Medical Outcomes and Customer Experiences

My father was diagnosed with an oral cancer last March. He had been staying with me in Delhi and fortunately, we had plenty of choice in selecting a hospital, where we could possibly have him treated. After carefully evaluating these choices, we zeroed in on two possible facilities –  Medanta Medicity, the new hospital in Gurgaon and Max Hospital in Saket. At Medanta the leaders of the Oncology team were my colleagues during my stint at Artemis Hospital in Gurgaon, and I enjoyed a great relationship with both Dr. Ashok Vaid and Dr. Teji Kataria, the medical and the radiation oncologists respectively. At Max Hospitals I did not know the doctors personally, they did not have a cancer facility when I worked there, but I had plenty of other close friends who ran the hospital and vouched for the caliber of their team of Dr. AK Anand and Dr. Anupama Hooda. Ultimately, with all things equal we chose Max, simply because it is closer to our home and the logistics prevailed.

This was in March and my father had since undergone Targeted Chemotherapy and Radiation Therapy on an IGRT machine. Post the treatment, he is doing as well as can be expected and I am extremely grateful to the oncologists at Max Hospital. In these past 6 months, I have been visiting the facility often and have become familiar with the customer handling processes at the hospital, which unfortunately still leaves a lot to be desired. While, the medical outcome of the treatment we have received at the hospital has been good, purely as a customer, my experience with the hospital services can hardly be termed satisfactory.

Here are some suggestions as to what can be done to improve the overall hospital experience.

The Issues with Group Practice

The radiation team at Max Hospital follows a group practice system and is led by Dr. AK Anand, who comes across as an extremely competent and experienced physician. He has a fairly large team of physicians, who support him in the OPD. Now, these are mostly young physicians earning their spurs under Dr. Anand’s supervision. Since, the team works on a group practice system, a patient gets seen by any of these physicians in the OPD. Thus, more often than not it so happens that one meets a new physician whenever one visits the hospital. From a patient’s point of view, it is very disconcerting to interact with a new physician and start the entire conversation right from the beginning every time one visits the hospital OPD. Also, the entire team is not of the same pedigree, many doctors are younger, less experienced and seem to be apprenticed with Dr. Anand. They often do not come across as confident and as sure as Dr. Anand, a very important factor, when the disease involved is a cancer.

The entire system revolves around a physical file, where all the doctors jot down their noting on loose sheaf of paper, which is than filed away. Each OPD visit means that the physician assigned to see the patient goes through the file, figure out what had happened in the previous visit and issues fresh instructions on the file. I submit it is quite impossible for a physician to study this file in the time that he is spending with the patient and fully understand what has happened thus far. The chances of human error are high. Max Hospital is bristling with posters on the notice boards about a state of the art e-initiative which is supposed to take care of all medical records electronically. While one goes through the tall claims about this new system, one finds it hard to reconcile it with the archaic processes in the Max Cancer Centre.

The system seems to have been designed around the physicians, one feels it should be, in this age and time around the customers. It should assign a particular doctor to a patient and he should see the patient through. If there are junior doctors involved, they should see patients along with the seniors, till they themselves feel comfortable in handling patients on their own. The physical files are ridiculous and can be done away with completely. Like in any other modern hospital, the information should flow seamlessly on a well-connected network. Reports, instructions etc. can and should be as far as possible e-mailed to patients.

The Appointment System

Strange as it may sound the appointments given to the patients have little value. Almost all patients are required to wait for a minimum of 30-40 minutes, whether they have a confirmed appointment with their physicians or not. Because of the prevalent group practice system, it is also quite immaterial whether you have an appointment with Dr. A or Dr. B.,  you can be ushered into the office of any  doctor on the team and he will see you irrespective of the fact that you have an appointment with a particular doctor. Thus, I have not really understood, why are appointments given for any particular doctor. In this system, it would make greater sense if one was to just walk in and gets seen by which ever doctor who is free at that point in time!!!

The Files

The files are the most important element in this entire process. Sometimes I have wondered what would happen if it would be misplaced. Actually it happened with us once, when the file had been requisitioned by the medical oncologist, and it took two hours, some very heated words and a few very flustered employees to find it. In the absence of the file, I would reckon the doctors too would be quite helpless. I have been assured that the paper file does have an electronic back-up, which honestly I doubt. I shudder to think that in this age and time, at Max Hospital, we might be at the mercy of a file, which changes hands every time a doctor sees us and God forbid, if somehow it is lost in the hospital.

While all this may sound strange and terribly dated, I must say that the system somehow works. We have no complaints on the medical outcome, which is the primary reason we have been visiting the hospital. As a patient and a care-giver I do not have much to complain about. However, as a modern-day paying consumer, wouldn’t I want my hospital experience to be far superior and fool-proof than what it is.

Hospitals must understand that in this age of customer experiences, it isn’t the medical outcome alone that counts. Max should know this better than anyone else.

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Panel Discussions on the occasion of The World No Tobacco Day

Today is the World No Tobacco Day (WNTD). It is observed every year on May 31st. World Health Organisation started observing WNTD from 1987 and it is promoted globally to create awareness about the perils of tobacco abuse and to encourage people to give up using tobacco.

To commomorate the day, I moderated two panel discussions in New Delhi on the harmful effects of tobacco and how can one kick the habit for good. The panelists were all eminent doctors from Max Healthcare. These included Dr. Sandeep Buddhiraja, who is the Director of Internal Medicine practice at Max Hospitals, Dr. Samir Parikh, who is a well-known psychiatrist and also heads the Mental Health institute at Max Healthcare, Dr. IS Virdi, who is the director of Cardiothoracic Surgery at Max Hospitals, Dr. Harit Chaturvedi, who is a Onco Surgeon and the Director of Onco Surgery at Max and Dr. Anupama Hooda, who heads the medical oncology practice at Max. We had a packed house, a very interactive audience and some very interesting discussion.

I have known Dr. Buddhiraja for many years. He is a founding member at Max Healthcare, we worked together for almost 5 years, when I handled the Marketing function at Max. He continues to be my physician and has on numerous occasions treated many members of my family. In all these years I have known him to be a quiet, sincere and thorough professional, somebody whom you can implicitly trust. Today, I discovered another facet of Dr. Buddhiraja, that of a fiery crusader against tobacco abuse. Sandeep, had come prepared with all the facts, which pointed to a huge burden of disease, that is caused by tobacco abuse. He spoke with great passion, while talking about the harmful effects of tobacco. He is clearly much distressed about the increased use of tobacco in its myriad forms, cigarettes, gutkhas, chewing tobacco, pan masala, snuff etc., which is being impudently hawked on our streets. ”On one end of a cigarette is fire and ash and on the other a moron”, is how Sandeep succinctly put it.

Dr. Virdi, made a simple point saying that you can trace almost any lifestyle disease today to tobacco. Be it heart disease, peripheral vascular disease, a stroke and oral and lung cancers, tuberculosis of the chest, all of them are linked to tobacco. This hit home much closer, and I wondered aloud about my father’s illnesses in his almost 60 years as a smoker. He has had tuberculosis twice, a stroke last year and is currently battling with an oral cancer. So much for a puff!!!

Dr. Chaturvedi and Dr. Hooda had a field day, with oral, lung and other cancers having a clear association with tobacco. They too are passionate doctors and see enough and more cancer victims every day, who would be  healthy, if only they had stayed away from tobacco. One can feel their pain and if I may say anger at young people not realizing the grave danger of abusing tobacco, till they reach the office of an oncologist. Dr. Chaturvedi, wondered how is it that once someone is diagnosed with oral cancer, he gives up smoking without missing a beat. My father kicked a 60-year-old habit, the day we told him about his cancer, incidentally diagnosed by Dr. Chaturvedi himself. He wondered that giving up tobacco can not be all that hard.

Dr. Samir Parikh is one of those irrepressible live wires, who have a view on almost everything. Being a psychiatrist and that too one of the most well-known in Delhi, Dr. Parikh counsels and works with lots of people struggling with substance abuse including tobacco abuse. Dr. Parikh and Dr. Buddhiraja talked about how and why one starts with tobacco. Peer pressure, cultural shibboleths including smoking being ”cool”, and myths like ”I can quit anytime”, came up as the most prominent reasons for most people lighting up. Samir and Sandeep, both were emphatic in their pronouncement that tobacco abuse is not merely a habit but a disease. They cited ICD classifications on nicotine abuse and gave medical reasons for nicotine addiction and elaborated on the treatment that can help one kick the disease. They run a tobacco cessation clinic at Max Healthcare and work with smokers, who are keen to quit, but find it hard to get rid of the problem.

My colleague Saurabh Avasthi, who smoked 30 cigarettes a day and then gave up one fine day in October last year also spoke about how he started and how steadily tobacco caught him in its vise like grip and how one day, he just decided that enough was enough. He said that he symbolically buried cigarette sticks and then just never lit up again. The first ten days were hard, when the pull of nicotine, was at its worst and he would count his smoke free days. Over a period of time, he realized that the urge no longer existed and now he says that the stench of tobacco nauseate him.

In the final analysis we concluded that there is no running away from the fact that even one cigarette per day is really one too many. In over 150 people, who attended today’s panel discussion, even if one decides to give up tobacco as a result of today’s session, I would reckon, we would have achieved a lot.

Thank God we have Private Healthcare in India

Last week I came across a piece by Sopan Joshi in Tehelka. The story titled ‘No Place to be Sick’ (http://www.tehelka.com/story_main48.asp?filename=Ne050211coverstory.asp) appears to be a shallow piece intent on maligning private healthcare in India. Mr. Joshi’s central point ‘even if you could afford it, a private hospital may be the last place you would want to be in’ is completely flawed. While Mr. Joshi, cites a case of a cancer patient, who died at Max Hospital in New Delhi, after receiving chemotherapy, quotes the relatives and employers of the deceased, who believe that the hospital knowing well that the patient was unlikely to survive went ahead with chemotherapy and ran a bill of close to Rs. 8Lacs, which coincidentally was close to the insurance limit enjoyed by the patient. Basically Mr. Joshi is saying that Max Hospital unnecessarily treated a dying man because they wanted to make money.The hospital of course has denied the charge.

Now here is my point, who decides whether a patient should be treated or not? Isn’t it the job of his doctor to take this call? Isn’t the patient and his caregivers supposed to trust their doctors and if they do not trust the hospital or the doctor, isn’t it best that they find another doctor or a hospital for their treatment. In my many years in hospitals, I have seen patients and their attendants asking the doctors to do whatever they can to save a life of a loved one, they beg and plead that the doctors do something, anything to prolong a life. Now if the doctors, try something and the outcome turns out to be negative, how correct it is to say that the hospital deliberately over-treated just because it is a commercial enterprise and making money is in its DNA. Suppose in this particular case, had the doctor turned away the patient, wouldn’t that have left him open to the charge of not admitting and treating a seriously ill patient because no hospital wants a high mortality rate. From the hospital’s perspective this really is a catch 22 situation.

It is not my case that private healthcare services in India are perfect. They are not. However, by highlighting stray cases of wrong diagnosis and hospital borne infections, Mr Joshi can hardly make a sweeping conclusion that all private healthcare in India is driven by greed and little else. While, I would be the first to admit that there are many hospitals, who try to fleece patients it certainly does not mean that most private healthcare service providers are out to rob the patients blind. In fact corporate hospital chains like Max, Apollo and Fortis (to name a few) are trying hard to provide world-class healthcare services and while they are expensive by Indian standards, they still are amongst the cheapest in the world.

The problem with private healthcare in India is that it is completely amorphous and unregulated. While there is world class medical services being offered by some hospitals, there are millions of mom and pop shops, usually owned by a doctor and his family, which also provide healthcare services. These so-called nursing homes usually have very basic facilities and since they are completely unregulated, they get away literally with murder. This huge underbelly of private healthcare in India is the soft spot, which the government needs to fix immediately. To make matters worse, the average Indian consumer knows very little about his rights as a patient and is too overawed by the highly educated, English sprouting doctors to ask too many questions and ends up getting a raw deal. What we really need is a much more organised and accountable healthcare services.

Let us now look at what the government has to offer. In the city of Delhi, the government owns many hospitals, which are all large tertiary care centres. These are incredibly filthy, overcrowded (often two patients on a bed), stinking and staffed with callous government employees, who care two hoots about a patient. The doctors, while extremely competent, are under such a huge workload that its is just not humanly possible for them to provide good quality care to so many. My words may seem harsh, but the reality is much worse. Most people seeking care in the government-run hospitals use their ‘contacts’, with the powers that matter, to secure a bed and a surgery for themselves. In smaller towns and cities the situation is much worse, with the district hospitals being poorly equipped, saddled with obsolete equipment and with doctors who consider their responsibilities as punishment postings.

The solution really lies in a Public Private Partnership and increased regulation. We must have a healthcare services regulator (pretty much like the insurance or telecom regulator), who should lay down guidelines and rules for private and public hospitals and ensure that these are stringently followed. Hospitals outcomes, its systems and processes and its people must be periodically audited for quality. The regulator should be empowered to act without fear or favour to weed out the laggards and the unscrupulous.

And now to revert to Mr. Joshi again, let me ask a simple question,  God forbid if he or someone in his family needs a hospital, where will he go-to a private hospital or to a government-run public hospital? To me the answer is quite obvious, we need more Max, Fortis and the like.

 

 

The Dilemma of Single Speciality Hospitals

DoctorA recent cover story in Business World highlights the growing influence of Single Speciality Hospitals (SSH) in India. I read the story carefully. First and foremost, I was delighted to see a cover on healthcare in Business World. It is not often that the business of healthcare gets prominence in a widely circulated and highly respected business weekly. That, BW decided to do this story is a testimony to the growing importance of the private healthcare sector, which is something to cheer about.

SSH’s make good business sense at least in some specialities. The investment required is low compared to a large Multi Speciality Hospital (MSH), funds can be accessed through PE firms and financial institutions, the hospital can be set up quickly and if one ropes in a well known medical luminary of that particular field, it is not too difficult to fill up the beds. Once the operations stabilise, one can consider franchising or expanding by setting up super specialised centres in large multi speciality hospitals. Specialities like Ophthalmology, Dentistry, Obs and Gynaecology (remember the neighbourhood mother and child centre) have always had Single Speciality Hospitals and clinics.  The trend is now towards large SSH for Oncology, Urology and even Day Care Surgeries.   Continue reading

The Power of a Compelling Story in the Marketing of a Hospital

cardiac-surgeryMany years ago, when I worked at Max Healthcare, I met an elderly man whose grand daughter had had a major cardiac surgery and was admitted in the hospital. The child was on her way to recovery and the old man was profoundly grateful to Dr. Anil Bhan, who had operated on the child. The old man narrated a very interesting tale.

The old man and his wife lived in Roorkee, a University town about 150 miles from Delhi. His son worked in a nationalised bank in Delhi and he had two grand children, twins as a matter of fact, a grand daughter and a grand son. The children now aged 11 years lived apart, the son in Delhi with his parents and the daughter with them in Roorkee.  The daughter from the time of her birth had been a sickly child and had required heart surgery, when she was 9 months old. Being a girl child and that too a sick one, her parents had entrusted her care to the old couple and they had brought her up. Clearly, the old man and his wife were extremely attached with this child and she was the apple of their eyes.

The child too enjoyed living with her grand parents and they clearly doted on her. They ensured that she received the best medical care and would regularly bring her over to AIIMS, the premier medical institute in Delhi for regular monitoring and check ups. About two years ago, when the child was 9, they had noticed that she would become breathless after a little exertion. Initially they did not worry too much, however things grew steadily worse and they became quite alarmed and brought her to Delhi.

The paediatric cardiologist at AIIMS, who has been taking care of the child in all these years told them that the child needed another surgery, an extremely rare and very risky procedure and she needed it fast. They were also told that without the surgery the prognosis was very poor. Dr. Anil Bhan, who was the paediatric surgeon who had operated on her as a eight month old infant had now moved to Max as their chief of cardiac surgery.

The old couple brought the child to Dr. Bhan, who examined her carefully and pronounced that while the surgery was extremely rare and very risky he was willing to do his best. The old couple let things in the hands of Dr. Bhan and prayed to the almighty to save their grand daughter. Dr. Bhan operated on the child and she was wheeled into the Paediatric ICU after the surgery. Soon post surgical complications set in and hopes of her survival dimmed. Dr. Bhan, however approached the old couple again and requested permission to try surgery once again. The old couple with nothing to lose, told him to go ahead.

The child was again wheeled into the OR and Dr. Bhan and his team once again made a heroic attempt to save her life. She survived the surgery and spent the next 9 days in the ICU under the watch of some very dedicated doctors. The child was than shifted to a ward and when I met the old man, he was preparing for her discharge from the hospital.

The gratitude this man had for Dr. Bhan and his team, the ICU staff and for the hospital was immense. He showed me a poem he had composed in Dr. Bhan’s honour. He could not help narrate the wonderful things that happened to him in the hospital, about the extraordinary skills of the doctors, their commitment and their indomitable spirit in not giving up on them even in the face of unbelievably daunting odds.

There can be no greater hospital marketing tool than a powerful and a compelling story narrated by the patient or a patient attendant about his experiences in the hospital.

 

PS: Dr. Bhan and his team has since moved to Batra Hospital in New Delhi

 

Pic courtesy http://www.flickr.com

 

A Recent Experience with a TPA

health-insuranceA few days ago a colleague mentioned to me that his wife has developed a painful swelling on the underside of her wrist. Knowing that I have worked in hospitals in Delhi, he wanted me to guide him to the right doctor.

An MRI was duly done and the problem was identified as a cavernous haemangioma. Cavernous hemangiomas are wild, jumbled growths of blood vessels fed by numerous tributary arteries. They are probably all present at birth, but start to enlarge rapidly after delivery.

My colleague fixed an appointment with Dr. Atul Peters a laparoscopic and general surgeon at Max Healthcare in New Delhi. Dr. Peters recommended surgical removal of the growth indicating that the patient will need to stay in the hospital overnight.   Continue reading

Service Recovery and Word of Mouth Hospital Marketing

Goof ups in hospitals are always round the corner.

I dare suggest that quite often they are unavoidable. Do what you may, there will always be someone who will slip once in a while and you will have an irate customer. The headcount in a typical 300 bed tertiary care hospital in India can easily be 800 people or more. In spite of all the care in hiring the right set of people and putting them through rigorous training, they will still end up making mistakes.

Good hospitals, while trying to minimise errors also learn to accept them as inevitable and put in place systems, that help them handle difficult situations well. Great hospitals go one step further, they not only do excellent service recovery, they also ensure that the the patients leave the hospital with a positive frame of mind, in spite of the mishap.   Continue reading