A Time for Reflection

The last week of December is usually a time for reflection.

And the private healthcare industry in India has a lot to think about. The last two months have been those of turmoil for the industry. The crisis related to the implementation of a draconian Clinical Establishment’s Act in Karnataka led to angry protests by the medical community in Bangalore, while in Delhi two cases of alleged overcharging and medical negligence at the two leading hospital chains caused an unprecedented furor. Much has been said about these cases, I won’t add more, however, we must reflect upon what lies behind these flair-ups.

These cases must not be considered as an isolated outbreak of public anger with the media and the politicians blowing up the issues. While that did happen, we must look at them as a trigger for a far deeper malaise.

For a long time, private healthcare in India is increasingly being viewed by patients with a great deal of distrust. With the public healthcare in tatters, the consumers continue to flock to the private establishments, where the care and services are of high quality, however, they no longer trust their doctors and hospitals. This is an extremely worrying sign because the only thing that binds patients and clinicians is trust, an implicit faith in the system that the hospitals and the clinicians will always act in the interest of the patient.

We must ponder over what has led to this catastrophic erosion of trust.

Private healthcare systems are being increasingly looked upon as businesses with commercial interests, which far out-weigh patient’s interests. The media has been peddling this narrative for a while, highlighting cases of ‘wrong billing’ without diving into the arcane of what exactly is wrongly billed. Selective charges of profiteering on things like syringes and gloves are bandied about causing more damage. Somehow, the real narrative of hospital profitability measured in terms of financial parameters such as Return on Capital Employed (ROCE) do not find any mention in these stories. The fact that most private healthcare companies are barely profitable just doesn’t seem to register. Private Healthcare systems need to address this urgently. They must get together and build a counter-narrative, which highlights their often precarious finances and the enormous risks they have taken to build a healthcare system, which actually takes care of the needs of the majority of the people of our country.

While this needs to happen on the external front a lot of house cleaning must also happen internally. The hospitals must review their pricing structures and make them more transparent. The patients today are educated and if the components of a hospital bill are explained to them in detail, I am sure many will understand and appreciate.

The other big issue that destroys trust is the difference that the patients find in the estimates given at the time of admission and the final bill that they end up with. Medicine is at best an inexact science and in many cases, it is hard to predict a patient’s course during hospitalization. However, large private chains do have the data and technology to be able to predict estimates with a reasonable level of accuracy in a high number of cases. Thus a system can analyze bills of say, the last 500 patients who underwent a bypass grafting, exclude the outliers and predict the probability of the bill is a certain amount. This can be shared with the patients transparently. Even if hospitals do this for cases of planned and routine surgeries, I am sure the trust levels will increase.

The real trust builder is, of course, ensuring proper engagement and communication with the patients. Large hospitals, with hundreds of patients, often forget to pay enough attention to individuals leading to a sense of isolation and abandonment. The hospitals need to establish protocols for patient communication. The clinicians must sit down with the patients and their caregivers and explain how the patients are doing in the hospital, the challenges that they foresee and the prognosis. My view is that even if the prognosis is grave, it should be shared transparently with the caregivers. This should be done with great sensitivity and empathy and in a language which is shorn of all the jargon.

Finally, the biggest builder of trust is the time that a clinician spends with the patient and their caregivers. In busy hospitals, clinicians often just do not have enough time to spend with their patients. The out-patient consultations are frequently cursory and fleeting, often leaving the patient wondering whether their doctor has even understood their medical condition or not. While admitted to the hospital, sometimes patients don’t even see their surgeons even when they are being wheeled into the OT’s. Why can’t we have a system, where the operating clinician would himself visit the patient either in their rooms or in the pre-op area, reassure them once just before they face the knife. There can be many such processes that can be established, which gives greater comfort to the patients.

The media noise of profiteering resonates with patients and caregivers only because they find their hospital experiences sterile and scary. As the healthcare costs mount, the patients will need better experiences for them to trust their hospitals and care providers.

My belief is that the time has come for private healthcare providers in the country to walk the talk on patient-centric care. No amount of external regulation will help build the lost trust. It is only actions, which build trust in patients and their caregivers, which will help regain the lost ground.

And once we regain our patient’s trust, they will not find us profiteering nor will the media’s false charges stick.

Here is wishing all my readers a Merry Christmas and a very Happy New Year.

The views expressed are personal

 

The Aftermath

While the slug-fest between the government of Delhi and private healthcare providers, the Indian Medical Association/Delhi Medical Association and a completely partisan media continues, one is left wondering about the possible aftermath of this ugly episode. The media will soon move on to other stories and the government having scored some brownie points and having successfully demonstrated its ‘might’ will look at another vote-catching device, only the citizens of Delhi will be stuck with a much worse healthcare system.

Let us look at some of the reasons for this.

With the kind of sheer hostility that is being shown by the consumers towards private healthcare and individual doctors, many are already talking about not accepting seriously sick patients. Their fear is that if the patient dies in the hospital, they will be blamed for the death and they run the very real risk of being publicly abused by vicious and ignorant television anchors, beaten up by patient attendants and may be sacked from their jobs. In an environment where the media and the patients believe that it is the doctor’s job to get them well and that he is fair game if the outcome is not the desired one, we are clearly telling our doctors not to treat patients where there is a risk of failure. This will indeed be very sad because as patients we must give our doctors the confidence and the strength to fight the good fight to the best of their skills and ability. That trust is the very basis of the practice of medicine.

The advent of private healthcare had also seen some of the best and the brightest Indian doctors returning to India to work in these corporate hospitals. The world over, Indian doctors and nurses are recognized for their skills and diligence. There is much demand for them all over the world. The prevailing atmosphere of distrust and antipathy is already making many of them uneasy. Many have started regretting their decision to return and work in India. Many who were contemplating to return would now prefer to stay put. Many who had plans to go abroad for training, would now look at ways to bring their plans forward and try to stay abroad longer. One can hardly blame them.

Private hospitals are beginning to realize that it is far more important to have paperwork and video recordings of their patient interactions rather than a caring system, where people are encouraged to go the extra mile to help a patient. Since, the hospitals are not sure when they may be facing a media or a court trial, they will ensure that they are well protected at all times. This will further push up the cost of private healthcare. The undue activism visible today will end up defeating its own purpose.

Setting up and running hospitals is an expensive proposition. Only investors with very deep pockets can build the required infrastructure and sustain operations till they see profits, which happen years later and are meager in any case. If the local governments pandering to their vote-bases arbitrarily decide to shut down hospitals, why would investors put in money to build healthcare infrastructure in the country? The government spends on healthcare are in any case minuscule and compare poorly even with sub-Saharan Africa. The government hospitals are already over-crowded, mismanaged, filthy and without much accountability. If the private investors decide that investing in healthcare is not well worth the risk, where will the people like you and me go for our healthcare needs? If I was planning to set up a hospital in Delhi today, I would certainly think twice.

Working for some of the leading ”corporate” hospitals in India in the last 15 years, I have had the opportunity to travel the world. Everywhere that I have traveled, I have been uniformly asked one question, which is, how has Indian private healthcare system evolved so well. Considering the country’s other developmental parameters, private healthcare, which attracts patients from all over the world (Max Healthcare received patients from 80 countries across the world this year) stands out. Not only is the quality of health care compares well with the world’s best, the costs are the lowest. Ironically, instead of taking pride in our achievements, we are trying our best to run down our hospitals and the people who work in them.

Private healthcare players in Delhi are quite dumb-founded by the political grandstanding, the unwarranted hostility of an ignorant media and worse of all the support of ordinary citizens to this madness. Are we, the citizens of Delhi willing to pay this kind of steep price just because we believe the half-truths being peddled by self-serving politicians and a biased, unprincipled media?

PS: Might be a good idea to find out where these same politicians and media warriors and their families go to when they need serious healthcare. No prizes for guessing though.

The views expressed are personal.

The Destruction of Trust – A Media Trial and a Witch-Hunt

The last couple of weeks have been a difficult time for the healthcare services providers in the NCR of Delhi. The media have been busy reporting about how Fortis and Max Healthcare ill-treat their patients and how the only thing they care about is profits. Having worked in both the hospitals, I can only say that this is completely wrong. The media-houses in their zeal to sensationalise and chase TRP’s are doing a great dis-service to these hospitals and the the medical profession in the country. The reporting is biased, short on facts and the conclusions drawn are completely unwarranted even bordering on fantasy.

The stories pertain to two cases, one at Fortis Hospital, Gurgaon where a 7-year-old child died of complications related to Dengue and the hospital is accused of over-charging and being callous. The other pertains to Max Healthcare, which is charged with negligence as one of the twins born at 23 weeks gestation was wrongly declared dead at Max Hospital, Shalimar Bagh, Delhi. The false narrative being spun is that the hospital chains are negligent, money- making machines and do not care for their patients. The outrage is completely manufactured and the stories falsely amplified and one-sided.

To make matters infinitely worse the politicians too have jumped in. They clearly want to be seen as championing the poor masses, who mostly cannot afford the services of these hospitals. The hospitals are being subject to multiple enquiries and the police has been called in to investigate the ‘murders’. The hospitals are being threatened with the cancellation of their licenses. (Strangely, a few months ago when scores of children died at a government owned hospital in Gorakhpur because the hospital ran out of oxygen supplies, no one thought of cancelling the license of that hospital)

Lest, we forget, both these hospital chains are amongst the top 5 private healthcare services providers in India. Between them they run more than 40 hospitals, treating thousands of patients every day. They are amongst the most well equipped hospitals in the country, boasting of the highest levels of technology, processes and systems and have patient outcomes comparable to the best in the world. They employ the finest of clinical talent available in the country and provide them an environment to excel. The hospitals attract thousands of patients from all over the world, who travel from across the globe seeking treatment for the most complex of diseases. Having worked in both the organisations, I can confidently say, that while there are many differences between the two institutions, both are thoroughly committed to the highest standards of patient care.

In-spite of all this, the hospitals are not infallible. No hospital in the world is. They can only aspire to do better, keep improving themselves and always try to do the best they can.We need to ponder, how these centre of clinical excellence have suddenly become pariahs overnight basis two cases, where there have been lapses. Like in any other profession or sphere of human endeavour, errors are inevitable. Tight processes, technology support and intent to weed these errors out is far more important than the errors themselves. On these, I can say without any hesitation that the hospitals compare favourably  with the very best that we have in the country.

The line between genuine errors and negligence is very thin. Doctors, while racing to save lives are required to make split second decisions, which may mean the difference between life and death to their patients. Sometimes not taking a particular decision may prove fatal and at others taking a particular decision may lead to complications. We have to trust our doctors to take the right decisions based on their experience and judgement. We also have to accept the fact that their decisions might turn out to be wrong and that these decisions can have horrendous consequences. This is just the nature of medicine. An adverse outcome doesn’t mean that the surgeon or the hospital messed up. It mostly means that they tried their best and yet didn’t succeed.

This is something very fundamental to healthcare. As patients or care-givers, we must support the doctors as best as we can. We can question, we can ask but let us not blame, at least, not every time something goes wrong. If we believe that there is a case of genuine negligence, as consumers we do have options. We can lodge a complaint with the Indian Medical Council, approach the consumer courts or go to the police. We must use these options judiciously.

Getting back to the baby, who was born at 23 weeks of gestation at Max Hospital, Shalimar Bagh. It has now been established that the decision, not to resuscitate the child was medically correct as he had a very slim chance of survival. The prognosis in case of survival too was also very poor. The decision to declare the child lifeless, without fully ascertaining the fact of death was wrong. Failure to properly communicate this tragedy to the parents too was an error. Was this negligence? Was their any malafide intent of causing harm to the child or undue pain to his parents? In my view this certainly wasn’t the case. I am not an expert in these matters and various eminent clinicians are conducting an enquiry about what happened. My view as a layman is that someone made a mistake, it was a bad mistake to make, hopefully some lessons too would have been learned and this would never be repeated again.

Does this mean that the hospital, the doctors and the administrators be called vultures, cheats and murderers and have rampaging mobs running amok in the hospitals baying for their blood?

The views expressed are personal.

The Advent of ‘Reverse Medical Value Travel’

Well, I don’t know what else to call it.

But this seems to be an emerging opportunity in the broader Medical Value Travel firmament. Last week, I learnt that my friend and former colleague Dr. Sunil Prakash, who is a well known nephrologist in New Delhi, was a part of a team that performed a kidney transplant at the Muhimbili Hospital in Dar es Salam, Tanzania. Dr. Prakash posted happy pictures with the patient and it appears the event generated excitement and a lot of publicity in Tanzania. Apparently, this was the first ever kidney transplant conducted in the country.

Essentially an Indian team of doctors carried out a complex surgery in a hospital in Eastern Sub Saharan Africa. Instead of the patient making the journey to a hospital in India, a team of doctors traveled and treated the patient in a foreign hospital.

I would call this ‘Reverse Medical Value Travel’ and I expect this to increase in the coming years.

This is certainly not new phenomenon. Many years ago Fortis Hospitals had tied up with the Talimi Hospital in Basra, Iraq. Fortis started conducting cardiac surgeries in the hospital in Basra. A team of surgeons, anaesthetists, perfusionists and a bunch of nurses would arrive in Basra and would go straight to the hospital and operate patients, who were pre-selected and already admitted in the hospital. A new team would arrive every week to replace the previous team and the teams would typically rotate every 6 weeks or so. This was a very successful program, ran for several years and I am told over 900 surgeries were conducted. I remember the initial problems we had in getting the clinical teams to travel to Basra but once the program started, it really took off.

I am sure there would be other examples of successful ‘Reverse Medical Value Travel’ elsewhere too.

The Reasons for the Emergence of Reverse Medical Value Travel

The primary reason for the inevitable rise of ‘Reverse Medical Value Travel’ is not difficult to understand. In many parts of the world, with healthy economic growth, are emerging exciting opportunities in the business of healthcare. Enterprising organisations and individuals are willing to invest in healthcare infrastructure such as hospital buildings and medical equipments, essentially things that money can easily buy. One can build a reasonably sized hospital in under 2 years but it is indeed difficult, well nigh impossible to develop a steady pipeline of clinical talent to work in the hospital. It takes several years if not decades for good medical teaching institutes to produce high quality medical talent. Thus, there is an emerging and deepening shortage of qualified and experienced medical teams who can sustain the new hospitals coming up at a frenetic pace.These hospitals are relying on importing medical talent from abroad. Successful clinicians with good patient base rarely uproot themselves and move to new pastures. Thus, we see clinical teams traveling for short durations and the emergence of “Reverse Medical Value Travel”.

The Advantages of Reverse Medical Value Travel

One of the key advantages of Reverse Medical Value Travel clearly is that it saves sick patients long distance travel. It allows patients to be treated closer to their homes, surrounded by family and friends and in a familiar environment. After being discharged from the hospital they can straightaway head home. I am sure this leads to faster healing and recovery.

The other advantage lies in sheer numbers. A single team of doctors can treat a large number of patients in one visit. Thus, a team of 5 can perhaps operate 25 patients over a a week. This implies that less number of people need to travel. Usually, when patients travel, they are also accompanied by family members and care-givers. The hassle is so much less.

Reverse Medical Value Travel brings the benefits of training and learning to the local clinical teams. They inevitably join in the surgeries and learn by working with experts from abroad operating in their hospitals. This is of immense value as the local teams learn and practice new skills with old masters. This transfer of skills and knowledge creates a ‘guru-shishya’ relationship with strong and long-lasting bonds. It also develops tremendous goodwill and bonding.

For the visiting clinicians operating in alien environments, often facing a language barrier and working in different cultural settings is also a tremendous learning. Most love the challenge and enjoy proving their mettle in these relatively difficult situations.

The local governments consider ‘Reverse Medical Value Travel’ as a boon. The precious foreign exchange outgo is much less, the skills enhancement and the goodwill generated in the local communities is tremendous, the media is very supportive – perfect for local politicians who welcome the foreign clinical teams with open arms.

This is a win-win for all.

The Pitfalls

While “Reverse Medical Value Travel” gradually takes wings, one has to carefully consider the risks as well. The clinicians operating in foreign hospitals have to be well protected with indemnity insurance and in some difficult places with blanket immunity. The hospital infrastructure has to be very good and the doctors should not be pressured into operating cases that they might not be comfortable with. The clinical protocols of the hospital, infection control measures and other critical medical parameters must be of a high order. The teams for post-operative care should be well trained to look after the patients once the foreign teams have departed.

In most countries, local hospitals or governments take care of most of these.

I believe that “Reverse Medical Value Travel is a great opportunity for Indian Hospitals. It can help them earn not only dollars but universal respect and tremendous goodwill.