VIP's with their peccadilloes are always tricky to handle and in a hospital the problem magnifies manifolds. If the VIP happens to be a politician, than he believes that he owns the hospital and everyone must be at his beck and call. This includes hospital staff, which is supposed to take care of the VIP at the exclusion of everybody else.

Ironically what escapes these VIP's is that in many ways a hospital is a great leveller. You might be the mightiest of the  mighty, an illness treats you exactly the same as anybody else. It does not differentiate amongst its victims. When a doctor examines a VIP he does it the same as (I would presume) anyone else. The medicines work the same way, the course of the disease is not impacted by the office that the VIP holds. Thus logically a spell in the hospital must be a lesson in humility to the mighty ones. Alas, this happens but rarely.  

Many years ago, while I was working at Max Hospital, we had a minister hospitalised with us. The minister needed an angioplasty, which was duly performed by Dr. Ashok Seth, the resident high priest of Cardiology. The minister was soon on his way to recovery. However, all through his stay the hospital had to endure scores of people, his so called well wishers, breaking every conceivable hospital rule. While the minister recuperated, he and his cronies had virtually a free run of the hospital, largely at the expense of other patients. To make matters worse, the minister, decided not to pay and asked that the hospital collect its dues from a PSU, which came under the ministry he was heading then. It took the hospital more than a year to recover its money.

Another former chief minister who suffers from a delicate problem, has a fetish of never undressing in front of a female person. Thus for him the hospital has to ensure an all male staff, including the nurses, orderlies, doctors et al. 

Business tycoons too have their peccadilloes. One family insisted on occupying a suite, which is fair enough. However, when they were informed that no suite was available, they still insisted on being accommodated in a suite. They ran circles around the hospital administrators, pressurising everyone to organise a suite, fully realising that this can only be done by asking someone else to vacate their suite. The hapless hospital managed to offer them two adjoining rooms, which they grudgingly took but never stopped cribbing about it.

I have never understood, what is it with people vested with power or money (or both), which makes them think only of their creature comforts, even in a hospital. What makes them believe that because of their position in society, they automatically have a right to jump a queue and that too in a hospital, where suffering and emergent need must always be the rightful criteria for getting ahead in the queue.

As far as hospitals are concerned, they quite often are a willing accomplice in this charade. They go out of their way to keep the power that be happy. While I can understand a policy of least confrontation and bending backwards to accommodate a VIP, to do so at the expense or discomfort a more deserving individual is just plain wrong. 

The Family Physician Revisited

This is the era of specialisation, nay super specialisation and more. In healthcare services, the immediate casualty of this madness has been the family physician. And what a loss it has been.

During my childhood and teenage, which happened in the eighties, we always had Dr. Bajpai as our family physician. Dr. Bajpai had a clinic in the MG Road area in Indore, where we lived. He also ran a clinic from his residence and we were regular visitors at both these places. His residence was closer to ours and we would visit him there more often. I still recall his magnificent dog 'Sultan', who would invariably greet us with his loud barks. Dr. Bajpai was a kindly soul, who would usually prescribe simple oral medicines and we would be back in school in a day or two. I do not recall being asked to submit to the needle too often or visit a radiologist for X-Rays. The only time we were sure of needles, was when we would be taken to him for cuts and bleeds. He would get his ancient compounder to give us a tetanus shot. After this trauma, our mother would buy us a Limca from a neighbouring store (Ratan Sweets if I recall correctly)  

Family Physicians of yore were very often family. They were always invited to a family wedding, were welcome home and really in a broad sense were family friends. I vividly recall my father taking a box of sweets to Dr. Bajpai, when my sister started medical school and Dr. Bajpai stopped charging her his fee as is the custom amongst doctors. 

We never ever saw a hospital in all those years in Indore. We grew up with our share of illnesses, which Dr. Bajpai had no problems in fixing. To us he was the final solution to all our medical problems. 

Now, when I see parents with young children in hospitals seeking specialised care for their family, I wonder where have all the old fashioned family physicians disappeared. I understand young graduates passing out from medical colleges hardly want to get into family medicine. The lure of a large hospital, big bucks and the the possibility of trying their hands on the latest gizmos drives most of them away from Family Medicine. Over the years 'Family Medicine' has slipped down the totem pole and many family physicians hate to be called family physicians!

This is sad but true. The gradual loss of the Family Physician is inducing more and more people to self medicate. Many people (including, I must confess, me) prefer to tryout self medication before going to a specialist. This I know can be very dangerous. Why would I do this? I believe I do not need a specialist for minor ailments, I would hate to undergo a battery of tests that a specialist would inevitably prescribe and for many folks going to a specialist is too expensive an option.

I would also like to believe that a Family Physician represents the most benign face of medicine. Big doctors in big hospitals around bigger machines are scary. A gentle family physician, with his stethoscope conjures up a friendlier image.

Family Physicians have traditionally been the repository of the entire medical history of the family. They knew when the little one had a upset stomach last, and when a bug had the elder one down with measles and when the naughtiest one broke his arm. All this and more allow for great continuity of care.

Here is my salute to Dr. Bajpai, and all those family physcians, who have kept the tradition of the friendly neighbourhood doctor alive. I would love to see their breed thrive and grow from strength to strenght. 

They have my best wishes.

Better

I recently read 'Better' by Dr. Atul Gawande. This is his second book after 'Complications', which I had read many years ago. Dr. Gawande is a staff member at the Brigham and Women's Hospital and Dana Farber Cancer Institute. He is also an Associate Professor of Surgery at the Harvard Medical School, Associate Professor in the Department of Health Policy and Management at the Harvard School of Public Health, and Associate Director for the BWH Center for Surgery and Public Health. Dr. Gawande is also a staffer at the NewYorker Magazine.

'Better' is a rare and a wonderful book and I thorughly enjoyed it. 'Better' brings forth a great understanding of issues facing the medical fraternity today, the constant quest to do better, to improve the delivery of medicine and care as we know it today. I discovered the importance of hand washing and how this simple act on the part of caregivers in a hospital can avoid infection and save lives. I mean I do know that handwashing is important but had never given a second thought, while I marched into a patient's room in any of the hospitals I worked in.

I was amazed to learn how the medical corps embedded with the American troops in Iraq, would save lives of soldiers seriously injured in terrible warfare. It is mindboggling to imagine soldiers being surgically treated in makeshift hospitals, stabilised and than being sent halfway around the world to Germany for the surgery to be completed and than if needed being sent to the US for more surgery and recuperation. Mortality Rates for those injured in battle have fallen significantly. We are doing better.

Another chapter focuses on the dilemmas of doctors, whose job is to supervise state sanctioned executions. Those condemned to death, must die with dignity and with the least amount of pain. Ironically, it is only doctors, trained in saving lives, who can ensure that a condemned man dies without suffering. Dr. Gawande brings out the issues facing the medical community and doctors with rare sensitivity.

The heroic fight against Cystic Fibrosis, a genetic disease, which limits the cells' ability to regulate the chlorides in the body, is captured in another poignant chapter. The painstaking effort, the diligence and the resolve to have better outcomes shines through Dr. Gawande's prose. Similar tales of WHO's unending battle against diseases such as Polio, takes the readers to rural India, where the logistics of reaching out to millions of illiterate and prejudiced people and convincing them about having their infants vaccinated against Polio comes across as a huge challange. Yet, their is tremendous hope as we know Polio has been on the verge of eradication for many years now.

Dr. Gawande writes with rare luminosity. His accounts are riveting. He documents failures and triumphs of his profession and his own journey as a surgeon, with candour and great understanding.

A must read for everyone and particularly those who have a stake in healthcare.

For a Hospital 'Doing Good' is Great

'The business of Healthcare allows you to do good, and maybe also make money', Analjit Singh, Chairman of Max Healthcare, once said this in my presence and since then I have never stopped wondering about how 'doing good' is just as much a part of healthcare business as is making money.

If one was to stop and ponder for a minute, one would realise that healthcare business allows one to do good from the day one starts a hospital, while the making of money takes time, sweat, blood and tears. 'Doing Good' to my mind is the soul of this business and anyone, who does not have this objective at the back of his mind may as well never get into this business. For as Mr. Singh would say 'there are dozens of easier ways of making money, if that alone is the objective'.  

Before, I proceed further, let me hasten to add that I believe that the twin objectives of 'doing good' and profits are both equally important. Profit in my lexicon is not a dirty word at all. No business would remain a business if it was to steer clear from profits. However, to rush towards achieving the profits goal at the exclusion of everything else is foolhardy.

While working in hospitals one comes face to face with desperate people needing urgent medical care, which is beyond their means, accident victims arriving in the Emergency unable to pay for their treatment, children from disadvantaged sections of the society requiring complex surgery. For a 'for profit' hospital the dilemma is acute. They have a responsibility towards the share holders, which means free treatment can not be offered (certainly not beyond a point). However, being part of the community turning away people, for want of money is difficult for most doctors. Often ways and means are found to accommodate patients. Doctors, waive off their professional fee, ask medical devices manufacturers to donate expensive devices, hospitals waive off room rent and charge only for medicines consumed. I consider myself extremely fortunate to have been part of hospitals, where we would do all of this and more to ensure that as far as as possible we did not turn away someone truly deserving of help and support at a difficult time.

I know of many doctors who run programs, (supported by the hospitals they work in), which allows them to treat the poor. Dr, Anil Bhan a well known cardiac surgeon works with destitute children from the hills in Uttarakhand. His program is truly remarkable as he has found an anonymous benefactor, who pays for medicines and consumables, while Dr. Bhan does not charge any professional fee for the surgeries and the hospital waives off the OR fee and the room rents. Dr. Harsha Hegde an Orthopaedic Surgeon, works with an NGO in Gurgaon, which takes care of street children. I am sure there would be many more conscientious doctors doing the best they can to help individuals seeking their help. 

Apart from these unorganised efforts, which are but a drop in the ocean, I wish there was an organised program to help the not so well off access quality healthcare. A simple solution that guards the stakeholders interests as well as allows the hospitals to do good is to set up an NGO, partly capitalised by the hospital, partly through corporate and individual donations and partly maybe by government agencies. This NGO can then refer deserving cases to tertiary care hospitals, which can provide medical care and charge the NGO a much reduced sum equal to the cost of consumables and medicines for its services. 

Like I mentioned earlier 'doing good' to the society must be an irrevocable contract that a hospital must have with the community it works in. Unlike other industries say a cola manufacturer or a car company, hospitals have a completely different set of responsibilities towards the society at large. 

And finally, 'Doing Good' makes great business sense as well. A hospital known for its large heart and generous spirit will always attract patients.

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.  

F&B and Billing are two areas in a hospital, where service failures are most common. The food would not arrive on time, would either be too cold or too hot, or too spicy or just unpalatable. Similarly the bill will take ages to get ready, it will have items billed, which in the patient's estimation were never used, there will be charges for doctor's visits, who never showed up or just came and said hello, while the hospital levied a big charge. All this and more are common in the hospitals. Too many such episodes, with a patient will lead to a bad experience and even if the medical outcome is fine the patient will (in all likelihood) have bad things to say about the hospital.

It is essential that the hospital actively seek patients' views on its services. While, a feedback form is usually available at the time of the discharge, it is of no use in service recovery.(The patient is afterall ready to leave the hospital).

Max Healthcare, thus employed a novel system called 'The Mentor Program' to collect patient feedback through designated executives called 'Mentors', while the patients were admitted in the hospital. The mentors meet the patients and their attendants on a daily basis and listen to their grievances and experiences in the hospital. They than pass on the feedback to the concerned departments (say F&B), which than takes care that the error was not repeated. The mentors check with the patients again the next day if all was fine and usually have a happy patient at hand.

I myself experienced the Mentor system at work, when my mother underwent a bypass surgery last year. She had complications and we spent a harrowing 3 weeks in the hospital. However, the mentor made our life easier by taking care of the smallest need that we had (even allowing us to break hospital rules at times). We got an impression that the hospital was willing to listen to us, really cared about us and was a partner in a difficult period in our lives. 

And look here I am talking about the our experience in the hospital rather than the infection, which my mother contracted after surgery leading to complications. I understand this can happen in any hospital across the world, the infection rate at Max compares favourably with other hospitals and we were just plain unlucky.

This is the power of a good experience and word of mouth marketing. A good customer experience and a positive word of mouth is never a product of an accident. It is only through a great understanding of consumer behaviour in a hospital, detailed planning and diligent effort, that magic happens.