Why the smallest candle burns brighter on a moonless night

Preface

Comprehending the darkness, the candle and the paradox

Comprehending Medicine: is it an art or a science?

Are doctors & hospitals different or just extensions of each other? Comprehending why it is getting dark in healthcare

The changing nature of healthcare: from the faith to trust to the contract model

Evaluating the three healthcare delivery systems: For-profit, Public & Charitable What does it take to be a candle in healthcare of present times?

Reiterating the raison d’etre for healthcare & doctors

Getting decision making right in healthcare settings

Congruent planning

Decentralization: walk the talk

Identifying strengths and weaknesses in the existing systems

Feeding on weaknesses of the system & creating powerful solutions

Creating additional USPs for your own organization through Disruptive innovation

Twice as strong systems Sustaining the light:

Nurturing the first candle

More candles

Rome wasn’t built in a day Defining Value based Leadership in Healthcare

Preface Comprehending the darkness, the candle and the paradox The thought of darkness brings with itself, perceptions of fear, vulnerability and ulterior motives. This darkness is actually a metaphor for all that is not right, not ethical, not transparent & maleficent. At the crux of this darkness is a power relationship where one individual can gain intentionally at another’s loss because the gainer has or can create a position that could enable him to exploit the other individual because he is in a dependent relationship with the gainer. Although such situations are increasingly being observed in various facets of our life, hardly few are as grave as the manifestation of this power relationship in healthcare. As we try to understand the relationship between the healthcare provider and the patient, it becomes obvious that the latter are in a seriously dependent relationship with the former, because the state of ill health is the most vulnerable position in an individual’s life. Healthcare providers form some most erudite groups of professionals we have amongst us. In view of the fact that their intervention could make a difference of life or death, they are accorded the very rare status of being ‘life saviors’ that is nearly incomparable to any other group of professionals. Now, this life savior status can be perceived in two diametrically opposite ways: on one hand it may be accepted with the greatest humility as a chance to do extraordinary humanitarian work. On the other hand however, it could be turned into the greatest power one individual could wield upon the other. This choice of perception of this status is the key to the potential for darkness in healthcare. Note that this very choice is also the key to the potential for light. The candle is thus a metaphor for this light that would dispel the darkness, like the virtue of ethical and beneficent actions of even a handful of professionals, who would choose to accept this life savior status, as not just a chance to do extraordinary humanitarian work, but also the responsibility to safeguard their patients’ interests at a time when they need it the most. The paradox is that as darkness continues to deepen; even the faintest light of even a small candle shines brightly, sharply cutting through the pitch darkness around it. In the field of healthcare, where at stake is life itself; at the darkest point of this power relationship, even the smallest ray of hope from those few healthcare professionals standing up to their ideals will shine brightly as a beacon reinstating the faith that there is a righteous way to practice medicine, only if we choose to follow it. This essay not only seeks to identify the factors and changes in social environments that influenced the darkness plaguing healthcare delivery systems today, but also projects why and how it is possible to do well by doing good* with an in-depth analysis of how healthcare providers who have chosen the right way, actually work. Comprehending Medicine: is it an art or a science? Despite the effort to study or control health scientifically by healthcare professionals, is it possible to define it completely in scientific terms? Probably not, because the ones studying it, are humans too! Additionally, medicine intimately involves dealing with emotions associated with ill health, which widely differ from one individual to another. This essentially involves an important element of the art of dealing with people. Medicine as such, becomes both an art and a science.

This gives rise to a complex situation, where we are not only dealing with something that is significantly difficult and finitely explained by science, but also the fact that it is understood only by an exclusive group of professionals, who themselves can’t claim to know it perfectly. It is thus an imperfect science in the hands of imperfect people, so it’s worth remembering that at any point of time, nothing is black and white, rather in shades of gray… Are doctors and hospitals different or just extensions of each other? Both doctors and hospitals offer similarly complex and highly skilled healthcare services. They invariably depend on patients to remain in business, yet both essentially have the upper hand in dictating terms since the patient is just as uninformed in either case. They are ideally bound by the same ethical codes but the outcome practically depends on how ethical they actually decide to remain. The only difference is in the scale. Simply put, hospitals can magnify either the benefit they offer or the damage that they can cause to patients. So a hospital is nothing but a giant doctor!

Comprehending why it is getting dark in healthcare The changing nature of healthcare: a transition from the faith to trust to the contract model What existed before the present day scientific system took roots, was an entirely informal faith based model that rested on the pillars of unquestioned divine beliefs and the alleviation of suffering largely by supernatural powers. Just a few chants, drops of elixir from the God’s foods, or even a healing hand were all that were needed to ‘cure’ suffering. In many cases we can’t explain today, this actually worked! As civilizations developed, rational questioning and scientific temper began to take center stage. A unique breed of learned individuals who took pains to scientifically research and understand the working of the human body and diseases came to be recognized as the earliest physicians. One thing that distinguished them from the present day physicians was the fact that they placed their knowledge and not themselves at the highest pedestal, and strove to protect its honor. Consequently, despite whatever modest knowledge they had in treating patients, they were trusted unconditionally by families for generations, and this was the essence of the trust based model of doctoring. With the advent of the Industrial Revolution, the World wars and the rise of capitalism & free market economies; value systems across religions & regions began to change. Medicine too, wasn’t insulated from these changes for it was essentially operating in those very circumstances. Given the fact that doctors were essentially groups of professionals who would need to heavily invest in their education in terms of time, skill and/or money, the returns on this investment not only started becoming very important, but also getting quantified in terms of wealth and success. The spirit of service to the suffering was replaced by a quid pro quo basis, where doctors were transforming into businessmen, out to sell their wares for a good price.

Interestingly, this transition wasn’t one sided. Patients knew the worth of their money too which is how bedside medicine transformed into evidence based medicine and doctors were brought on the anvil to provide explanations whenever treatments did not work. In this process, it wasn’t always easy to get rich even if doctors were trying to sell outright, so by-routes had to be devised, which is precisely where the power relationship came in handy. A new breed commercial and unethical physicians and hospitals emerged that worked on the Machiavellian principle that “ends can justify the means” sending tremors down to the very foundations of Hippocrates’s medicine. This was the real onset of darkness in healthcare that continues to date, and threatens to worsen with every passing day. The irony now is also that although the poor are usually worst hit, hardly anybody can escape this racket irrespective of their financial power or otherwise, because they are still subordinated by the exclusivity of knowledge that these skilled professionals possess. Whereas the poor are commonly victims of unethical acts of omission, the rich can be additionally exploited by unethical acts of commission because of the money that can be extracted from them. It thus becomes imperative to examine the existing healthcare scenario to understand the crisis faced by patients who are at the receiving end of this transition. Evaluating the three healthcare delivery systems: For-profit, Public & Charitable With the evolution of healthcare delivery systems, broadly three types of systems are in place today, based on their purpose and costing patterns namely:

1. For profit (corporate and private healthcare) 2. Public (government hospitals) 3. Not for profit (charitable hospitals)

We examine the proposed aims and reality in each case. The for-profit are per se the most blatantly commercial of the lot, as they wear their intentions on their sleeves. Theoretically, the concept of free for-profit market economy claims this enhances quality and value for money simply because of competition and consequent cost-cutting. However, there is one important distinction that it does not make as obviously- as to what levels hospitals could stoop to, in order to ensure this profitability. Also, competition occurs in healthcare too, but in the for-profit hospitals, it does not necessarily result in quality or value for money as is expected and rather ends up escalating costs as a result of marketing, adding tones of unrelated secondary services under the guise of quality. Hospitals end up with investing more for gaining more which is why even if they manage to provide very high quality services, they are priced exponentially. What is more important is that these very hospitals can maximally exploit the power relationship because eventually, it is easier and quicker to make more money this way, than to wait for cost effective innovations or intelligent management policies that can cut costs. The public hospitals that are operated using tax-payers money are a part of the state’s

obligation to provide healthcare to ALL, at highly subsidized prices or even free of cost wherever possible. There are different types of issues here. Firstly, not all funds allocated towards the hospital’s functioning, actually reach the hospital thanks to the long chain of hands it travels in a typical bureaucracy due to it getting siphoned out in varying extents at every stage. Given the limited funds it must work with, there is often lesser scope to bring in newer and state of the art technology. Secondly, with most

employees being permanent government servants, there is no likely risk of losing one’s job irrespective of what quality or quantity of performance is delivered, and there are no incentives for improvements either. Lastly, typical seniority based promotions, unreasonably rigid and age-old rules for functioning, and a ‘distrust’ approach for employees, leads to a typically bureaucratic functioning huddled with scope for work inertia, red-tapism, bribing etc.

The charitable hospitals are a unique concept. It ideally starts with a philanthropist who wishes

to do something for society by providing affordable healthcare to the needy. Such philanthropy however, may not be everlasting, and in today’s times may not even be philanthropic in the first place! Charitable hospitals, in many cases, genuinely try to serve the underprivileged class of society. In the endeavor however, they overlook the need for effective management of funds, which is why in situations where funds don’t come in continuously, (which can be pretty common), their functioning suffers and consequently compromises the quality of care they may be able to provide. Eventually, they may either be forced to close business or continue functioning like public hospitals or even shift to a for-profit model. Also, the state, as a token of appreciation of the efforts of philanthropists, offers various tax benefits to those who contribute to such ventures. The more sinister issue with charitable organizations is that a lot of profit-making companies often initiate trusts to use the loopholes for acquiring these tax benefits or direct the surplus to personal benefits. What has followed over time is a slew of officials appointed to check on these charities with the effect that in the bargain, even true philanthropy has unfortunately turned into a punishing experience.

Charitable hospitals in reality can infact actually become the best system of healthcare delivery

if they get the fundamental concepts of sustainability, growth and ethical practice right.

What does it take to be a candle in healthcare of present times? It may be difficult, but it is not impossible to create honest healthcare delivery models even in

today’s materially driven times. This is not just a theoretical prescription, because there are professionals who have begun to do it based on the concept of ethical and sustainable & scalable charity. They stand firmly on the belief that medicine can only be practiced ethically, coupled with the realization that patients too, believe that healthcare providers need to be fairly compensated. It starts with the goodwill of the generous few, builds on intelligent systems that bridge the gaps left by the other models and steadily grows on its own strengths without losing sight of its primary aims and ethics at any point in the journey. It is not a practically ideal model; it is rather a practical model that preserves its ideals.

Let us try to understand how this actually works. 1. Reiterating the raison d’etre for healthcare & doctors Lost in the haze of wealth and success, the medical profession is primarily losing track of what

possibly was its fundamental reason for existence. In most cases, as may be obvious

from the issues discussed above, crucial priorities are not in place, because they are displaced by unrelated priorities like ‘bottom lines’ and ‘apparent success’.

There are only three primary aims for healthcare providers to exist, in that order of importance:

1. Best possible treatment for patients at a cost they can afford 2. Stable careers with steady growth and fair compensation for doctors 3. Commensurate benefits to the rest of the employees of the hospital

2. Getting decision making right in healthcare settings Internalizing these aims of the medical profession are a pre-requisite to getting decision

making right in healthcare settings. This is because the cost of decisions is not just in terms of money, but in terms of the patient’s life. Consequently, decision making must proceed in the order of the aims. A simple rule is to reject the activity even if any one of the condition is not being fulfilled, and to accept the activity only after it completely fulfils the first condition and reasonably fulfils the other two. Most importantly, this approach needs to be ingrained from the top management downwards to the lowest rung of staff.

3. Congruent planning Congruent planning at every stage is a must to ensure that the framework of ethical systems

does not weaken or collapse. Policies must be in line with the mission statement of the hospital, and must again follow the

order of priorities listed above. Strong and tight policies that safeguard interests of those who are most vulnerable are the fundamental to ethical organizations, especially hospitals. Not compromising on quality, while finding intelligent ways of cutting costs to keep prices of services low, is an example.

Strategies, like policies need to be intelligent enough to benefit those who need them the most, without hurting the organization. Offering discounts on pharmacy drugs to senior citizens is an example that not only benefits people who are most likely to be chronic patients, and also creates loyal customers for the hospital. One time OPD fees for a week of follow-up consultations is another bright idea that benefits the patient first by letting choose any other doctors from the department. Also, doctors and the organization benefit as the better the doctor, better the practice he builds, while the hospital only benefits in the bargain.

Procedures and processes at ground level too, must follow inline with the policies and strategies for the end result to be achieved. Free ambulance service for emergencies upto a reasonable distance for example, is both a very good policy and an honest strategy for getting patients to the hospital. It must be supported however, with the fact that hefty deposits or complex paperwork are not a part of the admission procedure for such acutely ill/injured patients or the entire purpose of reducing the suffering for the patient is lost!

4. Decentralization: Walk the talk One of the most important pre-requisites for decentralization is the level of trust amongst employees. Most hospitals forget the fact that their employees are first their own internal

customers. How you treat them, is how they will treat your external customers i.e. patients. A hospital is a unique organization which entirely depends on trust through the entire span of hierarchy of employees. Decentralization here; is akin to trusting them that they would do their jobs honestly and effectively without you demanding proof from them, just like they would treat patients as though they were their own kith and kin. It needs to be developed by constantly reiterating the mission of the hospital, and living it by leading through example, for them to reflexely follow suit. 5. Identifying strengths and weaknesses of existing systems Most people merely crib or complain about the problems and weaknesses in the system as hindrances to their functioning and growth. Intelligent planners identify these very weaknesses as opportunities to work on. When we examine the transition from faith to trust to contractual model of medicine, we realize for example that the faith model simply cannot work in today’s world. The trust model is infact the most rational model of medicine that needs to be restored. However, to maintain a practical perspective, the concept of evidence based medicine from the contractual model if implemented without significantly increasing costs, can be put to good use to bring in better accountability and transparency in the system as it helps to weaken the power relationship by reducing ambiguity and standardizing medical protocols. 6. Feeding on the weaknesses to creating powerful solutions Retaining employees for example, is a challenge for most hospitals, even more so in case of charitable hospitals because salaries may be less than industry standards. Most hospitals incur serious costs in terms of money as well as diminishing performance in the process of holding back key employees. That identifies a weakness. A powerful solution is letting go of even key employees when they genuinely have better prospects somewhere else. They will retain their loyalty to the hospital in many other less obvious forms, and it is less expensive to train a new candidate than retain an unhappy one. Working on targets is another common trend in most organizations that has been adopted into hospitals too. That it merely creates pressure to manage quantity of performance makes it prone to finding short cuts to achieve them, identifies a weakness in the system. Correctly identifying and offering incentives for those who actually work harder and discouraging those who don’t- is a simple and powerful solution! 7. Creating your own USPs for your own organization through disruptive innovation In this process, we have so far only developed a day-to-day sustainable organization. For the organization to grow, we need to have our own distinct strengths apart from the weaknesses we built on, to be to get an actually competitive edge in the field. Hence, the need for atleast some special service that we can become pioneers in, using a combination of highest quality of that service at affordable cost. Again, the key is affordable cost, as many others may offer the same quality at higher costs. An example is Hyperbaric Oxygen Therapy (HBOT) at subsidized costs in a charitable hospital. This therapy is available at very few places in India and its demand is being increasingly recognized. This will not only give the hospital an edge in terms of exclusivity of the service, but also brings the hospital into focus amongst all leading competitors who could refer patients to this hospital for this specialized treatment. Patients obviously gain, whether they were primarily taking treatment at the charitable hospital or even at any other private hospital, because the cost cannot be matched by those private hospitals even if they happen to start offering the service themselves.

8. Twice as strong systems This is the key to actually challenging the status quo squarely, because the lack of either one, will not sustain the initiative long enough to make an impact. No matter what is the initial scale of the impact, given the enormity of unethical practices in healthcare today, even the smallest effort will create a great impact on those affected the most. This is why the smallest candle burns brightly…

Sustaining the light Nurturing the candle The journey for this initiative is bound to be turbulent especially in the beginning as it will have to break many new grounds. Infrastructural growth would be gradual & people would be difficult to find and retain as employees because funds will be scarce. The management would constantly have to be on the lookout for innovative cost-cutting measures that would help them reduce their input costs so as to maintain affordable prices for their patients. Patients, who have been largely disillusioned by the existing systems, may take time to believe the hospital’s mission, so trust will have to be continuously built and maintained. Authorities would ridicule or even oppose the attempt as it could unsettle many established nexuses. For-profit competitors will soon start recognizing the threat and try to malign the hospital, grab patients, staff and so on… This period would infact be a test of the hospital’s commitment to its own mission. Once it manages to tide over the initial steep curve, the flame will become more resilient, shine brighter and start inspiring more candles… More candles One of the best things about this type of an approach is that you would like to encourage others to imitate you! Primarily, this is because the rigor and ethical commitment needed for the effort itself will retain only those who truly want to make a difference. Also, it is a larger cause to serve, and there is room for as many helping hands as possible. An important step is to target as many healthcare professionals by catching them young, to show them that there are ethical means to growth and wealth. Infact they need to be explained why this is the only way that won’t backfire! Rome wasn’t built in a day We are unfortunately living in an age where everyone seems to be in a hurry to make it big, by hook or crook. There is a need to redefine the very perceptions of ‘values’, ‘ambitions’ and ‘achievements’ in healthcare. Such paradigm shifts however, are not meant to be achieved overnight. They will happen gradually but steadily, because there are really no short cuts to the top. Sustained efforts would be required and as they get compounded over time, once they reach the acme, they start paying back exponentially in outcomes far greater than money. What we wish to achieve here, is to create an ever-increasing team of healthcare providers who will restore the fading trust in Medicine, by building systems that are transparent yet absolutely sound in business principles.

Defining value based leadership in healthcare Taking the path less traveled certainly calls for inspiring leaders who can pave the way for other professionals to follow. Leadership in healthcare, much less value based leadership has been a scarcely attended necessity. The need for trained management personnel in healthcare is being increasingly recognized, and many doctors as well as allied healthcare professionals are training to take up administrative roles in healthcare settings. There is tremendous scope to mould these budding healthcare managers and senior management for striving towards ethical and affordable healthcare, before unethical material aspirations become an inseparable way of their professional lives. These professionals need to specially review and experience how such sustainable & scalable charity hospital models can work successfully and progressively reinstate the essence of medical service. This type of value based leadership that defines the ideal vision, mission and objectives for healthcare organizations is the need of the hour. The essay ultimately seeks to appeal to institutes and students pursuing healthcare management to help sustain and light more candles in this overwhelming task of eradicating the darkness of unethical practices in this phenomenal business of saving lives - called healthcare.