Monday, 5 June 2017

Why current healthcare will be obsolete and what we need to do about this

The writing is on the wall.

The last few decades have seen 2 groups of people: One group that is “dying longer”, yes some might call it living long but not healthy. As a physician I call it dying longer. These are folks who are disabled, obese or emaciated and depressed or demented, with multiple medical issues spending a quarter of their life in the medical system, and the last decade of life in a long term care facility. Everyone knows someone in the family that is taking a multiple medications and is still sick and needing care. 

The other group has people whose symptoms similar to their sick family members but want to resist going down the same path of chronic illness with multiple medications. Since the traditional system seems to offer nothing beyond a pill for every ill these folks are seeking alternative healing pathways.

Why are they not using the constantly advancing medical system? It is because medical system is making advances in leaps and bounds on diagnoses and management of diseases with AI (artificial intelligence) however what they are failing to see is people do not want to have the next best treatment or the greatest new drug. They simply want to be and feel well with no medications and have complete resolution of their symptoms.

Here comes the total disconnect: A system that is creating newer tests and drugs and a clientele that is interested in partnership and cure and not a patriarchal dispensing of drugs.

This has created a new group of “healers” who have taken to the social media and the web with personal experience of healing themselves as the only qualification needed to become an “alternative health care provider”.

How did this shift happen? Why did this shift happen?
The shift was slow and steady and now it has exploded (reaching that critical mass). Everywhere you turn there are several online courses to help you finding healing opportunities. Courses that help you heal your thyroid. Courses and providers who help you heal your metabolism and your gut. Businessmen, actors, activists, who have created apps and tests to address your true weight gain issues, hormone issues, autoimmune issues and the list is endless. Not only are they providing what the public is looking for they are also creating this distrust in the current medical system.

As with everything else that starts off with a noble cause like climate change, like animal rights, like alternative energy, seeking great health is a valid cause, but is now being monetized by everyone. And when people are desperate they will find themselves spending a lot of money and taking a lot of ill-advised treatment till they find the right solution or they actually harm themselves in the process, and become skeptical of the whole system.

The shift happened because the medical system is behind in times. It is not held to other service
industry standards where the clients’ voice is heard.
Clients I do not believe want a cable TV in their hospital room. They do not want their powdered
scrambled eggs on a platter, for breakfast. They simply want to feel well. They want results not another surgery or pill for their ill. They are tired of being tired and sick. They are tired of taking another medication or adding another supplement to their

On the other hand today’s medical world is considered a great place to stay employed for a long
time. It costs 16 to 19 % of our GDP and yet the outcomes are a growing list of chronic medical
conditions with rising costs and insurance premiums with no end in sight. Our development is trying to put the care into the hands of the patients using apps, artificial intelligence and the growing field of telemedicine where we are educating people that their care is a click away. We are educating people to look for sickness and quick relief of symptoms when they are seeking permanent wellness.

So how do we sort through this dynamic shift?

The medical schooling needs to change. We need to embrace the need to understand how and why the body shows symptoms not simply identify and suppress this instantaneously with a drug that can only potentially cause another problem.

Hospital profitability needs to change. When a hospitals’ profit is tied to full beds (healthy people
do not occupy hospital beds) we will be promoting illness not wellness. Hospitals should be fewer and most of the hospitals should become healing sanctuaries where people are admitted initially for acute care they need and then transferred to the sanctuary part, where they address the root cause of illness. Here, they should educate and engage the patient in change in life style addressing stressors and the outcome being getting the body back to health.
This would be the best of both worlds where the provider is educated in the art of true healing and the study of the science of disease.

The medical industry is riddled with contradiction. We are trying to “cut medical costs” by getting mid-level providers to provide early detection and not true prevention( primary care), we are trying to emasculate the image of a physician by making them data collectors and with increasing regulations, in the name of efficiency(standard guidelines and EMR). We also promote the newer drugs and more expensive testing and surgeries. The medical associations
are living off the support of “Big Pharma” that thrives off of illness.

So what do we really want? What business are we truly in and who is our ideal client?

This should be our food for thought.
Nisha Chellam M.D. ABIHM 
Internal Medicine

Find out more about Dr N Chellam's work at this website 


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Saturday, 27 May 2017

Ebbinghaus Illusion : Philosophical and Human Factors thoughts

The Orange Circles, both of them are exactly the same size. However, at a quick glance, it is very obvious that one looks bigger than the other.

Philosophical questions

The first question is which orange circle would you like to be? Small fish in a big pond or big fish in a small pond? Why? If you are the fish, do you realise that the fish is the same irrespective of the pond. Are you living in hope? Are you living in false hope? Do you think the big pond means that you have a great opportunity etc? The size of the pond does not allow the fish to become bigger or smaller.  Is it a protection mechanism that you are using? Small fish in a big pond, are you trying to hide to protect yourself? Are you trying to be insignificant? Do you fear that you might be attacked by predators? Big fish in a small pond, are you the predator? Are you trying to show off and dominate? If you are, what impact is that having on your eco-system?

Political questions

If you are surrounded by ‘small’ people it may make you seem/feel big and if you are surrounded by ‘big’ people it may make you seem/feel small – would you be aware of that? How comfortable would you be with that? What would upset you? How can you use it to your advantage?

Human Factors perspective

What goes on around you can distort your perception. We also know that our perception is our reality. We face adverse effects for ourselves and create adverse effects for others by distorted reality.

Let us say you are selecting someone for a job or a promotion and you faced this distortion and always picked what you thought was a bigger orange circle, you would be causing chaos and confusion. Let us say both the orange circles are urgent medical conditions and you constantly chose the ‘larger’ one you would continuously disadvantage one particular group of patients.

Similarly, when gearing up for tasks, you could be under prepared or over prepared depending on how you perceive. You could then face surprises, nasty surprises that could harm. It is this kind of illusion that results in over estimating our strengths and underestimating our weaknesses.

It is okay for poets to talk about the moon being larger and closer or smaller and farther but when it comes to operations of any kind but especially in healthcare - Measurement and objectivity are important, they become even more important in complex situations.


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Saturday, 25 March 2017

Busting Myths in Healthcare Management

Busting myths in healthcare management
A dozen at a time

Myth 1

Quality can be measured

(But, Quality Improvement can be measured)

Myth 2

Publications and guidelines (national) are a good source of evidence (for QI)

(Often published evidence is invalid, not robust enough or gets outdated soon. Guidelines are rarely tried in their totality before being recommended)

Myth 3

Increasing Quality Increases Cost

(Improving Quality Decreases Cost)

Myth 4

Improving Quality Improves Safety
Often No

(Improving Quality Improves Quality, Improving Safety Improves Safety. According to definitions they are two different things.)

Myth 5

Management by Objectives/Targets are good (for QI)

(Targets especially mandatory ones are prone to scamming)

Myth 6

Above Average is a Good Indicator of Quality

(Averages are flawed. Averages are not real)

Myth 7

A high percentages of good things and a low percentages of bad things are good indicators of quality improvement
May be but not really

(Percentages could be misleading. Percentages are not real numbers)

Myth 8

Culture Can Be Changed

(Processes can be changed and that may change culture)

Myth 9

All Directors in the Board of Directors are Leaders

(Leaders are follower defined not position defined)

Myth 10

Management Principles are the same for Healthcare as in any other field

(The frontline in healthcare is unique and very different)

Myth 11

Errors can be eliminated (in healthcare)

(Errors can be reduced but cannot be eliminated. But harm can be eliminated.)

Myth 12

Human Factors is about Changing Behaviour

(Human Factors is about changing Design)

 You can learn more about these from many sources (eg. University of Hull or enquire about a bespoke course )


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Sunday, 1 January 2017

Medical Education Reforms in India - Too Little Too Late?

Medical education reforms in India - Too little too late?

India is the second most populous country in the world with a population of 1.3 billion. The numbers are an issue, however, the diversity of our population is an important consideration as well.  This diversity is reflected in almost every aspect of our culture and policy including education; this often is worthy of celebration. However, when it comes to healthcare, this diversity results in fragmentation. Without a unified approach we cannot improve our performance in public health, which lags far behind other countries on nearly every health and human development indices.
Therefore, the need of the hour, is a robust system of medical education, which improves the quality of doctors it produces.

When we discuss health education we need to look at three important aspects:
a) the selection of students,
b) their training and
c) their evaluation when they complete the course. 

Till this year we had problems beginning in the very first step, the selection of students. In a country with multiple certification boards of school education and varying standards, we obviously did not have a single system of entrance examination. This meant every state conducted its own entrance examination. To add to the complexity some of the private medical colleges indulge in malpractices helping students slip through the cracks of such a fragmented system.  One of the most apparent manifestations of such malpractice was the concept of “capitation fee”. A student who had obtained a seat in one such medical college last year stated under anonymity that he “booked” his seat in advance and entrance test was a mere formality. The admission tests conducted by state funded colleges are not free from malpractices either. In the newly formed state of Telengana, the admission test was conducted thrice possibly because of similar issues in 2016, putting the students through a lot of inconvenience and extreme uncertainty.

The National Eligibility cum Entrance Test (NEET) was introduced in 2012/2013 for entry into postgraduate and graduate courses. With the NEET it is mandatory that a student should have a minimum qualifying mark to be in the merit list, which is applicable even to private medical colleges as they also come under NEET unlike earlier times when there were no such criteria. For political reasons some of the states and the private medical colleges appealed against it in the apex court. The court ultimately quashed the exam, calling it illegal. This verdict was unfortunately pronounced after students appeared for the test and exams had to be conducted again by the respective states for admission.

Again after three years it could be reintroduced for graduate entrance in 2016. This year too, plagued by confusions it was conducted twice. Later because of lack of clarity the states were given the option of accepting or rejecting the test. This resulted in windfall for private colleges which increased the fee steeply because parents of children who would have let them repeat the test in the normal course next year, if unsuccessful in the first attempt, crammed for the seats paying hefty donations.

From this academic year we are going to have NEET on regular basis for graduate, postgraduate and specialty courses. This would at least curb manipulations in the conduct of the test because it is an online test. This also ensures the students get a qualifying mark to be in the merit list.
Dealing a double blow to  merit is the system of reservations which being  primarily caste based instead of income based, results in quality medical education being put even further out of reach of meritorious but economically backward students. Even with NEET, this system of caste based reservation has not been done away with.

Moving past the testing process, we find issues with testing methodology too. We still persist with methods which tests only memorized knowledge and not the student’s analytical skill. Likewise ,there is a gap in testing the student’s aptitude. There is no method at the time of admission to check if a given student has what it takes to become a doctor. The Charaka Samhitha, an ancient medical treatise which dates back to 2nd century BC candidly describes the attribute of a medical student. It states: ”The ideal medical student should be of  mild disposition, noble by nature, never mean in his acts, free from pride, strong of memory, liberal minded, devoted to truth, likes solitude, of thoughtful disposition, free from anger, of excellent character, compassionate, one fond of study, devoted to both theory and practice, and seeks the good of all creatures”. No one could have put down more succinctly what is required of a medical student. Not paying heed to these words of wisdom over the years has resulted in generations of doctors who are poorly informed and unprofessional.

The problems, unfortunately, do not end with selection process and continue into training. There has been no major change in the curriculum, which continues to encourage rote learning. It is not formulated according to requirements of the population which the doctor under training would be catering to, but focuses on a learning a lot of theory. Such a curriculum fails to inspire students, whose studies are getting so diluted that they would choose to read study guides instead of text books. None of these augur well for the training of good doctors. This issue was addressed in the Vision 2015 document, which was drafted by a Board of Governors who took over from the MCI. The blueprint, which covered both graduate and postgraduate education, detailed an entry level exam which is common, a curriculum which has both horizontal and vertical integration where the students are trained in basic sciences, lab sciences and clinical sciences from first year onwards and a nationwide common exit level exam before the degree is awarded. The whole process is yet to be effectively implemented though the document was drafted in 2013.

The infrastructure in government funded colleges leaves a lot to be desired, due to the inadequate budget allotment to health and education. A mere 4.05% of the GDP is spent on health, which funds government hospitals which are supposed to be training the medical graduates. Even what is allocated is not fully spent, due to the leakage of funds at all levels. Added to this is the shortage of faculty who, because of better remuneration choose to work in private hospitals. The private institutions also do not spend their revenue on upgrading the infrastructure after their approval and do not most often have required staff.

Realising the need for the long awaited reforms in medical education, a three member committee of the NITI Aayog drafted the National Medical Commission Bill 2016 which would replace the Indian Medical Act, 1956.This in itself is a topic for discussion. The draft bill, aimed at bringing about a complete reformation has flaws which require immediate correction. The most important one is the issue of fee capping in private colleges, which is not clearly spelt out, which means deserving students inspite of a good rank in NEET, may not have access to most of the seats due to non affordability.

The next major feature of the bill which may be self defeating the purpose of improving the quality is the proposal of allowing “for profit” medical colleges. Though the rationale for this may be the need for increasing the number of colleges to meet the demand, this would once again bring in the private players whose intention of starting a college would be commerce. We have now 426 colleges, nearly half of which are private. One proposal that frequently comes up to overcome this problem is to upgrade large district headquarters hospitals to teaching hospitals.

If we need to have a medical education system that would be comparable to the rest of the world, we need to pay attention to student selection which should be purely merit based, infrastructure, training and their evaluation. This is the only way to produce doctors who would be able to face the unique challenge s faced by the society and health care industry.

Dr Usha
Hyderabad, India

All views in the above write up are the personal views of the author (and not that of this blog site)


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