In the Defense of Doctors and Hospitals

Finally, 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 judgment 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 health care 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 judgment has the potential to become a lightning 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 judgment 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.

A Business Case for Branded Primary Healthcare Services In India

This winter Delhi has been smothered with fog or rather smog. While, I am one of those who enjoy the cold and love my walks in the neighbourhood park, pretty much like almost everyone else in the city I am not immune to the cough, cold and the respiratory track infections that that the damp and the cold brings.

I have been struggling with a bad cough for the last few days and have been wondering that it is perhaps about time I saw a family physician. Unfortunately, we do not have a regular family physician and I am not sure where to go. I also know if the problem worsens and a fever materialises I would go and see a specialist at Max Hospital and with a course of antibiotics I would be fine.

However, this is not the way it is meant to be. For something like this shouldn’t I be going to a neighbourhood clinic and getting the problem fixed before it became bad enough for me to see a specialist at a big hospital? And this brings me to the point that we need good quality and reliable primary healthcare in our neighboourhoods. There is a significant business opportunity here waiting to be tapped.

A Little bit of History

Apollo Hospitals tried setting up Apollo Clinics a few years ago. I was part of the founding team, which went into planning the clinics and the business around them. Apollo however was clear that it was not going to own or fund these clinics. They were supposed to be franchised with Apollo providing medical knowhow, its brand name, some of its doctors and IT support connecting the clinics with the hospitals. Ratan Jalan the than CEO had a vision of opening 200 clinics in 3 years. The clinics were supposed to provide outpatient services, namely consulting with doctors, diagnostic imaging services which included an X-Ray and an Ultrasound basic cardiology diagnostics like an ECG and a Treadmill test and a pathology sample collection centre. We sold some of these franchises and the Apollo Clinics started functioning with the first one commencing operations in Janakpuri in New Delhi. The owners were businessmen running a computer hardware store in Nehru Place and had no prior experience of healthcare. Similarly a few other clinics were also franchised and were set up in Delhi, Kolkata, Bangalore and elsewhere . However, it became apparent early on that Apollo was hardly serious about this business. They were keen on netting more patients for their large hospitals through this network and saw these as no more than referring centres and the support that was promised to the franchise owners  never materialised. The smarter ones quickly realised that in this new business they were pretty much on their own, learnt the ropes of this new business fast and managed to survive. Many did, many shut shop. Apollo was hardly bothered with any of this.

Max Healthcare too experimented with Dr. Max Clinics in New Delhi. Two clinics were set up in South Delhi. Unlike Apollo, Max invested in the clinics and had no desire to franchise. This experiment unfortunately failed mainly because Max in those days was focussed on rolling out its large hospitals and these clinics did not get any management attention. They were just not worth the trouble in the larger scheme of things and were closed down after a few years of experimentation.

The Learnings

While Apollo and Max both tried to set up Primary Healthcare Clinics, they were hardly serious attempts at the business. Apollo did not want to invest and was keen on skimming profits at the cost of the hapless franchisees and Max was just not ready at that point in time for something like this.

Apollo Clinics had a large upfront investment of approx. Rs. 20MN in the venture and since they themselves were not investing, they allowed the costs to go up and with the franchisee not knowing any better, they got away with this. When we crunched the numbers at Max we realised that a fairly decent clinic can be set up for as much as INR 5-7 MN.

The biggest challenge really here was about getting quality doctors (Family Physicians, Paediatricians, Internal Medicine, Obs and Gynae and Cardiologists) to join the clinic. Since the clinic is a very local enterprise one would want to pull in local doctors. However, we discovered at Max that many of them were just not interested as they saw the clinic as serious competition. They were afraid that if they moved to a Dr. Max Clinic and asked their patients to come there, the patients in future might prefer the superior and more professional services of the clinic. We tried hard to convince the local doctors that we sought a win win partnership but it really did not go anywhere.

The solution thus lies in forging a relationship with the local prominent doctors, which safeguards their economic interests. This can be achieved by asking them to invest in the venture. Thus 50% of the ownership of the clinic can reside with the lead consultants in the clinic. Thus let us say a sum of INR 2.5-3.5MN can be invested by the doctors and the balance by the entrepreneur, who sets up the business. A city like Delhi can easily absorb at least 100 such clinics and the model can be scaled up and rolled out across the country.

The clinics can than be established as a chain and can be marketed under a single brand name, 50% owned by an entrepreneur and 50% by local doctors. The clinics can all be connected under an IT backbone and data can be shared seamlessly. This can also open up enormous revenue possibilities from scientific research and allied work. Costs can be driven down by centralised purchasing and efficient supply chain management. Superior and unique customer experiences can be delivered through processes integrations and people training. I personally believe time has come for these clinics to emerge and claim their rightful place under the sun.

Finally, will this mean the McDonaldisation of primary healthcare in India? Well, may be yes, but than don’t we all love the neighbourhood McDonalds.

Pic Courtesy http://theapolloclinic.com/CorMainArticle.asp?Id=3

My Travels circa 2008

 The festivities of a New Year never fail to lift my spirits.  It is that time of the year, when one stops to look back  and than ahead, with a mixture of hope and renewed  vigour. As the old year slips into oblivion and we  celebrate the new one I thought I would look back and reminisce about some of the wonderful places I have been to in the year 2008.

The year saw me traveling both on work as well as on vacations with family. In January, I visited Oman on work. I barely made it as my passport needed renewal and had to be organised at the last minute. The Omani authorities in Delhi worked on a holiday to organise a last minute visa. We landed in Muscat on Jan 07 and lo and behold had a car waiting for us right besides the aircraft. We were quickly whisked into a most magnificentlounge and accorded the traditional welcome with halwaand dates. I had the honour and privilege of experiencing the legendary hospitality of our Omani hosts.  We had many meetings with the Omani officials, visited their hospitals and were entertained like visiting royalty. I would always remember the most wonderful banquet hosted by Shaikh Hilal in our honour at his palatial residence outside Muscat. And surprisingly all this, when the purpose of our visit was to solicit business for Artemis from the various arms of the government of Oman.  

Oh Kolkata!

Well well well! I never thought I will write about my experiences during my first visit to Kolkata. I consider myself reasonably well traveled but I had never been to Kolkata. Last week I spent a couple of days in the city. 

 

The Ubiquitous Queue

I landed in Kolkata close to midnight. I was staying at ITC Sonar and as soon as I collected my bag from the carousal I Iooked around for a prepaid taxi booth. Stepping out on the streets at close to midnight in a strange city and than trying to hail a cab was not something I fancied. Soon enough I spied a counter, which said Pre Paid Taxi and immediately my heart sank. There must have been over 60 people standing patiently in a queue that wound its way almost across the terminal. There was no chaos that you would expect in Delhi. I mustered as much courage as I could and joined the queue at the fag end. After about 15 minutes I realised that I was in the middle of the queue only because more people had joined in behind me. Realising the futility of this I plucked up some courage, left the queue and stepped out of the terminal. I crossed the street right outside the airport and was soon approached by a cabbie, who readily agreed to take me to the hotel. And he also kindly directed me to a pre-paid counter, right across the airport terminal. And guess what, this counter was completely deserted. I readily paid my fare and was off to the hotel wondering about the oft heard and now seen Bengali enterprise.