Monday 23 March 2015

Do we need a Honor System in the Worlds Largest English Speaking Democracy ?

The Education System is Shaped by the Ones Educated in it !
From the Heart of Sagar Galwankar, MD

The whole western world went berserk when they viewed pictures of the mass cheating at a high school in a state of India.

It does not matter which state of India did the school belong to. The fact is the School was from India.

We are at a very vibrant stage in India wherein our National Leadership is advocating India and Indians to be the largest supplier of English speaking, technology savvy, knowledge rich and high skilled human resource in the world. Complimentarily the government is pitching the case to the world to come and Make in India.

At moments like these where our Nation is making such an honest case to the world, instances like these have left a big question mark across the western world.

It is very easy to use the famous Indian terms “It’s OK, It’s one school”…Well let me tell you it’s not OK, it’s not one school, it’s A School in India.

Being an ardent Indian working in the United States I was sad when one of my colleagues from USA came and showed me this news. I was shocked and embarrassed and I said nothing except, “Don’t Judge the Nation and its Citizens by what you hear and what you are shown. I understand that this happened but that does not reflect on the nation”

Why should we bring ourselves to a stage where we have to defend ourselves?

The whole education system in India needs a Second Look and a thoughtful solution.

The whole Education Systems revolves around three important  points

1.   Marks

2.   Caste

3.   Financial Capabilities

We should be reminded that a country is made by those who are aware and educated and not by those who are ignorant. The world is now connecting in seconds and India has reached Mars.

Our Education system is facing the biggest challenge it has ever faced. Competition has been limited to only 10 % of the whole education system because commercial education dominates the rest of 90%.

Students of today believe that if they pay they deserve to get the Degree. They believe education can be bought. There are only a few who believe that real talent will always win and there are those who give up all hope when they fall on the border and get eliminated by the Caste Line of Scores where a student with lower grades can make it to top institution but a student with high grade can’t get in because his quota is filled up.

 This gives rise to what I called “Fractured Progress”. We sow the seeds of dissent in the system which is created to cure dissent.

We speak about BRAIN DRAIN but we forget that the very reason for brain drain is the loss of faith in the future.

If the affording believe that they can buy any degree at any cost and the struggling believe that marks are the only way they can be educated then be it any caste there will always be a race to win and win at any cost and that cost could amount to cheating and academic dishonesty too.

What happened at one school is a small indicator of what can happen.

The world has many achievers who are Indian. Let us not stigmatize them.

The government has to fortify its vigilance and regulatory framework in Education by partnering and learning from Successful Education Systems across the world.

It’s not that difficult.

I will give the Example of Allopathic Medicine in India:

1.   Make Common Entrance Test applicable to getting admission in any medical school which comes under the Medical Council of India be it Private or be it Government Funded

2.   Offer Student Loans to students to fund their own education

3.   Keep Points for the resource limited students but don’t divide merit on caste

4.   Let One Apex Agency be responsible for Accreditation of the Medical Institutions of Under Graduate, Post Graduate and Sub Specialty Education

5.   Let another independent agency be responsible to conduct nationwide examinations of every field, discipline with complete freedom.

6.   Create a National Medical License Tracking system

7.   Empower a regulatory authority to accredit the healthcare facilities to provide quality healthcare.

8.   Penalize those who default at any level

9.   Encourage Physicians to become teachers by offering training initiatives and incentives and set up benchmarks for career advancement.

10. Integrate the vibrant corporate healthcare system into the academic medicine system by cross sectorial collaboration

These are 10 Points which by itself will reform Health Education and HealthCare in India.

With current existing scenario where Caste, Marks and Finance dominate the future of smart citizens,  it is reforms like these which will change the face of India.

There should be no student who should feel helpless because he could not avail the education he desired, there should be no student who should be compelled to compromise in order to win at any costs, there should be no student who believes that money can buy the degree they demand, there should be no student who should be left behind.

I believe in Bharat where Universities like Benares Hindu University and Nalanda University made history, I believe in my country which has institutes like All India Institute of Medical Sciences, I believe in my country where the largest skill population of the world lives, I believe in my country which placed me where I am today !

 I believe in my country which has the potential to bounce back when challenged.

Let’s bring the honor code into education, let’s create an environment to implement the honor code, let us value that an Educated Nation is an Empowered Nation, An Educated Nation is an Economically Progressive Nation.

 I have a dream and I dream to make it true !



Wednesday 11 March 2015

The story of Merging HealthCare, Insurance Industry and Quality in Emerging Economies: When…… it’s OK ….IS NOT OK!

From the Desk of Sagar Galwankar, MD
I often look at Economies in Transition, where healthcare is considered an emerging market and wonder whether the speed at which consumer demand grows for materials ever aligns with the demand for more healthcare.

When we say …we need something…that means we don’t have the thing and we need it…..or we have something but we want it more or we want better.

When we put healthcare into the same perspective …….an increased demand or what the capitalist calls “Emerging Market” means the market is so ill that it is extremely thirsty for health care solutions.

To the world an Emerging HealthCare Market definitely gives a different picture when you say Health of the Nation is Wealth of the Nation.

 When speaking of nations some nations have universal healthcare while some emerging nations have a two forked system of health care…one funded by the government and one funded by private money.

The Government Funded is considered or utilized maximum by the “Less Affording/ resource limited patients” as well as mandated government employees and the Private Funded is utilized by insured and self-paying patients.

I don’t deny that there is a miniscule overlap and cross over.

Now we come to a scenario where there is rising economy and employers are mandated to insure their employees as well as people realizing that they need insurance …thanks to advertising, sensitization, and mass realization, we now have a rising number of insured citizens.

Based on the few facts namely:  1. Rising Population 2. Rising number of insured 3. Increase burden of illness and 4. Growing economy .....the phenomenon “Emerging HealthCare Market” is born.

This phenomenon leads to a radical tsunami of investor enthusiasm and promotor confidence.  Everyone dreams of becoming a Billionaire, this is again based on the fundamental that there are many affording ill people to support the industry of patient care.

These investors who have names like Venture Capitalist, Equity Players, Private Funders etc. now start pouring money into healthcare.

How do they pour this money into healthcare?

They do this via four mechanisms:

1.    Support Big Players in the HealthCare like big chain of hospitals to diversify and create day care centers, lab networks etc. and grow further

2.    Support Small hospitals to become big by opening more branches

3.    Buy stocks in health sector in the stock exchange

4.    Buy shares and invest via funds who again invest directly or indirectly into health care markets, hospitals etc.

When Investors put their money they want their money back.

They want margins and profits.

Hospitals start looking like hotels and healthcare equates to hospitality.

The difference is that ….in Hotels clients come with happiness and to hospitals patients come with pain.

It’s a different set of situations but for investors it is the same when it comes to ….money in and money out.

So now the Invested HealthCare system has to generate revenue instantly to prove growth and reinforce investor confidence.

What do the promotors do: Hire Marketing Teams, Get Advertising to the door of every primary care doctor, reach out to every potential patient, Offer different products like Health Check Ups, Create inquisitiveness to hunt out some disease so that some cure can be offered at their hospital. Skin, Anxiety, Breast Exam etc.  Run Banners and hoardings showing a patient holding his chest with a tag line # “Chest Pain….it could be a heart attack…call ……”

E-Marketing….That’s another gateway to publicize.

Marketing more than Medicine is a reality.

Advertising Firms, Door to Door Agents…you name it and the strategies exist. Facebook, Twitter, Social Media, Events …..There is no end.

Revenue is the Key …..Patient Flow which Pays is the answer.

Health of the patients becomes the business of the promotors.

The maximum importance is giving to marketing and advertising in order to increase paying patient flow….this is the truth about new as well as established hospitals and healthcare facilities.

The administrator/ CEO/ Managing Director is rarely a Physician, this is because Supply Chain, Maintenance, Instrumentations, Security, Food and Beverage, Billing, Human Resource, Finances, Strategies are major areas in a heavily invested healthcare system.

The Physician and the patient on whose shoulder the system is fundamentally existing suddenly becoming a miniscule part of the whole picture.

It’s definitely an Oxymoron from my perspective.

Now comes the aspect of QUALITY: Where does this aspect exist in this whole story of GROWTH

Imagine…..You have borrowed Millions, Set up a big hospital which looks like a Hotel, spent tons on marketing and advertising …..What is left for Human Resource and Quality ?

Instruments, Equipment, Approvals, Staff all cost money. Administrators, Advertisers, Managers, Marketers all cost money. So does Maintaining Quality….but is there enough left after so much consumed by the earlier?

Quality HealthCare in the real sense means practice of Evidence Based Medicine.

Example: When a Patient of Chest Pain Comes: The Emergency Physician rules out all causes of Chest Pain from Myocardial Infarction to Pulmonary Embolism to an Aortic Dissection and many more.

In nations where Troponin Test is the most expensive test and is priced 100 times the Retail Price, it’s impossible to practice Quality Care. Where EKG continues to be used to triage chest pain then Quality is always a Question. Where CT Scan is a medium to extrapolate profit, quality is always a challenge.

In Emerging Markets Insurance Companies mandate that a 24 Hour Admission is required at the least to claim for healthcare benefits from the policy. Well that results in increase rates of admission.

When a simple fever costs thousands then insurance cost goes up. The hospital wants to recover the cost it has invested in the system so it bills thousands.

 Just Talking about Quality is of no use when there is demonstration of lack of practice of Evidence Based Medicine.

In any HealthCare system the Emergency Department Care reflects the overall quality of care given by a HealthCare System.

Until every physician in the Emergency Department is duly qualified by a Single Accredited National Agency governing a Uniform Set Training Model, it’s impossible to establish quality care.

Till the time every physician practices the same evidence based guidelines and does not use his own guidelines based on the science of “In My Experience” things will always be the same.

The perception that Insurance Companies will continue to insure people and people will continue to feel that they have access to health care......will break very soon.

Insurers will crack down on healthcare facilities, charges/payments will be questioned, quality will be accessed and care decisions will be challenged. They too like others have to make money...they also have investors to answer to !

Insurers will question: Admission Criteria to High Billing Critical Units, Criteria for keeping patient longer in hospital, payments for hospital acquired infections, payments for patients who come back to the hospital within few days, justification for multiple consultations, number of outpatient visits, number of investigations….it’s just a matter of time.

It took a decade in the developed world for this Insurance Industry crack down, it will happen faster in Emerging Markets.

Where the mantra is “If you have a fever and the malaria parasite test is negative still don’t do blood cultures but treat for malaria, typhoid and admit in ICU for observation” “It’s OK to do that…”

It will soon be “Not OK”

Investors are banking on paying patients who will either pay from their pocket or insurance will pay for them.

In the times to come it will be the Insurer who will decide the fate of investors.

Quality will become the leading question very soon.

“It’s OK ……..will soon be ……it’s not OK!”

Tuesday 3 March 2015

“Patient Satisfaction”- A Biomarker for Quality HealthCare !

From the Desk of Sagar Galwankar, MD

 As the world continues to invest in HealthCare and as Administrators are born to rise continuously, “Patient Satisfaction” has emerged as a Crucial Biomarker in the Diagnosis & Prognosis of Quality of HealthCare.

#PS as I call it … is indeed the Indicator which is now being used with greater intensity to grade the quality of healthcare delivery.

Across the so called “Developed” World which is “Enveloped” in its own existence #PS continues to exist and grow with scores, patterns and algorithms being built to access the end point i.e. Quality Health Care.

What is the #PS, How does it affect us, what are the things that matter the most, how do you get the maximum score, what does that relate to, how do scores translate …….

In simple terms #PS means when a patient is asked how did you like the care provided to you ….he/she should say Great/Good/Satisfactory/Not Good/Bad.

Now this end point is broken into several questions with scoring sheets, numerical grades and with complex calculations and that emerges a score which is compared to averages across the industry.

#PS can refer to a whole system Example: “Care in the ED” or “Care by an Individual physician/ Nurse”.

Administrative Leaders stress a lot on #PS. This is because of the influence of the materials and service industry where it’s the rule “customer is always right”.

I am intrigued “Is the Customer-The patient – Always Right”

Well that’s an answer which by itself can institutionalize the debate generated around it.

The world of Litigation, Regulation, Accreditation, and Consumer Rights revolves around Customer Dissatisfaction and Enforcement of Patient Rights –which by the way I support totally.

But again ………How is #PS is a crucial biomarker?

I recently read somewhere about comparison of patient attitudes in USA and South America featured around an ED visit where two patient attitudes were compared: One in USA who is upset because his ED visit took 2 hours from entry to medication filling and discharge versus a patient in South America who walked miles to get seen after waiting for hours outside a busy ED and was happy with simple pain meds and thanked the physician and walked back home.

When I review all the writing and think simply I feel it is all about relationships. In Emergency Departments there is very little time to build a relationship and establish confidence.

No matter what we do , If corporate culture has entered healthcare, if investors are reaping returns in healthcare, if there are administrators who are accountable and if patient is considered a customer and physician/nurse a service provider like Fast Food Chain or Cell Industry ……. Then #PS will not only live, but thrive, survive, advance and expand.

The Developed World is full focused on #PS but this phenomenal has yet to oblige the economies in transition.

Countries where HealthCare is considered an Emerging Market like India #PS is sparingly used and restricted to patient complaints and compliance to satisfy these unsatisfied/ dissatisfied customers.

The Investor Industry which drives accountability from administrators will soon introduce and foster the #PS Phenomenon and institutionalize it in India in a BIG WAY.

It will not be long before Administrators who are already singing the Phrases of Quality and Safety will start speaking and proctoring #PS and making their operating systems, health care, executives and physicians accountable.

It is just a matter of time!

I will say few points which affect me and my care:

1.    Patient is First, his/her welfare is first

2.    Addressing the primary concern is my focus – Pain, Fever, Bleeding , Rash are things will I address stat

3.    Humble Approach, apologize if patient had a long wait, be considerate about the complaints, privacy while examining and regular discussion with patient, relatives through the stay of patient are crucial skills

4.    Keeping patient comfortable and pleased is the key

5.    Good manners and giving full attention to the anxiety of the patient is important.

Don’t answer Phone calls when patient is with you. Apologize that phone rang and switch the call off. If you get called for a serious patient, ask patients permission and then apologize and leave and affirm that you will be back as soon as the task is over etc etc.

There are times when you perceive that patient’s complaints are exaggerated. Even if the complaint seems Exaggerated – that by itself is a symptom which has to be addressed by you.  

Pain Control is a big player in #PS. Many times in Developed World patients are prescribed strong pain control medications which can get the patient into habitual use.

Use, Overuse and Abuse are very closely related. In all these processes the healthcare provider is involved as the patient evolves.

Controlling Pain is crucial like all of many complaints.

No matter you made a correct diagnosis, no matter you gave the best treatment, if you did not satisfy the patient, then #PS suffers so do you and your future!

As the payments, performance and progress gets tied to #PS , physicians have to revisit their past training. Bedside Manners were taught to us in Medical School… #PS now continuously grades those skills.

Knowledge is Key but Strategic Techniques to customer service are crucial.

Do we need Coaching Classes for that…….better than remediation after faulting! Prevention is better than cure…….we all agree to that!

We should not forget that we the physicians call our HealthCare Lifestyle as “My Practice”. It means in true sense you as a Physician continuously Practice your way to Perfection and Progress. This is a continuous process.

The New “P” is Patient Satisfaction which if good will improve your practice, perfect you and will definitely progress you.

“It’s the little things that matter the most”!