Nursing-The Big Differentiator

If someone was to ask me what truly differentiates one hospital from the other, I would unhesitatingly answer that it really has to be the quality of nursing. Yet most hospital managers pay scant time and attention to what is perhaps one of the most critical functions in the hospital. In India, nursing is perhaps one of the most under rated professions and in a hospital senior managers, who are busy driving patient volumes and revenue and focusing on delivering cutting edge medicine often forget that it is Nursing, which truly is the back bone of  hospital operations.

The last few months for me have been nothing less than traumatic. My father lost his battle with cancer and he continued to be in and out of hospitals virtually all of November and pretty much most of December. While, he gradually deteriorated and my worries and frustrations of doing battle with as implacable a foe as cancer, mounted I could clearly see the wonderful role nursing played in delivering round the clock care to him. My admiration for the profession has since multiplied many folds and it also led me to reflect on how we need to acknowledge and appreciate the role Nursing plays in the life of a patient and indeed that of the hospital.

If a hospital is about ”care”, truly speaking it is the Nursing, which is the face of the hospital. While a patient who is admitted in the hospital sees his doctor, usually twice in the day, (when the doctor is on his rounds), he sees nurses all through the day. While, the doctors have the largest role to play in achieving a cure, it is the nurses who deliver care and comfort in a hospital. Their role gets magnified many times, when the doctors know that they do not have a cure or sometimes when hope is in short supply, it is the brisk efficiency and the caring hand of a nurse, which makes a big difference. As my father grew progressively weaker and his condition deteriorated, we became more and more dependent on the nurses. We needed them to give him medicines, control his infusions, give him feeds, rub his back, sponge him, draw samples for tests, help him turn in the bed, decipher his almost incoherent speech and comfort him. Often, they bore the brunt of his ire – many a times he was petulant like an ill-mannered child, difficult to reason and get along with, yet those nurses never flinched, they never once walked out of the room in anger or said anything, which might be hurtful.

I watched all this and more play out in front of my eyes every day for several weeks over the last few months. The more I saw, the more ashamed I felt of how senior hospital managers like me treat nurses in the hospital. The doctors usually take them for granted, order them around, some pull them up for even small infarction, hospital managers just do not have time for them, they are just there, pretty much like hospital furniture.

Is this because the nurses that we have come from a socio-economic milieu, which is very different from our own? Is it because most nurses in our hospitals can not converse in fluent English, which is the undisputed currency of social mobility in our country? Is it because many of these nurses are not as well-educated as the doctors, hospital managers and probably most patients whom they care for slick private hospitals?

Whatever, be the reason we need to introspect about the critical role of nursing in our hospitals. I would surely like to believe that a hospital can easily have a long-lasting and sustainable competitive advantage over its competitors if it gets its nursing right. A bunch of efficient, dedicated and caring nurses are a far more precious asset than fancy equipment, smart doctors and smartly turned out-patient services executives.

Come to think of it, isn’t it strange that a hospital charges a fee for the doctors, there are charges for the use of the OT, the consumables and the medicines and even the hospital bed. Yet, no hospital that I know of charges a patient for nursing care!!!

PS: My father spent his last days at the Max Hospital in Saket in New Delhi

Pic courtesy http://acceleratednursingprograms101.com/wp-content/uploads/2011/07/Accelerated-Nursing-Programs-08.jpg

Experiences at Indraprastha Apollo Hospitals – I

Indraprastha Apollo Hospitals in New Delhi is our neighbour. Thus, one morning earlier this month, when my brother-in-law called urgently that my father was unwell, extremely lethargic, drowsy and a little disoriented, we decided to call an ambulance from Apollo and rushed him to the hospital.

In the Emergency room, we got prompt attention and we quickly determined that my father had low BP and his leucocytes counts were high indicating an infection. He was admitted in the hospital under Dr. Prasad Rao, who is a specialist in internal medicine. Dr. Rao turned out to be an articulate and soft-spoken man, who explained to me the plan of treatment (basically antibiotics) and said that he was hopeful of getting my father back home in the next 2-3 days. As expected my father made a swift recovery over the next couple of days and Dr. Rao discharged him from the hospital, the entire experience being on the whole quite satisfactory. Now this is what happened at the time of finalising the discharge.

As I went through the detailed itemised billing sheet, I noticed that we had been charged two nights of hospital stay, which was correct. However, under another head something called ‘Other Services’ we have been charged for a laryngoscopy, (which was actually done) and strangely another day’s bed charges. Since Laryngoscopy is a OPD procedure, I was baffled to see the additional bed charged buried under ‘Other Services’ and thought that it must have been a mistake. Enquiries with the billing clerk however revealed another story.

Indraprastha Apollo Hospitals I was informed now has a check-out time of 9 AM, which means that anybody being discharged after 9 AM in the morning has to pay the room rent for that day as well. Strangely everyone knows that in a hospital most discharges are planned after the admitting physicians take their morning rounds, which usually begin around 10 AM in the morning. Thus, it is just not possible for a patient to be discharged from the hospital before 9AM, and hence virtually everyone has to pay the additional charges. The Billing Manager, informed me that at least 130 out of the 150 discharges that happen everyday at the hospital, lead to irate patient attendants venting their anger on him. Clearly, this is a dodgy practice as the hospital knowing fully well that discharges can not be finalised before 9 AM, charges patients for an extra day.

In most hospitals the check-out time is 11-12 noon and the hospital management usually does not charge for a delay of an extra couple of hours as they clear the discharge formalities. The intent clearly is not to bill the patient and all efforts are made to finalize the discharges before the appointed hour. At Apollo, this is clearly not the case as the 9 AM check out rule is designed to bill the patient for an extra day, even when they know that their doctors will not be able to finalize the discharge summaries before 9 AM.

Complaint Redress Mechanism

When I asked the Billing Manager, about the process for lodging a complaint, I was told that I should speak with the GM for Resources Utilization, who refused to meet me saying that if I had a problem, I could write an email to him. When I insisted that I wish to lodge a formal complaint, I was directed to speak with Dr. Priyank, who turned out to be someone who worked in the office of the Managing Director of the hospital. Dr. Priyank too was far too busy to meet me and when I questioned him on this particular practice, he explained that this was all for the benefit of the patients, as it enhanced hospital efficiency!!!

As the word got around about my complaint, I received a message that Rajeev Bahl, GM Resource Utilization has now agreed to meet me. When I sought clarifications on this, he said that this was a new practice and that the hospital felt that this will encourage their doctors to finalize discharges faster. Basically, what he was saying was that since the hospital management is chary of asking its doctors to begin discharging their patients earlier, it would like the patients to put pressure on their doctors to do so. Strange to say the least.

Peculiarly, while the hospital authorities insisted that charging for the additional day was the right practice, they agreed to not charge the same to me now that I had protested. Thus, it seems if you protest and protest hard, the hospital moves quickly to placate you by waiving off the additional charges.

Indraprastha Apollo Hospital is a JCI accredited hospital and yet it seems that there is no formal complaints mechanism. In spite of my best efforts to lodge a formal, written complaint, there appeared no process for the same. Since no complaints gets lodged, the hospital would appear to be running faultless operations and the JCI accreditation can continue unabated.

Thus, in spite of having a reasonably satisfactory medical experience the hospital goofed up at the last leg. It spoilt my overall hospital experience and I came away wondering about the greed of the hospital (150 discharges per day at an average bed charges of Rs. 7500 makes a very tidy sum indeed), its ethics and its philosophy of ‘caring with a human touch’.

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.

Ramrati and some Questions

I learnt about Ramrati from the pages of the Hindustan Times a few days ago. Apparently, the newspaper found her living in a urinal outside of the All India Institute of Medical Sciences (AIIMS), India’s most renowned medical facility located in the heart of the capital. Ramrati had a defective mitral valve and was seeking treatment for her medical condition.

Ramrati hails from a village in the Hamirpur district of UP. She is a mother of 5 and is 50. Needless to say that Ramrati, her husband Bhawani Din and their family lives in abject poverty and can hardly afford cardiac surgery, even at government-run hospitals, which are supposed to treat the poor free, but very often do not. Ramrati traveled to Jhansi for her treatment, from where she was asked to go to the Post Graduate Institute (PGI) of Medical Sciences in Lucknow the provincial capital. From there, she was sent to the AIIMS in Delhi, where she had been languishing in a men’s urinal for close to two and a half month hoping to have her surgery at India’s most premium medical institute.

Bhawani Din mortgaged all of his land to raise Rs. 100000 to fund his wife’s surgery. It would probably have been possible for Ramrati to undergo surgery at AIIMS, but then the hospital is over crowded and Ramrati has to wait her turn and since she has no place to live in Delhi, she found an unused men’s urinal, outside AIIMS and shared it with some other patients in a similar predicament.

Thanks to the story in the Hindustan Times, Ramrati found help. A local NGO found her room to board in a dharamshala and an eminent cardiac surgeon Dr. A. Sampath Kumar, formerly the Head of CTVS Surgery and now at a private hospital, Pushpanjali Crosslay Hospital in East Delhi agreed to operate on Ramrati free of cost.

The newspaper duly wrote about Ramrati’s good fortune also highlighting its own role in bringing succor to her. Pushpanjali Crosslay Hospital too did not miss the opportunity of grabbing headlines by positioning itself as a hospital with a heart. Dr. A. Sampath Kumar, who was part of the team of surgeons who had operated on the Prime Minister a few years ago got an opportunity to present himself as one of the ‘finest’ cardiac surgeon in the country.  Pushpanjali Crosslay Hospital, released pictures of a tired looking Ramrati being taken to the hospital for treatment and undergoing treatment at the hospital. AIIMS agreed to refund the Rs. 100000 deposit it had accepted from Bhawani Din.

Well, all this does sound like a fairy tale but it does raise disturbing questions. Why does Ramrati need to run from pillar to post to seek medical attention? Why does she need to travel to Delhi, via Jhansi and Lucknow, when the medical attention she needs can be provided to her in Lucknow? Why does Bhawani Din need to mortgage his land to raise money for his wife’s treatment? Why does Ramrati need to languish for two and half months in a men’s urinal outside India’s best hospital to get treated? What happens if she dies waiting for her turn? Who is accountable for all this? How many Ramrati’s are waiting outside AIIMS and other such facilities desperately seeking medical attention and why no one does anything about it? At the end of the day, who is accountable for Ramrati’s fate?

Now let us look at Dr. Sampath Kumar’s intervention. I would like to believe that he is a genuinely altruistic man and by responding to Ramrati’s predicament, he is only honouring the Hippocratic oath. But look at the way Pushpanjali Crosslay Hospital has gone about talking to the press about the free treatment that Ramrati has been offered by them. There are Ramrati’s photographs with the hospital ambulance serving as a nice backdrop and every mention of Dr. Kumar is followed by a statement that he is now with Pushpanjali Crosslay Hospital. It seems that the hospital wants the media spotlight firmly on itself, somehow the entire things looks way too opportunistic.

While the likes of Anna Hazare and the so-called members of the civil society prepare to commence a Gandhiji like fast, hoping to bring the government down to its knees, who is looking out for the Ramratis of the world. Why don’t we have the civil society empathizing with the poorest of our land and the callousness of our system, which does not care for them? Isn’t the right to reasonably good healthcare a fundamental right derived from the right to life? Isn’t  this something to agitate for? How can we have a shining India and a Ramrati’s India existing together and for how long?

And finally,  today as we have our netas shamelessly mouthing platitudes to our freedom from the British, we need to look inwards and ask ourselves if Ramrati is free today. Unless we get an answer in the affirmative, India will continue to struggle for real freedom.

PS: I believe Ramrati has since been successfully operated upon and is on the road to recovery

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

Why some of our doctors have such poor bedside manners?

I have often wondered, why some of our doctors have such poor bedside manners and never more so since my father’s surgery.

My father underwent an urgent Prostate Surgery earlier this week. The surgery was conducted at one of the most well-known and if I may add, sought after hospitals in South Delhi. The hospital and the surgeon are familiar to me from many years and yet this is what happened one evening.

The surgery in the morning had been uneventful and the surgeon was happy with my father’s progress. In the evening as my wife and I sat in his room in the hospital, two gentlemen barged in and started examining my father. They lowered his pyjamas for the examination, chatted with each other, assured him that all was well and walked off. As they were leaving I asked them who they were and one of them introduced himself as an associate of my father’s surgeon and left.

Now here is my problem.

I have no idea who these people were. They wore no surgeon’s gowns, they had no telltale stethoscope around their necks. They marched into our room without a knock and proceeded to examine a patient, without his permission. They removed his pyjamas for an examination, with two people sitting in the room and the door wide open. I was shocked to witness this humiliation and I could feel my father’s acute discomfort.

To the doctors, strangely nothing appeared to be amiss! When I stepped out to have a word with these gentlemen and pointed out their completely unacceptable behaviour, they appeared surprised that a patient’s attendant has the gall to question them and arrogantly dismissed me saying that if I had any complaints I needed to address those to my surgeon! They did not deem it fit to utter a word of apology for their appalling conduct.

All this at as I said earlier  at one of  Delhi’s finest and most expensive hospital.

Why do some doctor’s treat their patients as if they do not exist or matter? I believe this is primarily because we patients allow them to. In India, a career in medicine enjoys tremendous social prestige and doctors are treated with enormous amount of respect. We bestow on our doctors God like powers of life and death and since in our eyes they are Gods, we refuse to see their shortcomings and failings. Gods afterall can treat us, the mere mortals, as they please.

To make matters worse, most of our doctors receive their training in government hospitals, where the poor and the uneducated see these doctors in their shiny white coats and stethoscopes as people from another world. In these hospitals overflowing with people from ‘darkness’ (to borrow a word from Arvind Adiga’s ‘The White Tiger’) they are treated as the lords and the masters of all whom they survey. These doctors  from an early stage in their training imbibe these behavioural patterns and one assumes that in later life, in different hospitals and while treating educated folks, the old habits refuse to die.

Lastly I also believe, that parental and peer pressure force many a youngster to choose medicine as a career, while they just do not have the calling. The admission procedures are also flawed as they test knowledge but not aptitude. Thus we have doctors, who have no business being doctors. They are trapped in a glorified profession from which there truly is no escape. Can we really blame them for (mis)treating patients the way they do?

How do we cope with such arrogant and errant doctors? Well, I see no reason why we cannot simply ask them to treat us better. Their ego may stand in the way of apologising or showing contrition, but I am sure they will think twice about being discourteous the next time around.

And that should be a good enough start.

PS:Lest this sounds like a diatribe against doctors I hasten to add that I also know many very competent doctors who treat patients with great courtesy and professionalism. They are warm individuals, love their work, have great compassion for the sick and look upon their profession as nothing less than a calling. They not only treat but heal and that is where the real difference lies.

PicCourtesy: http://thyroid.about.com/b/2008/08/19/six-rules-doctors-need-to-know-and-six-ways-to-be-a-better-patient.htm

My experiences at the Indraprastha Apollo Hospitals

Apollo HospitalThe other day I landed at the Indraprastha Apollo Hospitals, a stone’s throw away from my residence in New Delhi.  My wife needed a test and our doctor at Max Healthcare asked us to get it done at Apollo as the equipment at Max was out of order. The moment I walked in I felt as if I was on a railway platform.  The hospital was full of patients as everybody appeared to be in a mad rush. In the OPD area, the ladies at the reception were busy, chatting amongst themselves, while patients and their caregivers waited for their attention. They wore no uniforms and for some strange reason, they were also collecting cash from the patients (apparently for the doctor’s consulting charges) and handing out receipts scribbled on small chits, which did not even have the hospital’s name on it.

Strangely, I was than directed to a cash counter to pay for the tests.   Continue reading