australia 161.1, 91–94. https://pubmed.ncbi.nlm.nih.gov/7832837/.
Nishigori, Hiroshi, Rachel Harrison, Jamiu Busari, and Tim Dornan. 2014. “Bushido and Medical Professionalism in Japan.” Academic Medicine 89.4 : 560–63. https://doi.org/10.1097/ACM.0000000000000176.
Ozeki-Hayashi, Risa, and Dominic J. C. Wilkinson. 2023. “Shinmi (): A Distinctive Japanese Medical Virtue?” Asian Bioethics Review 16.4 : 563–73. https://doi.org/10.1007/s41649-023-00261-6.
Tulchinsky, Theodore H. 2018. “Bismarck and the Long Road to Universal Health Coverage.” In Case Studies in Public Health, 131–79. Amsterdam: Elsevier, https://doi.org/10.1016/B978-0-12-804571-8.00031-7.
Yamey, Gavin, Rishi Rattan, and Andrea S. Christopher. 2020. “Universal Healthcare in the United States of America: A Healthy Debate.” Cureus 12. 11: e9349. https://doi.org/10.7759/cureus.9349.
Good job Vikram San. Omedetou gozaimasu. -Watanabe Sensei.