Targets and Doctors: A Fatal Flaw
© Dr. Rajas Deshpande
“What will you become when you grow up?” a common question heard in childhood. Always weary of doing the routine and fond of a little spice in life, I had kept a list of answers to surprise and occasionally shock the questioner uncle / aunt, based upon the spontaneous dislike they generated by other questions and general behaviour and replied something like “It’s a secret” or “It depends upon when in future” etc. There is no better revenge than vagueness for some. In the moment when they paused to react to that vague answer, I would make an innocent face and ask “What was your percentage when you were my age?”. Then the explanations of how things were more difficult and in general marks were lower back then were very entertaining! Curiously, those uncles / aunties did not ask me further questions. Target hit.
© Dr. Rajas Deshpande
For the better and polite class of grown ups, I had the standard answers that my parents would like: Doctor, Scientist etc. The real answers were too “out of the league” for the culture I grew up in then. One thing was sure: the big-eyed respect that the words “I want to be a Doctor” evoked from the listener was sure better than any other response.
Somehow the wish to become a doctor caught hold better, probably because of parental influence. Once I completed MBBS, I loved the actual interaction and started realising the enormous satisfaction potential that the skill generated. The ‘high’ of vast complicated knowledge sharpened daily by experience was superior to the ability of a non-medico to understand or praise it. It was an autonomously growing satisfaction.
Then came the thought that I want to learn more. There are better skilled people, who could treat better than me. Getting admission to MD Medicine was very difficult, there was no question of paying in private colleges as we could barely even afford the govt. medical college fees. A lot of somersaults later, I got admission. There was an explosion of medical knowledge and wisdom suddenly, and there was no choice but to comply. Good and bad patients, good and bad teachers, good and bad friends, good and bad times were all drowned by the prime necessity and survival technique of every genuine doctor: Study!© Dr. Rajas Deshpande
Ego is greedy. Mine too. After MD, there was a desire that I want the highest specialisation: DM. More battles. More scars. All worth the title. With that degree, it felt like I have won the world.
At that time if anyone had said I worked for a financial target, I would have declared a war.
Many more steps in education later, I woke up to the naked reality: however good a specialist you become, you have to either have your own multicrore hospital, or work at someone else’s. Basic medical practice is far different from specialty practice, which requires more time, more investigations, intensive care and complicated treatment strategies / surgical techniques.
When one joins a private hospital, one realises this more intensely: there really are good and bad specialists. Some are very thorough in their academic base but cannot convert that in good patient outcomes or numbers. Some are very sweet and courteous with patients but they lack proper skill, knowledge or experience. The spectrum is wider than one can imagine. Obviously like in every profession, some think of earning more money as their primary aim.
Anyone who owns a hospital must invest many crores of their private money, directly or via bank loans. Sometimes the govt. helps in reducing the cost of land. But in each case, the maintainence cost of any hospital runs usually in lakhs to crores, more with each bed added. Intensive care beds are the costliest investment.© Dr. Rajas Deshpande
When the owners of any hospital invest crores of rupees, they have targets to return their loans., to maintain the expenses that run in crores again: right from 24/7 failproof electricity and water arrangements to the availability of medicines, stents, catheters etc. in the hospital premises. The nursing, reception, helper, technician staff (in most major hospitals, the staff runs in thousands) must be engaged in three shifts, and paid in time commensurate with other establishments/ professions.
The only help that comes from the govt. is initial subsidy in land / water prices. There are no tax relaxations for any hospital/ staff. 20% of all services and beds are reserved for the poor. (If anyone has doubts that the poor-reserved services are not utilised, they can verify with the charity commissioner any day). On top of this all govt. employees must be seen at pathetically low rates, and even that amount is usually pending to be paid for years if not decades.© Dr. Rajas Deshpande
Add to this the profiteering that the medical insurance companies have created: on one hand twisting the arms of private hospitals to provide specialty medicare at bare minimum rates, while on the other hand declining many deserving patients medical coverage due to idiotic reasons.
In this scenario, the last thing that a corporate / private hospital can afford is a non-performing specialist, whose salary runs in lacs of rupees every month (which is what that cadre deserves).
Most corporates / private hospitals are aware of this, and usually support a budding practitioner till his practice picks up. After that, the least he / she is expected to do is to maintain that level of practice or increase it, returning the investment that the hospital has made in his growth. The provision of a furnished room, electricity, washroom, cafeteria, parking, staff and salary to a non-performing or underperforming doctor is not affordable for every hospital.© Dr. Rajas Deshpande
This generated the word “Target”, which was quickly coloured villainous by many. Which financial endeavour can be run without setting financial targets? If anyone is naïve enough to think that all hospital owners will invest their hard earned crores for charity and leave the returns to fate, they must get examined by a qualified practitioner. If the hospital cannot generate enough profit money, there won’t be any growth in medical technology. If they cannot repay loans, the hospital will be confiscated by banks.
Many hospitals of excellent doctors have closed down because they could not sustain the charity they attempted. Indian poverty and healthcare need is beyond the capacity of even the govt. to cope up with, so to expect a private company / doctor / hospital to provide free / concessional high quality continuous medical care to everyone can only be a fool’s dream. This applies to the MRI centers, diagnostic facilities, labs, physiotherapy units etc. where multiple crores are invested.
Some hospitals realised the potential of profit making in this “Target setting” and turned greedy. Mostly good specialists do not stay at such hospitals. Even if most hospitals pinch most doctors to achieve certain numbers, not every specialist works to achieve that target. I know many who would rather keep their ethics and be good clinicians, still staying in the lesser favourite class of management, rather than selling their ethics to shine among the administrators.
The notion that “Every specialist in every big hospital is working to achieve targets by deceiving the patient” is a fatal flaw developing in the mind of our society . Fatal because this also generates fear of going to the right specialist or reaching too late for them to be able to save life.© Dr. Rajas Deshpande
If I cannot afford a Mercedes, I will drive the car I can actually afford, rather than blaming and maligning the entire car industry. Many other cheaper, equally safer options are available for travel.
The problem is, everyone wants the best, highest class of super specialty medical care in luxurious set-ups, at the price list of a sarkari dawakhana. Most doctors who studied in govt. hospitals know that the quality of doctors is very good there too, but if we give that option to the patient, they say “No, not in sarkari” because they want to avoid long lines and “general population treatment”.
As the doctor is the only responsible face that the patient sees in the hospital, many obviously end up thinking that every penny they pay is going to the doctor, at least in percentage. Many will be surprised to know that a doctor usually gets less than 10 % of the total hospital bill as his fees in most cases.
Few will understand that the real “Target” that most doctors work for is to do good to the patient, to save lives. Millions of successful treatment and surgical outcomes from the corporate and other hospitals are a proof of this.
© Dr. Rajas Deshpande
Dedicated to the private hospitals started with the aim of making available specialty medical care for the society and caught up in unfair, unjust allegations because everyone wants free healthcare.
PS: There are greedy doctors and hospitals, like in every other profession. This article is not about them. It is wrong to advise patients unnecessary procedures / tests to achieve financial targets. This article is to explain to the society that target setting is essential for any hospital where recurring investment in new technology and maintenance is also the responsibility of the owner.
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The Sweetest Pinnacle Of Life© Dr. Rajas Deshpande
To many students who are lost in their search for the right aims and goals in life, who trusted me enough to ask that question, I have suggested that they imagine what they actually want in their life at its Pinnacle.
Success, riches, fame, awards and accolades, a legacy, achievements are all good to show and leave behind oneself. The truth is far more than that. Love and care, affection and respect in one’s evening of life is what everyone deserves, but few are fortunate to achieve. For what good is s life that spends its aged years in desolation, isolation, despair of an uncaring, loveless family one has sacrificed much to bring up well?
Hollow words of “show- love” and “pretend care” are commonly employed everywhere, especially among the rich, educated and culture-claiming pundits of humanity.
One experience I have is worth sharing: that the poorest of the poor, like the farmer in the wheelchair here, are cared for with far more genuine love and affection than many. This family collected alms and help to get him to India, and never asked for any concessions, free treatment etc., always saying they were willing to do anything for the happiness and health of this grandpa. His son standing by his side is an illiterate farmer, but is caring for his father . quoting proudly “He brought me up!”. There is no smell of “I am obliging my parent” in his behaviour.
I have met hundreds of Arabic Muslim patients who care for their parents, sons and daughters equally well, willing and with total faith in the treating doctor. It does not change with their financial status. They insist on the parents staying with them, ask questions about their food, exercise, medicines, happiness and comply strictly with the given instructions.
They naturally do not know the words “Culture, Rights, Medicolegal, Elderly care, Nursing Homes, Mercy Killing etc.”. Rarely have I seen them unemotionally “okay” with a bad diagnosis of a parent.
This old man, in my personal opinion, is one of the luckiest human beings upon earth!
© Dr. Rajas Deshpande
Thank you, Mr. Naser Ali, Mr. Abdul Hakim Mohd. Al Malahi, Mr. Majdi Jamil Aiselwi, Mr. Ahmed Anwar Aqlan!
The Real Disability
© Dr. Rajas Deshpande
“I heard your fees is high. So we collected money and came. Actually we are below poverty line” Kallappa said, with a big smile.
His father intervened angrily: “No, no doctor, don’t listen to what he says. We will spend whatever is required. Just please cure my son of his headache. He cannot work at all when he gets it”.
Kallappa’s spectacles were broken, but tied together with a colourful thread. Clothes were clean, but patched. The vest was more holes than cloth, the wrist watch a worn out yellow metal with an elastic band. His footwear was worse than the morals of most politicians, and as unpatched.© Dr. Rajas Deshpande
Feeling offended, I told him “Don’t worry about money. We have a free OPD too. You may not pay, it does not make any difference.”
He insisted on paying, and said “Doctor, I am only below financial poverty line, but we are rich at heart. I don’t want to take advantage of your service”. The big smile on his face persisted.
I wrote his prescription and asked the receptionist to collect a minimal token amount, just so that he is not offended.
In a sea of rich and affording patients who are trying to save money every which way, and claiming concessions, this was a reassurance. And it justly came from a poor man. Most people presume that a doctor must be available at “minimum or no service charge” as an open end social service.© Dr. Rajas Deshpande
I remembered my Canadian boss Dr. GPR.
Travelling together in a stretch Limo which took us back from a presentation venue, we were also accompanied by Dr. Tabitha, my British colleague.
“The concept of richness is wrongly tied to money, Rjaas!” he said with a handsome smile, “the real rich are the cultured ones who know the value of every human being, of art and literature, and earn respect through their wisdom and behaviour. Taking advantage of others in any way is the real poverty, those need help.”© Dr. Rajas Deshpande
Dr. GPR was brutally honest. He considered any manipulation of speech to suit others a ‘mental pollution’. “I am not ashamed or afraid of my mind” he often said, and meant it. Whether it was taboo words or concepts, a discussion about most embarrassing or difficult, he spoke plainly, without colour or guilt.
He was super rich, had three luxury cars, each one of them a dream car for most aspirants of riches. What he had was the best in the world, and what he gave was too. Dr. Tabitha, already too much impressed with him, commented sadly “but people look down upon those who are not rich, Dr. GPR”.
“They are the real challenged, disabled of this world. They do not have any understanding or acumen beyond gold and cash” he replied, “there is nothing wrong in earning money, as much as one can, through service, skill and art. But to earn by twisting someone else’s hand is as criminal as pick-pocketing”.
That stuck in my mind.
In his book “Ideas and Opinions”, Einstein has commented about money, saying “Can one imagine the likes of Jesus Christ and Mahatma Gandhi sitting upon piles of money?”. I had once told this to a friend whose dream was ‘to become very rich’. He shrugged his shoulders and commented “I don’t want to become Mahatma Gandhi. Too tedious”. Then I understood what Dr. GPR had said: there are disabled / challenged people who do not see beyond personal financial gains.© Dr. Rajas Deshpande
My childhood fluctuated between lower and upper middle-class, and my bicycle was bought via an installment plan (a tradition I continued in my later life). I considered myself lucky that I had a bicycle to go to my Sanskrit tuition everyday 11 Kms away. It built up a wonderful stamina that helped me in various curious ways, including the hard work required of a doctor. I remember laughing while searching through the drawers at my home cupboards with my mom, to find enough money to pay the newspaper and other trivial bills. Nothing stopped for the want of more money, satisfaction and happiness were not married away to money.
I wrote a note to my boss for a concession for this patient, and he agreed graciously. Of course the next time Kallappa visited, he brought a big gunny bag full of home-grown veggies as a gift for me and my boss too. So different from the many rich patients whom we had given heavy concessions, but who still went disgruntled and never even thanked in words! “Thankless Rich” is a universal medical patient category I feel. Calculated gifts are also sometimes received, and there of course are rare honourable exceptions who value the doctor’s service with rich rewards.© Dr. Rajas Deshpande
Be it Picasso or Van Gogh, Einstein or Newton, Wodehouse or Amrita Pritam and so many Nobel laureates, they had one thing in common: an inherent sense that only money is not an achievement, nay, money is not at all an achievement.
There are many in India who are legally “Below Poverty Line” because of their financial status. But the number of people “Below the Cultural, Ethical and Moral poverty line” is ever increasing, especially among the rich. There are immensely rich hearted poor still able to truely laugh and love, and extremely poor rich roaming around worried and sad in their luxury cars all around us!
I am struggling to stay above both these lines, like many others whose parents gave them the best possible training in the world: not to tie one’s happiness and pleasures with finances. I will continue to teach my children the same.
We once went for a trip to Goa during our MBBS. One of the “lewdish” guys with us decided to make fun of an old roadside dhaba owner. It was dinnertime.
“Do you get everything in this dhaba?” he asked.
Smiling, the dhaba owner uncle said “Yes. What do you want?”
Touching his nose with his middle finger, this student asked again in a twisted tone “Everything?”.
With the same smiling face, the dhaba owner replied: “Yes, beta, I can get you anything you want. There are only two things your money cannot buy: a mother or respect from others. Now what else do you want? Tell me”.
© Dr. Rajas Deshpande