Why some of our doctors have such poor bedside manners?

I have often thought about, 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 profession, 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

So much for my ‘Indian Hospital Experience’

While trawling the net I came across a blog (http://www.travelblog.org/Asia/India/National-Capital-Territory/Delhi/blog-440604.html) about the travails of an American, getting treated for a mole/wart/skin cancer in New Delhi. The experience narrated in this post is exactly the kind of stuff we do not want. I am amazed at some of the narration and the stereotyping this does of the Indian doctors and medical system.

The blog has a semi mad sardarji (sikh) as a doctor who speaks and understands no English, laughs at his own jokes in Hindi and does not understand the difference between a mole and a pimple. The doctor has never heard of the United States and knows America, a country whose citizens are rich and ripe for fleecing. The doctor prescribes lotions and creams for treating the mole, which are not available at his own pharmacy and the patient (the author) walks out, having parted with Rs. 500 and nothing to show for it. Astoundingly, this gentleman returns to the clinic of the mad sardarji, encounters a ‘wildeyed’ patient on a wheelchair, and asks the doctor to burn off the offending mole in the emergency room next door.

Can you really believe this? A dermatologist who knows no English, does not know what the US is, prescribes lotions for treating moles and does strange surgery in his ER. All this in Delhi. To me this sounds stranger than fiction.

One can not study medicine in India unless one knows English as the language of instruction in medical schools across the country is English. I refuse to believe that there exists a dermatologist, who can’t differentiate between a pimple and a mole and if I ever encountered, will I let him treat me not once but twice! Come to think of it, will I let someone operate on me if their was a serious language barrier, when I am not sure if the doctor/surgeon understands the problem. If I agree to all this, than it is me who is playing with fire and taking completely unacceptable risks.

I am willing to grant that the author might have been lured to a quack’s place by someone. However, his complete gullibility and his willingness to try out this kind of treatment, which one would instinctively recoil from appears to be a product of his imagination. This as I said earlier only reinforces Indian stereotypes of a land of great mystery, faith healing, strange medical practices and half crazy doctors.

I am sure this makes for great reading back home.

However, what it also does is that it mocks at the great advances India has made in medicine. It paints a very distorted picture of Indian healthcare. India has some of the most modern hospitals and qualified medical personnel, which attract thousands of foreign patients every year. While, there is no denying that there are quacks and the like who exist, not going to a qualified dermatologist for the removal of a mole and continuing with the treatment of a doctor/quack who does not understand ones language will be considered foolhardy anywhere in the world.

Let us have none of this kind of crap.

Pic courtesy http://www.flickr.com/photos/robotalphabet/2693142482/

An OPD Experience

The other day my wife had an appointment with her doctor at one of the well known hospitals in town. We were to see her at 8PM, but what with under construction Metro line collapsing and the resultant traffic snarls bringing the city to a halt, we were running late. Hoping against hope of catching the doctor, we reached the hospital 20 mins late.

Luckily for us, as we arrived the doctor was finishing with her last patient of the day and agreed to see my wife immediately. She indicated that some tests were needed and while she went about doing those, I might run along and pay the bills as the billing counter would be closing. She scribbled the tests on a medical form and off I went to do the needful.

Sure enough the billing counter was deserted and the billing clerk appeared to be in a hurry to rush off. As I put in my request a surly lady (let me call her N) told me to wait. I waited patiently, and again enquired about settling the bills. My wife had by then joined me as well as the doctor had finished with her. Nothing happened. Finally, I requested an audience with the duty manager, who arrived promptly. When I explained the situation to him he asked N to open her system and do the billing and for good measure added she can ‘easily do it for one patient at least’.

N finally accepted my papers and opened her billing system. After fiddling around with the system for a while, she summoned another colleague ‘D’ for help. Apparently, N was not able to find the tests on her billing list. Apparently, she did not know where to look. Her colleague D who was supposed to be more competent on the system too, could not find the tests. As I waited patiently N in true style of a government owned medical institution ordered me to move away from the counter and wait elsewhere till she sorted out the problem. (Do not forget that I am the only guy on the counter and am not holding up anything).

This is where I lost it and told her to shut up and seek help in organising my bill. The duty manager again materialised and after murmuring some instructions in N’s ears hurried away. N than started calling up some folks to figur out where and how to bill. Another guy sauntered up and tried finding a solution, he too seemed completely at sea. He disappeared just as quickly.

Finally after waiting for close to half an hour to get a service billed, I was handed over an invoice. And than it was discovered that while the procedure has been billed, a canula used during the procedure has not been billed and the entire pantomime of finding it in the system and billing the same was repeated.

“We are really having a serious problem with our front office executives. They are all new as the trained ones have all moved on to greener pastures and other hospitals. Even the duty managers, who would earlier get involved and sort out these problems deftly are new” admitted a friend of mine who works in the hospital. He also added that training people in understanding medical terminology and gaining proficiency on the Hospital Information System (HIS) takes time and by the time a new set of people are reasonably proficient, they move on. ( mostly to call centres, which pay a lot higher).

While I can understand the hospital’s problems, a bad patient experience is something most hospitals can ill afford. N and D and the duty manager had a problem understanding the medical terminology, they also lacked the empathy and a caring attitude that is a must for folks who work in hospitals. In this day and age, you can not be rude with patients. Moreover, as I pondered over this I realise that a small error in billing can have some very serious consequences. For, instance whatever tests are billed, will be run by the lab. If these are not what the consultant ordered…you can imagine the problems.

Considering all this, I would like to believe that investing in employee retention is far better than having a crop of new recruits manning customer touchpoints in the hospital. Cutting people costs in a hospital can really prove a lot more expensive than what a hospital might have bargained for.

Hospitals are all about people's skills

I have rarely come across an industry, which requires a range of skills, which are wider than what one sees in the people, who work in hospitals. A hospital actually is an amazing aggregation of skills and talent, which one would hardly see in any other human enterprise.

Among the medical folks, there are doctors who are hugely knowledgeable, highly educated and supremely skilled in the art and science of medicine, there are nurses and paramedics, who symbolise compassion and care and there are support folks who provide critical support for running the medical function in the hospital.

Amongst the managerial teams, there are managers who handle the front office and interact with patients and their attendants. They are the face of the hospital, well trained, well groomed very presentable folks, who help put patients at their attendants at ease. They usually have very good communication skills, are people with immense patience and a sunny optimistic disposition.

A hospital also needs a lot of technical support and thus you find high tech bio medical engineers, who ensure that all the equipment in the hospital works flawlessly. Imagine what can happen if an equipment in the OR or in the ICU malfunctions at a critical moment. Much like doctors, their role requires quick thinking, complete mastery of technical matters and planning for any eventuality. Most bio medical engineers are rarely seen and heard in the hospital but behind the scenes they control the levers of the hospital.

These days a modern hospital runs on state of the art software, which connects every hospital function. A doctor can not write his notes or ask for medicines till the orders have been punched in the Hospital Information System (HIS). The nurses can not dispense medicines unless requisitioned through the HIS. A patient can not be admitted or treated unless the relevant files and records have been created in the HIS. While most hospitals do have a back-up manual system, it is rarely used largely because an IT team employed by the hospital ensures that the HIS is rarely down. These people are often quintessential techies, with very sound knowledge of hospital systems and processes.

At a 180 degrees of separation from these folks are people who look after functions such as Food & Beverages, Housekeeping and Security. They are all trained individuals as much an expert in their areas as any techie. They interact with patients and their attendants and hence also have superb skills in handling patient grievances.

While all of those mentioned above contribute towards keeping the hospital humming, another set of people are those who manage the business side of things and have a completely different set of skills. These include the sales and marketing folks, who represent the hospital to an external environment, purchase managers and store keepers, who ensure that the hospital is well stocked with all the essential supplies and the finance guys, who keep an eye on how the money is being spent. People in all these functions have unique strengths. The finance guys are very good with numbers, the sales people drive innovation and have good communication skills and the purchase folks have tremendous negotiation skills and an uncanny smell for a deal.

A good hospital will always have good Human Resources and training personnel. They are the ones who ensure harmonious working relationships amongst a very varied and highly skilled workforce. They make the rules, which govern the conduct of individuals in the hospital, play a critial role in rewards and recognition systems, act as agony aunts and handle conflicts. To my mind the most important skill they bring to the table is an ability to get on with people, understand differing point of views and manage aspirations of a very diverse bunch of people.

If I was to select two critical skills, which an individual who aspires to work in a hospital must possess it has to be compassion and communication skills. Anyone, who works in a hospital must have loads of compassion towards fellow human beings, an innate ability to see things from the patients perspective and take decisions with empathy and with an utmost regard for the plight of the patients. The ability to communicate well with language or through a meaningful silence or by just a touch, would be a close second. Be it a doctor, a front office manager or a sales person the ability to communicate the right thing at the right time to the right person is an immensely valuable gift.

On the Back of a Star

The star syndrome is a common phenomenon, which dazzles many a newly minted hospital.

I have been part of several start-up hospitals and have attended numerous meetings where all those who matter spout the now so familiar arguements about staying away from the 'stars' in the medical firmament. The arguements run something like this.

The star doctor (a well established doctor with a roaring practice) will be too set in his practices, will bring too much baggage and will never follow our pristine processes, which are far superior to his current practices. He will be a bad influence on everybody else. Another arguement goes that we do not believe in the 'star' system. Why should a 'star' enjoy priviliges, which are not available to our other doctors. A third arguement goes that we believe in growing our own stars. The hospital brand should be the real star and not individual doctors.

One can not really pick a flaw in any of these arguements. Star doctors are known to be egoistic, believe that making patients wait only adds to their stature, often indulge in practices, which are against the laid down hospital policy, break rules with impunity and in general do what they please. The management treats them with undue deference often causing resentment amongst peers. All this because they know they pull in a large number of patients and contribute significantly to the hospital revenue.

Once a new hospital commences operations without stars and the overheads mount relentlessly, while the revenue stream is at best a trickle, the need of a 'star' is felt acutely. The desire to ramp up fast and keep the promoters and other stakeholders off ones back takes precedence over all those arguements cited earlier.

The Star becomes the saviour. The CEO and all other 'chiefs' go 'star' chasing. The star is difficult to catch and quite often one can only sight it in the middle of the night. Meetings happen at his convenience usually anytime between midnight and 3 in the morning. Once on board he is treated like royalty. The star joins with a retinue comprising of his personal staff (numerous secretries, personal assiatants etc.), other doctors ranging from senior consultants to residents and the like. The star is presented to potential patients as as a great trophy. The hospital starts shining in the star's reflected glory. The patients start coming in and life becomes wonderful.

The bliss lasts for a few years. The star is able to fill up many beds. The trouble begins when one realises that under the star's dazzle nothing else grows. He eclipses the hospital brand, does not allow others to take roots, keeps the hospital management genuflecting to his whims and fancies and often bullies patients leading to bad word of mouth. The aura of the star starts diminishing.

Soon the hospital realises that probably they were better off without the star. The old arguements are resurrected. The star starts becoming a mere mortal. The hospital realises that getting rid of the star might not be a bad idea. However, it is easier said than done. Rememeber within the hospital's system the star has many a planets revolving around him.

Eventually the star is either eclipsed or simple allowed to wither away. The management team now believes that they can pull in patients on the strength of the hospital's brand name and soon the star finds itself being wooed by another new hospital, which has come up in these years and is desperately looking for a star to shore up its fortunes.

I wish this was a fable. Folks at all the leading hospitals in Delhi, which include Max Healthcare, Fortis, Apollo Hospitals and Artemis will bear this out. Some are at the stage where their 'stars' are falling, others are desperately looking for the stars to light up their lives.

The great game goes on...

The image is from http://www.flickr.com/

The Marketing of a Doctor

Do doctors need Marketing ?

I have worked for more than 8 years in healthcare services Marketing and am yet to meet a doctor who says that he does not need Marketing support. The funny thing is that all of them believe that the Marketing team always does more for the next guy and all of them collectively believe that the Marketing team does very little work in the hospital!

Dr. Bharat Inder Singh a well known family physician in South Delhi and former colleague at Max Healthcare, once told me that the only marketing he knows is putting a board outside his clinic and start treating patients well. Things have moved on since. Things really have moved on since.

I have learnt that while the hospital needs to quickly establish itself as a centre of excellence, the individual doctors are the most important element in the Marketing of a hospital. In the early phase of a hospital it is mostly the doctors who will draw new patients largely from the pool of patients they have treated earlier. While this may last as a steady stream for a few months, this stream of patients will never be adequate to sustain a new hospital. Thus doctors need to get involved in the Marketing of themselves. The Marketing team's task is to create opportunities of engagement of these doctors with potential patients, referring doctors and increasingly HR managers in large corporates. In this post I will examine the role of the doctors and the medical teams in connecting with the referring physicians.

The success of this effort is largely based on how well this collaboration between a doctor and the Marketing team works.

A doctor, who has joined a new hospital needs to understand that it will take some time for the patients to start trickling in. I have known many a doctor who are extremely chary of going in the 'field' with the sales team. This is somehow considered to be infra-dig. They would much rather be in the hospital and wait for the patients to materialise. Some would rely on expensive advertising rather than 'soiling their hands' with the sales folks, asking for patient referrals.

Rarely has this approach succeeded in generating patient traffic.

Most successful doctors know that their is no shortcut to success. Customers today have choices and those who go out to engage with customers, the local populace and the referring doctors stand a much greater chance of building a thriving practice. They also know one simple truth...there is no shame in asking people to visit them if they need help or taking out a prominent local doctor for dinner to get to know him better and build a relationship, which will culminate in patient referrals.

Continuing Medcal Education (CME) programs generally a euphemism for an evening do, involving local physicians (or those of a particular speciality) are common. These provide a platform for a set of doctors usually from a hospital to engage with local outside doctors. In my experience these are necessary in the initial phases to introduce a set of hospital doctors to referring doctors. It is rare that on these occasions a relationship can be forged, which will culminate in patients for the hospital. The next stage of engagement is generally with a smaller group of doctors (10-12) over cocktails and dinner. Finally the sales team will get the hospital doctors to meet referring physicians one on one. It is of utmost importance that a relationship is established between the doctors themselves. Patient referrals follow automatically.

Once patient referrals start, the hospital doctors must keep the referring doctor in the loop. A thank you letter, a phone call informing of the patient's progress can go a long way in cementing the budding relationship. The sales team's role here is to ensure that nothing slips between the cracks and they usually facilitate the communication between the hospital doctors and the referring physicians.

Medical conferences, paper presentations, academic newsletters also help in establishing the hospital doctor's credibility. It is important that the referring doctors be fully aware of the capabilities of the doctors they are refrring their patients to. The conferences also serve as a networking platform for all the doctors.

While all these help get patients for the first time, a doctor will start referring patients on a continuous basis only once he develops confidence in the doctor he is referring patients to. This can only happen when the medical outcomes are good, the patient has a great experience in the hospital and the communication channels between the referring and the referred doctors are working well. I have known of a hospital, where an orthopaedic surgeon and a laparoscopic GI surgeon will happily get patients from the referring doctors, while the cardiologists and the cardiac surgeons will endlessly struggle. The reasons for this were not far to seek. The medical outcomes in cardiology and cardiac surgery were not as good as those in other areas, the doctors hardly ever communicated and the reasons for poor outcomes were always swept under the carpet. I am afraid the situation in this hospital is unlikely to improve unless the core problem is acknowledged and fixed.

At the end of the day the sales team is just as good as the weakest link in the medical delivery team.

6 Ways To Get the Best Out of Your Doctor

Doctors too are humans. Very often, when confronted with a medical crisis we tend to forget this simple fact. In my many years of experience of working closely with doctors in large corporate hospitals, I have learnt that by observing the following few simple rules one can extract the best out of ones doctors.

1. Honesty is the Best Policy

It is imperative that you be brutally honest with your doctor. Hiding things such as a bad drinking habit or a past history of parental abuse will only make things difficult for your doctor. Remember a doctor is trained to understand and he will not pass judgement on your lifestyle or your past. It may also help if you were to make a small checklist of things that you plan to share with your doctor.

2. Trust Your Doctor

It is of immense importance that you trust your doctor completely. Do not hesitate to ask questions but never give the impression to your doctor that you do not trust his judgement. Medicine is endlessly complicated. No two individuals react to a disease or a medicine in the same manner. Your doctor has the knowledge and the experience to the do the best he can do for you. And if you have genuine reasons for not trusting your doctor, do not continue under his care for a day longer. Have a honest chat with him, explain to him your reasons for discomfort and inform him that you will be unable to continue under his care. Many of us hesitate to engage our doctor in a discussion like this fearing that our doctor will take it otherwise and will be offended. Most doctors will understand and even help you find another specialist who will probably be able to help you better.

3. Knowledge is Power

Try and learn as much as you can about your ailment. Information is easily available over the internet or ask for Patient Information Literature from your care managers at the hospital. It is a myth to believe that doctors are uncomfortable with knowledgable patients. The truth is that most doctors encourage their patients to learn more about the disease and the treatment options. This helps your doctors to engage with you much better.

4. Be Vigilant...Always

Illnesses seldom happen all of a sudden. While on a hospital bed one often looks back at the small tell tale signs that one ignored before the onset of an illness. That momentary loss of sensation in a limb, that small black out that one ascribed to fatigue, that heaviness in the chest, which one tried to cure by popping an antacid all return to haunt us as serious illnesses. The surest way of getting the best out of your doctor is to visit him or at least call him when you feel anything, which may be out of the ordinary.

5. Follow Instructions

When you have decided to continue under the care of your doctor follow her instructions carefully. If you have any doubts, ask her as many times as you need to. Do not discontinue medication the day you start feeling better. Quite often we tend to ignore certain advise, which involves lifestyle changes such as regular exercise or a daily constitutional. Remember there is no advise, which is less or more important. If there are some instructions that you genuinely can not follow, inform your doctor. She in all likelihood will offer you an alternative that you will find more suitable.

6. Be a Patient Patient

During bouts of ill health, patience is difficult to muster. We all want to regain good health as soon as posssible. We must understand that our doctor is not a magician. Medicines which work instantaneously are yet to be discovered. The simple truth is that healing takes time. Lifestyle changes if required take even longer to take effect. The best way to recover from a bout of illness is to first accept your situation, understand what your doctor is trying to achieve and wait patiently for the time to come for you to resume normal life.