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 Advantages of an Aware Care-Giver

My father started Chemotherapy and concurrent Radiation therapy for an oral carcinoma earlier this month. Cancer is a scary disease and putting a loved one through the ordeal of  cancer treatment is not easy. The disease is a devious one, you beat it back in one place, it pops up somewhere else, you get rid of it for a few years, and you never know when it will turn up again. Now while I have worked in hospitals and am familiar with terms like Chemotherapy and Radiation Therapy and things called IGRT (Image Guided Radiation Therapy-the first machine in Delhi was installed at Artemis in Gurgaon, where I was employed), it is only now that I am discovering how little I knew about the disease and its treatment.

I believe it is very important for family and care-givers to be well-informed about the disease and the treatment modalities being offered by the doctors. While we chose a hospital and the team that will take care of my father’s treatment, I read as much as I could about the disease. With the knowledge explosion around us and the almighty Google, at my service I found a treasure trove of information that was very handy in equipping me with managing my father’s illness and monitoring his treatment.

My father suffers from a cancer of the base of the tongue. The disease had spread to his adjacent lymph nodes, when it was diagnosed. A FNAC, wisely ordered by our internist revealed the tumour. The onco-surgeon I met ordered a PET-CT Scan to check if the disease has spread any further. I knew about the PET CT and how it worked and what it revealed, to understand why was it necessary. Once we had found the Primary tumour and settled on the treatment modalities (Radiation with concurrent targeted chemo-therapy), I read about the latest advances in these areas.

I also met medical oncologists who explained to me how the targeted therapy worked and why it was far superior to the conventional chemotherapy, which entails horrendous side-effects. The Radiation oncologists I met, explained to me about the radiation planning, the fantastic capabilities of modern-day radiation equipment and how they can deliver high doses of radiation with a great deal of precision and finesse. While, I marveled at the technology at our disposal, I knew the real test would be when we go through the therapy and how would my father cope with the like side-effects of the treatment.

Learning about the disease and the treatment options have helped me tremendously. Firstly, it has made me a partner in the fight against the disease. I am able to understand, what the medical teams are doing and how it might be helping us in dealing with the disease. This is most important as it gives me a semblance of control, a little power over a mighty foe. It also allows me to explain to my father about what to expect, to comfort him and to give him strength. Last night, as he blew his nose, a blob of blood coloured his handkerchief. Alarmed, he called me and I was able to explain to him that this was something that we would expect because of the radiation he is undergoing. A small matter, but a big reassurance for the patient.

Knowledge about the disease also allows me to hold informed discussions with the doctors treating my father. They too feel that they can explain to me in simple terms, what they are attempting and what has been the progress so far. Communicating well with your doctors is always a good idea, once they are comfortable, they can share with you a lot of information, which one can use and relate to during the course of the treatment.

Most importantly, as I sit besides my father watching the cocktail of the chemotherapy drugs drip into his forearm, I am able to supervise his treatment. This is not to say that the team of nurses and the residents are not good enough, but as we all know mistakes do happen and when one is dealing with cancer, they may prove very costly. Also, I realize the fact that for the nurses and the doctors, my father is one of the many patients they handle in a day, for me he is the only one and hence, even if I raise a few false alarms, it is worth it.

Finally, I would like to believe that a well-informed care giver, who is actively participating in patient care, while ensuring he does not get in the way, is a huge asset for the patient as well as the medical teams. I am willing to bet, medical outcomes would be far better for patients, who get this kind of support.

When faced with a sudden medical exigency it is imperative for caregivers to arm themselves with the relevant knowledge of the disease and for medical folks to encourage care-givers to do so. It really helps everyone.