Customer Advocacy is the new buzz word in the healthcare marketing space these days. Actually it is in many ways a bit of some old wine in a shiny new bottle. For many years now, healthcare marketers have known the power of customer advocacy, which in the olden days was known in somewhat more prosaic terms as ‘Word of Mouth’.

Customer Advocacy is all about patients talking about their experiences at hospitals and at various touch-points as they engage with healthcare service providers. In the healthcare space, patients talking well of a hospital, doctor or nursing care has always resonated a lot more than say, someone discussing a wonderful evening out in a restaurant or a five star hotel. In a hospital, a good experience usually means someone overcoming all odds, someone coming through a debilitating illness or someone recovering uneventfully from an emergent and unexpected surgery.

That patients will speak well of a hospital and its services is premised on one single fact – that the hospital will deliver a great experience to patients all the time. This is unfortunately easier said than done. A patient in the hospital today has many touch points and as the patient navigates her journey around the hospital, her experiences keep mounting. In the past, patients expected very little from the hospitals, the basic expectation was to just get out of the hospital alive!!!. Today, the hospital has to ensure its floors and rooms are spick and span, the doctors communicate well with the patients and the attendants, the nurses are ever vigilant and responsive, the quality of food served is comparable to a gourmet restaurants (no more jokes about the hospital food of yore!!!), the discharge process is quick and the billing is transparent. And an expected medical outcome is almost a given!!!!

There is nothing wrong with these expectations. A good modern day hospital should offer these and more. However, from the point of view of driving customer advocacy, it is a must that the hospital offers these experiences in a manner that meet patient expectations. To make matters more interesting a hospital, which hopes to use customer advocacy as a key marketing tool, must ensure that some of these experiences are delivered way beyond patient expectations and thus can become ‘talking points’. Thus, some of these experiences have to be tailored differently, delivered with great sincerity and truly from the heart to sway a customer to talk well about the hospitals.

Now if a hospital is geared to deliver superlative customer experiences, the marketer’s task becomes a little easier. He has to now ensure that the customer has easy ways of communicating his experiences to the wide world. In today’s 24×7 connected worlds, social media platforms like Twitter and Facebook come in very handy. Large hospital chains in the country have huge fanbases and followers and they encourage patients to record their experiences and then share them on these platforms. Hospital chains like Fortis and Max Healthcare extensively use slickly shot video testimonials, which are put up on different social media platforms and shared to generate the buzz.

A few hospitals also use in-hospital communication in the form of the traditional ‘wall of fame’ where they talk about positive patient experiences and simultaneously recognise employees showing exemplary behaviour based on patient feedback.

Many hospitals also encourage patients, who have had great experience at the hospitals to come and engage with others, currently undergoing therapy. This is usually a cathartic experience for many as they are able to closely identify with the speaker and feel motivated in their fight against a disease. In my many years of working in hospitals, I have organised many such events and the goodwill and joy that these events generate is best experienced by attending a session in person.

Many a times, I have seen patients volunteering to even participate with their doctors in media events organised by hospitals as spokespersons for the hospital. Recently, I was in Kenya for a media interaction that we were holding for the local media in Nairobi. The interaction featured two patients, who had received outstanding care at hospitals in India and they spoke beautifully about their successful fight against implacable foes like cancer and traumatic injuries. John began by saying that ‘Let me tell you that cancer can be cured…I know it better than anyone else…’ and Omar narrated how his 12 year old son recovered from an accidental injury that everyone has given up on. They spoke eloquently, answered questions, hugged their family and thanked the doctors for their support and care during difficult days. –Real patient stories at their best.

No amount of advertising can have the kind of impact that a patient telling his stories from the heart has. It is immensely powerful and the most potent way of building a brand and winning hearts.

An edited version of this piece has also appeared in Healthcare Radius/Feb 2015


The Story of John and Omar – How Customer Advocacy Builds Brands

200308966-001I was in Nairobi earlier this month. The occasion was to inaugurate Max Healthcare’s information Center in the city. I was accompanied by our partner based in Dubai and the program consisted of the usual run of the mill stuff. We had a couple of doctors accompanying us for the almost obligatory OPD’s, which were being hosted by a local medical center in the Upper Hill area of Nairobi. In the evening was a small press interaction, where all of us were to make some noises about how we expected to partner with the local medical fraternity in improving healthcare services in Nairobi and other parts of Kenya.

I was quite apprehensive about this. It is a known fact that the local medical community does not much appreciate foreign doctors landing up on their shores under the guise of OPD’s and taking away ‘their’ patients to sundry hospitals abroad. Though, I have never really understood the cause of this antipathy, (after-all only those patients will choose to travel abroad whose medical condition is such that can not be treated locally) I have been told by our Kenyan hosts that this is for real. Thus, I was a little concerned about a media interaction, where I may have to respond to some sensitive questions.

Also, I was worried that we really didn’t have much to share. After all an information centre of an Indian hospital chain is not really the most interesting piece of news even from the point of view of the news starved media of the city. When we reached the venue in the late afternoon, I was relieved to see our guests trickling in, the PR guys were busy settling the media folks down, the atmosphere was convivial and relaxed.

We had lined up the doctors to talk about their specialities (cancer and neuro-surgery), I was to speak briefly about Max Healthcare and our reasons for landing in Nairobi and our partner from Dubai was to talk about their reasons for joining hands with Max in this venture. We also had two patients, who had been treated at our hospitals and had returned home safely with wonderful experiences in Delhi.

We were soon done with our respective spiels and I could feel a sense of disappointment in the room. The journalists had come with hopes of an interesting evening and our stories had hardly set the room on fire. The presentations from the doctors were also a little technical, which too added to the gloom. They had tried hard, however for doctors to speak in front of an audience and not to lapse into medical jargon is an herculean task. The only saving grace seemed to be the booze and the plentiful food.

As the evening wore on, we had John come up to address the media. John is a cancer survivor, full of life and vitality. Earlier in the day, when I had met him he had told me about his struggle with the big C and how he had fought desperately to beat it. He had been treated by Dr. Rudra Acharya, the cancer surgeon who had spoken a while earlier. “I am here to tell you all, that cancer can be beaten, I am a living proof of this” began John. He narrated his ordeal with a great deal of emotions, the hopelessness of a patient diagnosed with cancer, how it hits you and what extra-ordinary courage it takes to fight this uphill battle. John appeared to be a man with a great deal of conviction and perhaps driven by a mission to share his story widely. He spoke eloquently about how he was taken care of by a team of doctors drawn from various cancer sub-specialities, how did they collaborate to ensure he received the most effective treatment and how everything came together in the end to pull him out from a very difficult situation. He was effusive in thanking Dr. Acharya and the team of doctors, who saw him through this very difficult phase of his life and spoke very highly of his experiences in an Indian hospital so far away from Nairobi. Soon he had his wife join him on the podium, and the two held the audience completely enthralled while sharing even small incidents that touched their hearts. ” I am planning to be in Delhi once again in February for my check-ups and this time round my doctors have invited me to stay at their homes. We missed the Taj Mahal the last time round, I sure hope to see it now” said John. He than invited Dr. Acharya to join him and his wife and both of them warmly hugged Dr. Acharya, who seemed a little overwhelmed with all the attention.

The media loved John. They were now firing questions at him and were literally eating out of his hands.

Soon we had our other guest, Omar, on the podium. He wanted to talk about the treatment of his son at Max Hospital in Saket, New Delhi. His 12 year old son had met with a freak accident in school. The child had tried jumping across a barrier, had landed on the edge and ruptured his urinary pipe. Omar had taken his son to at-least half a dozen centres in various parts of Eastern Africa. Nothing had worked till he landed with Prof. Anant Kumar  in Delhi. Dr. Kumar took up the challenge and re-constructed the ruptured pipe. Omar had been delighted to see his son recover and for him his Indian sojourn had truly been one of the most rewarding experiences ever. I had met Omar for the first time in the office of Dr. Anant Kumar in Delhi, about two weeks before this press interaction.I had told him of my plans to travel to Kenya and he had volunteered to come and speak about his experiences with the local media. Omar is of Somali descent, not only did he come over to see us and share his story, he helped arrange many Somali TV stations based in Kenya to come for the press conference. He first narrated his story in English for the benefit of the Kenyan media and than for good measure he repeated everything in the local Somali dialect for the Somali audience both in Kenya and back home in Somalia.

John and Omar both did us a great turn, though all they wanted was to help others overcome similar obstacles in their lives. They volunteered to share their stories of difficult times and their struggles and how they found comfort and happiness with a couple of highly skilled doctors and their dedicated teams in a faraway, strange land.

Thank you John and Omar.

Learnings from the World Medical Tourism Congress

074Last month, I had the opportunity to represent Fortis Healthcare at the World Medical Tourism Congress, held at the Caesar’s Palace, in Las Vegas. The conference was organized by the World Medical Travel Association and had participants from across the world.

Here a few things that stuck me as relevant for a larger discussion.

Medical Travel is now such a huge global phenomenon that we had thousands of people assembling in the wonderful Vegas to discuss how to make sense out of all of this. The conference had the mammoth Caesar’s Palace full, with all rooms sold out. The conference was held simultaneously in multiple conference rooms across the hotel, with folks attending sessions that were of interest to them.

The Congress had various stakeholders in the Medical Travel arena coming on a single platform. These included hospitals, medical facilitators, insurance companies, third party administrators, health plan managers and benefit managers from large corporates interacting with each other. Since the conference was in the Us we had a large number of hospitals from the Latin American countries. These included hospitals from Mexico, Costa Rica, Colombia, Argentina and even the small Dominican Islands. Fortis and Apollo Hospitals were representing India, while we also had hospitals from Turkey, Thailand and even Poland setting up stalls in the display area of the conference.

The Medical Facilitators, whom I met were really from across the world. We had a fairly large number of these who are based in the US and are largely sending patients to Latin America. We also met facilitators from China, Kuwait, Ukraine, Uzbekistan, Colombia and Nigeria.

The US seems to be completely in the grip of Obamacare. The law has spawned a small industry of experts, each trying to interpret the complex law in their own way. many experts held forth on how the law was a great opportunity for reforming the healthcare environment in the US. Almost, everyone agreed that the present mess of huge costs and a very large population of the uninsured will certainly be addressed well by the law. There were a lot of doubts on the execution challenges confronting the law and with the health exchanges taking off, all kinds of plans were being bandied about. I believe the law will create new opportunities for medical travel and will open many doors for people to travel and save costs on their medical bills. The travel will probably be more domestic than international, but as time goes by the confusion will clear and this will turnout to be the game-changer in the US healthcare.

While representing an Indian hospital, I was very pleasantly surprised to see the immense goodwill Indian doctors enjoy in the US markets. Most people I met believed that the Indian doctors were the best. Many had seen them at work in their local hospitals and the doctors had apparently impressed with their knowledge, skills and compassion. The other things that stood out as a distinct advantage was the English language (of all things). many wondered at proficiency that we had in the Queen’s language. I sent silent prayers to Thomas McCaulay,who unknowingly and with a completely different intent had introduced the charms of the English language to the natives.

Strangely, while many whom I met were aware of the prowess of Indian doctors, they did not know too much about Indian hospitals. Several people had no idea as to who were the leading players in healthcare in India and what was the value proposition, apart from healthy outcomes. When, we shared our price list with the local facilitators, there were only gasps of complete surprise and disbelief. With a CABG in the US going for USD 105000, our price of USD 7500, was truly unbelievable.

I believe Indian Hospitals need to engage with the US market a lot more. They just don’t know much about us. The government of India and other industry chambers such as CII, FICCI etc. must help facilitate this dialogue. In the conference, many countries were actually represented by their trade bodies promoting Medical Travel and individual hospitals were represented under this broad umbrella.

Finally, my compliments to the organisers. They really put up a massive show, very well organized with clearly defined programs, relevant content and mostly expert speakers. I think we need to have more of these to happen, so that Medical Value Travel really takes off around the world.

In the Defense of Doctors and Hospitals

Medical NegligenceFinally, the Supreme Court of India has bit the bullet. In a case of medical negligence, leading to death, the court has ordered a mind-boggling Rs 5.96 Cr as compensation to be paid by AMRI Hospital, Kolkata, to Dr. Kunal Saha, an Indian American doctor, who lost his wife in the hospital. The court decided that in this particular case, the doctors and the hospital were negligent in their conduct, which led to an unnecessary loss of life.

In the past, it has been very hard to prove medical negligence in a court of law. To be honest, even today it is quite difficult to establish deliberate negligence on the part of medical folks. Often, what looks like negligence can also be a momentary lapse of concentration, an error of judgement or just a genuine mistake. The consequences of the mistake can be horrendous but medical folks are like, you and me, prone to errors. These errors can be reduced but never eliminated. Better training, superior technique, state-of the art technology, greater knowledge, enhanced processes can all help reduce the chances of a mistake, but mistakes do happen. The real question is how does one differentiate genuine mistakes from gross negligence?

While one welcomes the court’s decision, one has to say this, the courts must be very careful in distinguishing genuine mistakes from deliberate negligence and dereliction of duty.

A person, who loses a loved  one unexpectedly, in a hospital tends to blame the hospital and the doctors. We see this kind of over the top reaction often enough. Most people find it hard to come to terms with the fragility of the human life and also do not realize that the treating doctors and other medical personnel are not perfect individuals. Most of the time, they are just trying to do their best in an environment of great uncertainty. They have the necessary knowledge and the skill to save lives, but surely they are not equipped to handle all the challenges that a human body throws their way. As consumers of healthcare services, we must always understand the simple fact that doctors can only do the best they can and sometimes their best may just not be good enough.

I fear that this judgement has the potential to become a lightening rod for many others, who nurse grievances against hospitals and doctors. If this leads to an avalanche of court cases against hapless doctors and hospitals, it will truly be a travesty of justice. I have worked with many doctors over the last dozen years or so and I have no hesitation in saying that I am yet to meet a doctor, who doesn’t take his patient’s and his responsibilities towards them seriously. In my experience, I have not come across negligent doctors. Yes, I have come across doctors, who are over-burdened with work, many who are over-confident and some, who are just incompetent, but never a single one who, to put it rather crudely, is out to kill his patients. All this at times leads to avoidable mistakes, some of those have terrible consequences and are irreversible, but never have I seen doctors deliberately hurting or maiming their patients. Before arriving at hasty and unwarranted conclusions about medical negligence, we must give the benefit of doubt to the doctors.

Medicine is an inexact science. Differences of opinion even among experts are common-place. Often, there are no right and wrong methods of treatment. It all depends on the knowledge, available information and the judgement of the treating doctor and often he is required to take a decision, which may be fraught with risk. However, he knows that not taking a decision is always a riskier option for the patient. In such a situation, if the decision does not produce an expected outcome, can it be later and with the benefit of hindsight be called negligence? The courts must put themselves in the shoes of the treating physician and examine the likely scenarios as they occurred to him rather than the distilled wisdom of other experts, proffered from the comforts of their offices and with the benefit of hindsight.

In short, medical negligence is a tricky thing to ascertain and the courts must always be more than satisfied about the intent and the real culpability of a doctor or a hospital before hauling him over the coals.

Rahul’s Dilemma – A Case Study

for blogRahul Jain warily walked up the stairs to the office of the Facility Director. He anticipated much of the discussion and was not sure if he had the energy to sit through another long session on how he needed to get more revenues for the hospitals. They have been having these discussions pretty much the whole of the last week and it was apparent to him that something needed to be done. Trying small quick fixes was not going to take them too far. The only question in his mind was whether he had the courage to bite the bullet. He had been dithering for a while now, but he knew that he had to bite the bullet now.

Rahul has been the sales head of the hospital for the last 6 months. He has worked his way up from the ranks and now headed the sales team. His team comprised of 10 sales people, 4 were designated as Asst. Managers and others were front line sales executives. Two of the AM’s were recent hires, hand-picked by him and the other two were older colleagues. The sales executives were mostly people who had worked at other hospitals and two were with large pharmaceutical companies. To his mind, he had a crack team. He had been trying hard to understand, why they were than under-performing as a team.

Rahul worked at a mid-size multi-speciality Hospital in Delhi. The hospital is a part of the large Fortis Group, which is widely regarded as one of the leading healthcare enterprise in the country.

Rahul walked into the office of Dr. Sudhir Sharma the Facility Director. Dr. Sharma has been the director of the hospital for just over a year. Rahul liked him for his straightforward approach. With Dr. Sharma, he knew there was never any mincing of words or sugarcoating of the pill. As Dr. Sharma waved him down in the chair opposite him, Rahul opened his laptop and sat facing Dr. Sharma.

‘Rahul, how are things?

‘Sir, things are improving. It is just that we need more time to reach to our full potential’.

‘Rahul, I know, but look at the numbers. The cash sales is tracking below par, the TPA channel is also below par, while the PSU and the government piece is ahead of the budget, which I am not sure is a good thing. We must drive our cash sales higher.’

Rahul too peered at the numbers, which in any case he now knew by heart.

Budget July 2014 (In Cr) Actual July 2014 (In Cr.) Budget YTD (in Cr.) Actual YTD (in Cr.)
Cash Sales 6.8 4.7 23.6 19.8
TPA/Pvt. Corp 3.2 2.4 12.8 10.4
PSU/Govt. 2.6 3.5 10.1 12.5
CGHS 1.2 1.5 5.5 6.4
International Sales 2.2 1.9 8.5 8.1
Total 16.00 14.00 60.5 57.2

‘Rahul, at about 95% overall achievement in the first four months, we have been barely able to keep our heads above water, but these numbers are hiding a big problem. The Cash and TPA sales are just above 80%, which is pulling down everything and the EBITDA numbers are in a very sorry state. We can perhaps prop up the EBITDA temporarily by reducing and deferring cost, but to reach an EBITDA of 22%, I need the sales channels to fire. To make matters worse, the CGHS and the other low priced business is ahead of the budget. Rahul, we must set this right and we have no time to lose’

Rahul also looked at the speciality wise distribution of the sales numbers. He felt that in these numbers were hidden some of the answers that he was seeking.

Budget July 2014 (In Cr) Actual July 2014 (In Cr.) Budget YTD (in Cr.) Actual YTD (in Cr.)
Cardiology 2.6 2.7 9.5 10.4
Cardiac Surgery 1.6 1.7 6.5 6.9
Orthopaedics 2.8 2.1 11.1 7.9
Neuro and Spine Surgery 1.3 .85 5.8 4.6
Urology and KTP 2.3 1.8 8.5 7.9
MAS and GI Surgery 1.8 2.0 6.5 8.1
Int. Medicine 2.6 1.65 10.2 8.9
Others 1 1.2 2.4 2.5
Total 16 14.00 60.5 57.2

‘Sir, if you look at the speciality wise data, we are clearly struggling with Orthopaedics. You know the team is new and we are trying our best to get the new doctors to connect with the referring physicians, it is taking time. Our other big problem is Neuro and Spine Surgery, where we just don’t seem to be getting the traction. And our bread and butter Internal Medicine is falling off the radar because of the internal team issues. While I am hopeful, that the dengue season, which is round the corner will help improve the volumes and revenues next month, we must have a longer term solution’.

‘Leave the Internal Medicine piece to me, Rahul. You know we are working on this and should get this sorted out in a couple of weeks, tell me how are you going to ramp up ‘Orthopaedics and Neuro Surgery pieces, what do we do there. You must look at the Urology piece as well; we are struggling there as well’.

Rahul took a deep breath and started narrating the outline of a plan that had been forming in his mind.

‘Sir, we have to attack these problems from multiple angles. To do that we must understand the levers that drives various parts of the business. We must have a comprehensive plan for Orthopaedics, Neuro and Spine Surgery and Urology. Let us identify these as our core specialities that we will drive across channels’.

‘Yes, Rahul but, where is the plan and when are we starting’. Rahul realized that Dr. Sharma was really running out of patience. He soldiered on.

‘Sir, as far as Orthopaedics is concerned, let us push the doctors both in the b to c space as well as b to b space. We need to re-launch the department. The Marketing folks must come up with a plan for the b to c piece. I shall speak with Manika in Marketing today itself. They need to pay us some serious attention. On the b to b front, I am working hard with the team to increase our coverage. Currently, we are meeting 300 doctors regularly; we need to push this up to 600. The A category doctors out of this lot must be regularly met every week’.

‘Rahul, I know but do tell me what you guys tell these doctors in your meetings. Do you have a plan for each meeting?’

Rahul winced; he knew he was on slippery territory here.

‘Sir, we have very little to engage with the doctors. We need more material, engaging stuff you know, interesting case stories, technically challenging cases, some nice giveaways…we have nothing’.

‘Rahul, please get what you need, the stories must come from the hospital itself. Get Jobi, to regularly source these from the doctors. Let me know, if you get stuck.

‘Right Sir, we will similarly develop detailed plans for Neuro and Spine Surgery as well Urology and come back to you.’

‘Rahul on the channel front too, my sense is that we are drifting. Please identify the top 10-15 clients in each channel and focus there. Can you come up with a Corporate Engagement Program, which allows us to connect with the corporates in a sustainable manner?’

‘Also Rahul, look at conversions, we have 500 OPD walk-ins every-day, I would like to know how many are recommended admissions and how many actually get admitted. Can we develop a system for tracking and improving conversions?’

Dr. Sharma in the flow and Rahul did not cut him short. In his mind he was also evaluating possibilities of introducing new clinics and new branded services, developing a robust plan for community activities in the neighbourhood and working out some local promotions to drive revenues in the short term.

‘Sir, allow me to put together a clear plan and come back to you in the next couple of days’. Rahul felt excited, even happy after his interactions with Dr. Sharma. He admired the man for his drive and ability to motivate. He secretly nursed a hope of becoming the facility director one day.

‘Thanks Rahul let us see the plan and let us get this beast moving quickly’.

Rahul walked out of the room, and called for a team meeting.

This is a fictitious case study written by me for a sales training session. Happy to share it here.

Connecting Better with Patients Works Wonders


Most doctors I know are reticent with their patients. Curiously the better they are at the work they do, the greater the reticence. They will walk over to the patient’s bed, look at the charts, confer with their colleagues, instruct the nurses, maybe inquire from the patient about how they are doing, mumble a few reassurances and then they are gone. The patient is often left pining for more information and hoping that their doctor would spend a little more time with them, maybe even share a light-hearted moment to lighten a grim day or just hold their hand for a while.

While medical outcomes do matter in the end, a doctor’s ability to connect with his patients is what matters during their stay in the hospital. I recall how Dr. Harsha Hegde a former colleague and a orthopaedics and spine surgeon would interact with his patients on his rounds. I have seen him checking on his patients, while chatting up with them on all manner of things. He would walk into a room, chat up with the patient about anything under the sun, engage with the patients as a friend, assure them that they will be out of the bed soon, crack a joke or two and in the same breath pass on the necessary instructions to the nurses or other colleagues. I even recall on many occasions, he would invite a patient out for dinner in the evening, particularly the day before the patient would be ready for discharge from the hospital!!!

Once we had a patient from the US, a school inspector if I recall correctly. He had come in pain and required a two level cervical disc replacement surgery. Dr. Hegde, duly operated on him and one evening as I was heading home, I saw him in the hospital lobby with the patient. Apparently, Dr. Hegde was taking him out for dinner !!! The patient too appeared to be in a state of shock, saying that he could hardly believe his luck. Three days back he had arrived from the US suffering from excruciating pain, and here he was heading out for a dinner with his doctor, who already seemed to have wrought a miracle.

While, what Dr. Hegde does is exceptional, most patients would be happy with a lot less. When the doctors start connecting with their patients, the patients also tend to be a lot more forgiving. A nagging unexplained pain, a sudden unexpected turn for the worse, a longer than planned stay in the hospital, and even a bigger bill are forgiven if the patient believes that their doctor was nice to them.

These patients than start spreading the good word around. They often exaggerate their experiences, the doctor turns into that wonderful knight in shining armour, who came riding on a mythical horse and saved them from the jaws of death. The doctor becomes a true saviour, capable of doing nothing wrong and the hospital too acquires a nice and warm halo. These patients are truly a healthcare marketer’s delight, they are the ones who do all the marketing and the doctor’s reputation and the number of patient’s queuing up outside their door goes up exponentially. The doctor loves it, the hospital loves it and of course the patients love it as well.

On the other hand, a very good surgeon with excellent outcomes, but with a grumpy, matter of fact style, would always be a lesser surgeon in the eyes of the patient. While, the patients would be happy with the excellent outcomes, they would always add a line saying that the doctor is rather ‘difficult’. And, here not surprisingly the patients would find many things wrong with the hospital as well. For some strange reason they will find that the nurses do not respond on time, that the food served is rather cold and bland, the pain relief offered to the patient is poor and the hospital overcharges for everything !

Life in a hospital is such. However, I do have a hunch, doctors, who connect with their patients better, also help in faster healing. The patients probably recover quicker and better, they return homes in a better and happier frame of mind and ultimately, that is really what truly matters.

Views on Preventive Surgery

Angelina JolieAngelina Jolie has now ignited a world-wide debate on Preventive Surgery. Can Surgery be really preventive? Is it worth going under the knife and suffer serious mutilation, only to prevent a disease, which may or no may not happen? Is it really wise to take the risk of surgery, when one is perfectly healthy, just to beat the odds that may or may not even exist? Where is medicine headed?

Angelina Jolie believed that she had a very high chance of developing breast cancer. She had seen her mother suffer and die from the dreaded disease, research indicates that it is possible to inherit breast cancer and she was given some fantastic odds of developing breast cancer in the future. From her perspective, she took the right decision of going ahead with a double mastectomy to beat what she believes are near certain odds of developing breast cancer. At the end of the day, it is her body and she has every right to undergo a surgery that she feels will help her prevent a deadly disease in the future. Anybody who has a quarrel with this position, I believe really has no case.

However, this does throw up interesting questions.

First let us begin with the odds that were offered to Ms. Jolie. I am not sure if we have enough data to give iron-clad probabilities of developing a disease. Science hasn’t really progressed, where it can say with reasonable certainty that an individual will develop a cancer with pin-point accuracy. Thus, how right it is to tell Ms. Jolie that the chances of her developing breast cancer are in the upper nineties. The number crunching at the end of the day is still really number crunching only. To decide to operate based on nebulous odds is hard to justify. Wouldn’t regular screening through high-end mammogram suffice? Do doctors now have the ability to look at the crystal ball and predict the future occurrence of a disease with near certainty? I am not so sure at all.

Second, does this mean that now many women with a history of this and other dreaded diseases opt for preventive surgical interventions? More importantly, is such aggression right? I believe this may trigger an avalanche of unnecessary surgery. As it is, the worst kept secret in medicine is that the quantum of surgery we presently do is much more than what is really needed. Now, with patients asking doctors for preventive surgical interventions, where are we really headed? The surgeons, who would want to be more prudent, may lose out on surgical work as their more scalpel happy colleagues will be happy to take up cases refused by their more conservative colleagues. Since, patients themselves will be keen on surgical interventions, it would really take a lot for a surgeon to say that he won’t operate because he believes surgery is not indicated. Do we really need this situation, where surgeons may be operating only because patients are keen on it !

Third, isn’t there a moral dimension to preventive surgeries as well. Performing surgery on a healthy individual, who may develop a disease later in life is fraught with moral hazard. Every surgery howsoever small comes with an inherent risk. The risk is of human error as well as of infections and unexpected complications. Should a healthy individual be subject to these risks in the here and now, only to prevent what may happen in the future? In Ms. Jolie’s case, mastectomy and subsequent reconstruction of the breasts are fairly complex surgeries. They do run significant risks. Are these risks higher or lower than those represented by the occurrence of breast cancer in the future?

Finally, who should decide whether a preventive surgery is needed or not. Should a patient ask for it, pretty much like a preventive health check. Should a surgeon operate, only because the patient is keen on it?

In my view there shouldn’t be anything called Preventive Surgery. We should operate to cure and not prevent future events. The fear of an uncertain future, must not dictate what we do in the present. This is where, I stand on this debate.