Saturday, 27 April 2013

Some thoughts on future healthcare

BMJ's doc2doc social media website's Matthew Billingsley recorded my interview at the 2013 International Forum for Quality and Safety in Healthcare at London for a podcast.

We discussed crowd sourcing healthcare, learning from other healthcare systems, the gate keeper role of UK general practitioners, etc. I hope you enjoy the podcast.

The future of healthcare is changing and could be unrecognisably different. How willing or ready or you to cope with it?

Follow me on twitter @HemadriTweets
PS: This podcast was originally posted on the doc2doc website and is reposted here.

Wednesday, 24 April 2013

My Conversation with Dr Ravindran, Chairman of Aravind Eye Care

I had the privilege of meeting Dr Ravindran, Ophthalmologist and Chairman of Aravind Eye Hospitals, India, at the International Forum for Quality and Safety in Healthcare London 2013. I had a general informal conversation but it was of course an eye opener - you bet he has experience in that!

I share some of the conversation here. 

Clinicians' Selection processes at Aravind


It is well known that Aravind has processes that are followed really well by the staff, especially doctors who work there. Protocols and processes are very important for their pathways and systems to work. It is also well known in healthcare that it is very difficult to get doctors to follow organisational protocols. I asked Dr Ravindran on how they do that.

Aravind appoints doctors after a 3 day selection process. Applicant to appointment ratio is a minimum of 3:1. Fellows and residents work and spend time with staff on those three days. Doctors then provide feedback to the appointments panel on the suitability of applicants. Anyone blackballed by existing staff are not selected. The main if not the only criteria for appointment is if the doctor is 'suitable for our culture and basic values'.

They obviously get people who are already high flyers with research credentials, publications, etc but Aravind's attitude seems to be that they want only normal average people to work with them and their system and culture will then make them do good work. (This sounds very similar to Toyota Chairman Cho's statement that they get brilliant results from average/normal people when other car manufacturers get average results from brilliant people). These high flyers, if they are not suitable for the Aravind culture are told that they are likely to be very successful outside the Aravind systems.

Chairman Ravindran says 'we want everyone to be pleasant and professional to each other. If we detect even a small amount of arrogance during the selection process, we will not appoint the person. Arrogant people can offend and upset others which will disrupt team work and increase staff turnover - we cannot have that'.


Student Nurses are selected after a written test and an interview. The test is a hand written test where they answer a question on a social concept. Hand writing is thought to be important (if you cannot read a person's writing the value of their documentation and written communication becomes a future problem). As for the content, it is thought that if a young aspiring nurse cannot write with genuine empathy about a socially important issue they would not fit in with Aravind's culture and communication.

Now comes the interesting part of the process. While interviewing the applicants is what everyone does anyway, Aravind interviews the parents of the applicants. They see this as very important. Attitudes of parents and aspects from home have an influence on how people behave and work. This is accounted for in the interview and selection process.

Once they are selected to be nursing students, Aravind pays for their training, accommodation etc. These students after graduation get to work for Aravind.

I probed their thinking - I said that the society will have many different types of people and their organisation will/should have different type of people; including and excluding some types will not reflect the society. Dr Ravindran was very clear with his answer, he said that of course the society  will have many types of people but in his organisation they only want the type of persons who can share their basic value.

Their basic value is compassion.
He also said that many in the organisation including the senior people continue to engage with the staff and their lives, he said 'I know a lot about many people who work with us, what they enjoy, what problems they have at work, what issues they have outside work and in general a lot about their lives. Due to this we are able to support them very early.'


I specifically asked him about where and whom he and his organisation learns from. He says that their main learning is from within their organisation, they try to improve everyday and share it with their internal colleagues -  mutual learning within the organisation. (This blog has in a previous post stated this as the fourth fundamental condition if healthcare is to be successful )

No external consultant has even been contracted. No lean specialist, no management consultant. They get regular visitors trying to learn from the Aravind system. Aravind staff do visit hospitals around the world to explore what might be suitable for adaptation.


When asked about how they deal with the high volume of patients Dr Ravindran said 'If we have more patients we simply start early - all of us. We do not put patients on a waiting list, we do not turn patients away'.
I asked about being lean and quick and his response was 'It is not about being quick. It is the attitude of not wasting anything. So if we don't waste time it looks like we are quick. We do not throw away anything; if a bed sheet is torn you can be sure it will re-appear in some other form to help with some other function'.

I think my commentary is not really needed as the conversation is very illuminating and self-explanatory. Their website shows that eight out of ten directors of their board are doctors - does that say something? I think we can learn a great many things from Aravind Eye Care and their practices. I wonder what we can actually adapt and use for healthcare delivery in the western world?

Follow me on twitter @HemadriTweets
Aravind Eye Care

Thursday, 11 April 2013

Anonymity, Privacy, Whistle Blowing and the use of Internet

Please see disclaimer at the end of the write up - by accessing this page and reading this blog you agree to the disclaimer.

There are two major topics that are really exercising the healthcare fraternity in the UK these days. First is whistle blowing and the second is the GMC's new social media guidance for doctors. It is very frustrating that at a time when we should be encouraging whistle-blowing including anonymously if needed and the department of health seemed to have banned gagging orders, we are also presented with what might look to some, as one mass gagging order for all doctors. The message from the top is mixed and hence confusing.

Whistle blowing is to report wrong doing to someone who has authority to do something about it. UK government has advice for whistle blowers ( )The NHS supports raising concerns ( ) The GMC obliges doctors to raise concerns ( )

Please do your very best not to post or whistle blow anonymously. Please develop the strength and courage to use your own name and then report the facts and evidence that concerns you. Anonymous whistle-blowers are generally not taken seriously ( ). The latest GMC guidance on social media says that ''If you identify yourself as a doctor in publicly accessible social media, you should also identify yourself by name'' - so if you are a doctor and talking medicine in social media you must use your own name.

Having said that it is also possible that some may be in such a vulnerable position or the impact of whistle blowing or otherwise writing non-anonymously will have a permanent and disproportionate effect on your life, then it is obviously important to protect your privacy and anonymity. You may also want to take steps to ensure that you are not ignored.

I personally feel that anonymity gives a voice to the voiceless and the weak; I wish those who are reading this are not weak and hence do not have to follow any of the methods in this blog. But for those who are forced into anonymity, what follows are methods to increase your privacy and anonymity while using the web.

For a lay person this is a basic explanation of how the internet thing works.

Your computer uses a particular piece of hardware to connect to the internet. That hardware identifies itself to your internet provider using a MAC number and connects to the internet. Then you open a browser (e.g. Mozilla Firefox, Google Chrome) and you start searching or browsing. Your internet provider (ISP) will know which websites you are visiting and emails you are sending though they may not choose to find out the actual contents of what you do in those websites or what you write in your emails. Your ISP then routes your requests to the website that you want to visit and the website you visit could fairly simply find out a lot about you.

So, for anyone using the internet it is quite easy with the right resources to identify more or less precisely who you are, what you did and where you did that from.

If you wanted to make it difficult for people to identify you a few steps could enable that (though with huge governmental resources normally reserved for high impact criminal activity, anyone can be tracked down).

Step 1
Use an Open public wi-fi network such as in shopping malls, coffee shops, etc where no log-in was needed to access the internet. You can use your own internet connection (at home, etc) but your ISP will know that you are accessing a particular service regularly (the service being the Tor network described in Step 3)

Step 2
Use software that can change the MAC number by which your computer talks to your ISP or to the open public wi-fi provider. You can change this every time you access the internet. By doing this the ISP will not be able to identify your computer specifically.
MAC spoofer ( or )

Step 3
This is the most important step. Use the Tor browser bundle.

Using the Tor browser would mean that the information that you send from your computer into the internet is encrypted and thus cannot be read on the way. Tor system then routes your communication (emails, browser requests, etc) through at least three computers with encryption. The communication then exits the Tor network to your destination but at that point it is not encrypted and hence can be captured and read but that will not identify you as the sender by revealing your computer and net details if you have not explicitly identified yourself in the communication. So you could send communication from India to USA and it will be very very difficult to identify your specific computer.

Tor browser ( )

When using the Tor browser use do not open attachments, do not send attachments (unless you are an expert in internet anonymity), do not open additional programs within Tor browser or when Tor browser is in use. Find out more about Tor ( )

Step 4

Even within the Tor browser if you are searching, use a search engine such as Duck Duck Go
who unlike conventional search engines do not track you or otherwise want to know too much about you.

So far it is about anonymity on the net.

You will still need to make sure that you do not reveal yourself. Hence you should not be using your own regular email id, if you want anonymity or privacy. So.....

Step 5

Open a new account using any of the regular email providers (e.g. Yahoo!, Hotmail, Gmail, etc - taking care to provide only the minimum legally required information) using a Tor browser to send emails with no personal or identifiable details in the content/body of the email, subject line or in the email id. Cancel the email account once the purpose is served.

Use a disposable email ids when possible (e.g. ; ) for 'forms' in websites and forums

If you are whistle blowing: Copy a news organisation for evidence record that you have reported/whistleblown. 

Step 6

Steps 1 to 5 above are things that you must do. This Step 6 is about things that you should not do:
a) do not attach any thing or send anything as attachments with your email or posts
if you attach anything you risk losing exposing who you are
b) do not open any files, programmes, or other software when you are using Steps 1 to 5 above as that will risk revealing your identity.

Please remember that all these steps and what is written in this blog post are for amateurs. Please learn about all these steps and related items, get yourself very familiar and confident before you use them. Do dummy runs, trial runs etc before you actually use it for any worthy purpose. Remember that there is no (and probably never will be) complete privacy or anonymity in the internet.

Do not use these methods for anything illegal, please do not use these methods to harass, intimidate, spread falsehood or anything else that is offensive. Please remember that internet is never anonymous and illegality should never be attempted even under anonymity.

Whistle blowing is a frustrating but noble act. Please check your facts before you blow the whistle; please see if you can raise your concerns confidentially within the organisation using normal/regular channels before you consider using whistle-blowing methods. Please consider every opportunity to whistle blow without taking recourse to anonymity.

Please note that these tools above are not just for whistle-blowers; they exist for people who just want to be anonymous. All of us could use Tor to maintain and enhance our internet privacy. We could use disposable email ids to avoid spam. 

If you have used Tor then keep the Tor on and allow your connection to be used as one of the nodes so that you will contribute to increasing the privacy of the net.

Follow me on twitter @HemadriTweets

Please check if the above steps and everything else in this blog are legal for use in your location, country, area, etc

Please do not do anything illegal (anonymously or not) on the internet (or in any other area).

I am not an expert in internet security/anonymity/privacy; I am merely a normal user of some of the methods described above. The anonymity and/or privacy and/or security enabled by the methods described above have not been personally checked/validated/guaranteed by me; I only write due to an interest in these matters; I cannot therefore take or accept any responsibility for any loss of any sort including financial, lack of anonymity/privacy/security, embarrassment, or for any negative effects of following anything written in this blog post. It will be your/the reader's responsibility to ensure your own anonymity/privacy on the net and the consequences of any loss of anonymity/privacy or other negative effects.

No vested interests

PS: If there are any errors in the blog or if you have any ideas to enhance the topic please leave a comment below.

Tuesday, 9 April 2013

Breaking down monuments

Here are a few examples of monuments that we can break down.

Ultra-sound scan room

There is no real need for in-patient diagnostic USS to be done in a specific room. Put them on wheels and take them to the patient on-demand. Doctors get bleeped for opinions for in-patients and they go to the patient, no reason why diagnostic USS cannot be done by the bedside after drawing the curtains around. This spares physical space for more work do be done (I think the managers call it creating capacity).

USS for outpatients - could it not be done at patients' home? District nurses do dressings at home why not USS?

Flexible Sigmoidoscopy

For in-patients diagnostic flexible sigmoidoscopy can be done in their own beds during ward rounds. For outpatients it should be done during the consultation at which it was thought to be required and in that same consultation's examination room. Why do we think we have the right to ask the patient to come back for something that can be done then and there?


In-patient diagnostic gastroscopy could very easily be done at the bedside or in the relevant ward's treatment room. Outpatient gastroscopy should be done in the consultation room at the same time as the consultation at which the gastroscopy was thought to be needed. Have we not heard of ENT surgeons doing nasal endoscopy in OPD? Have we not heard of ultra-thin scopes? Have we not heard of oral sedation if it was indeed necessary?

Oh, by the way, we have not obviously heard of companies willing to provide clean scopes by motorcycle courier delivery wherever we want.

We have this rigid old-world belief that patients should be moved around to where the 'facility' is and when that is not possible clinicians and others should become runners to connect patients and a variety of facilities. We have to stop such thinking and move with the modern world. We used to run to telephones

Arterial Blood Gas analysis

Hand held ABG analysers are available and these ought to be used as POCT (point of care testing). It is well known that blood gas results have to be acted upon within minutes if it needs to make any difference to patients. ABG analysers are situated as some centralised monuments when they should be available near the bedside of any acute patient anywhere in the hospital. We call for a demolition of this monument.
This blog has already argued for improved ABG turn around times as an example of clinical lean

Bedside Hemoglobin, WBC and other testing

Hemocue POCT hemoglobin testing has been available for a few decades and has been used by many para-medical services but still not used routinely in many hospital operating theatres and other areas. There is really no reason why this should not be available anywhere in the hospital or be carried around by doctors and nurses. When we can provide treatment in life and death situations using POCT blood sugar testing, we could do these couldn't we?

General Practitioners as Gate Keepers

In the modern world where information is provided in plenty by Dr Google, where patients are far too knowledgeable than when the NHS was created 60 years ago, patients must have the liberty of seeing any specialists of their choice without having to go through a general practitioner. Seeing the specialist directly happens in other parts of the world especially with post service self-pay patients, in UK having pre-paid patients do not get the same liberties or choices. There are innumerable myths on the gate keeper role of UK GPs which need to be challenged if clinical practice is to be compatible with current expectations.

This in no way an attack on the role of GPs as clinicians providing an invaluable service and is essential; I am only questioning if any value is really provided by the gate keeper function and whether there is any sense in putting hurdles in a particular patient's chosen pathway.

There will always be a 'this is too risky and against the rules/regulations' brigade. I am looking at how we can innovate and improve safely. Yes, if we put it that way, risk and improvement do not make comfortable bedfellows. 

Please add your ideas on what monuments that you would seen broken down in your hospital/clinic by leaving a comment below.

Follow me on twitter @HemadriTweets