Subjectivity is the curse on examinations for UK doctors - get rid of it

Subjectivity is the curse on examinations for UK doctors - get rid of it

There is currently a controversy raging in UK healthcare about doctors. For many years it was known and was passively accepted that if you were of Black or Minority Ethnic origins more so if you were an International Medical Graduate (IMG - a doctor with a primary medical qualification outside the UK or European Union) facing a Royal College examination you would have a much lesser chance of passing the examination. If you were of BME or IMG origins and were of a generous persuasion you would call this sub-conscious bias but most called this racism, whether it was racism or not. If you were representing the establishment you put out phrases that are superficial gibberish, such as 'reasons are multi-factorial and complex' but certainly not racism.

The issue came to a head with the MRCGP examination where in the new version of the examination the differences between white and non-white candidates were so gross that you would notice it even if you were colour blind.

The medical post graduate examinations conducted by the Royal Colleges are essentially about medical knowledge both theoretical and applied. Given that these are knowledge tests, why did the results show racial differences? We will not discuss racial supremist reasoning here.  Many of us will remember the days before the MCQs - the essay answers were often a demonstration of your wizardry in medical English. Apparently even in the MCQ based knowledge tests we can use linguistic jugglery so that a non-native English speaker comes out as having poor medical knowledge - we are not discussing that further here.

The curse of subjectivity

Applied knowledge in medicine is tested in vivas, OSCEs, with patients and simulated patients. Here the marking is done by examiners, that is where subjectivity comes in despite current best efforts, subjectivity is ruining careers.

The rest of this blog post is about subjectivity (the collection of the perceptions, experiences, expectations, personal or cultural understanding, and beliefs specific to a person - Wikipedia)

The sad paradox is knowledge especially in medicine is objective but part of the testing process of this knowledge is subjective. The tension that results from an objective topic tested subjectively is where the fundamental flaw lies. Where subjectivity exists, there bias exists and hence unethicality at the best and fraud at the worst exists.

Subjective assessments must not have a place in career make or break decisions such as exit examinations or in any arena where career progress or ability to practice the chosen profession can be stopped. Subjective assessments do have a place and can be used for progressing in learning and development - some of which are known as formative assessments. Must not be used for stop-go decisions where only objective assessments should be used.

Reducing or Eliminating subjectivity

Examiners in vivas, OSCEs, patient encounters, interview and other areas currently suffering due to subjectivity, are generally given questions - they should also be given answers and as long as the candidates answers fit in with the recognised accepted answers the candidate passes, when the answers fit in with recognised unacceptable answers the candidate fails and where the answers fit in with recognised borderline, a published formula for accepted number of borderline for a pass or fail should be defined (no, this is not the 'borderline method' that is used in standard setting).

This may beg the question whether vivas are needed at all - verbal communication is essential in all walks of life and especially so in healthcare; a candidate should be able to answer effectively and accurately under stressful verbal conditions and hence vivas are needed but the subjectivity of the vivas must be eliminated.

Subjectivity cannot be sometimes avoided but when forced to use it the answers should be 'force fit' in a pre-defined uniform manner and the candidates be assessed against that uniform force fit. The candidate does not have to know what the defined force-fit answer is but all candidates would be marked against the same answer.  

Lets look at an example: Let us assume that in a scenario where there is a certain level of oxygen desaturation which does not impact on life or limb but where a candidate has to act - say an peripheral oxygen saturation that has fallen from 98 to 89 but where the patient is otherwise very stable. The candidate has to make preparations for an adverse eventuality but there was no need to act immediately. Let us also assume that currently this is subjective and hence an assessor would mark someone and this would be variable (depending on the other skills of the candidate). Let us try a force-fit answer for this scenario - the examiner would be given a set of answers and would give the candidate a mark for each correct answer, for instance, a) the patient if conscious was asked if she was okay within two seconds 1 mark

b) the pulse oximeter probe was checked and re-applied within 4 seconds

c) capnograph reading checked within 6 seconds

d) the oxygen flow and any gas mix ups were checked within 8 seconds

d) airway tube position checked within 10 seconds

e) airway change kit and reversal drugs asked to be brought in and kept ready with 12 seconds

etc. You get the picture.

These answers may not be based on evidence because there is no evidence to base it on. However, for the purposes of the assessments the answers are defined on the basis of agreement between examiners and are used uniformly with all candidates. Then the chances of the examiner being influenced by mastery of the language, social status of an accent, the image projected by clothes, the false confidence provided by a charming smile or colour of the skin would be less.

Subjective experts are simply socially acceptable influential frauds providing a certain voyeuristic celebrity value when they are reviewing wines, films or restaurants. Techniques similar to those have no place in medical examinations. It is of course a completely different story that the British are not able to trust the training provided to their young doctors for somewhere between a minimum five years (in the case of general practice) or an approximate minimum of twelve years in the case of surgeons that makes an 'exit' exam essential to cross check knowledge (which is then pretty badly due to the subjective components). In the USA exit exams are not mandatory, they are voluntary, the Americans obviously have a great degree of confidence in their trainers, trainees and training system. The British system needs reform and a commitment to eliminate subjectivity when the stakes are high could be core to whether the UK will ever have a equitable outcome in examination results.

 

© HEMADRI

 

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This blog has argued for reducing or eliminating subjectivity from re-validation http://successinhealthcare.blogspot.co.uk/2012/11/revalidation.html

We have discussed differential results in surgical Royal College examinations http://successinhealthcare.blogspot.co.uk/2012/12/exit-exam.html

Warning: Legality could be injurious to health

This particular blog post is fictional. Any resemblances to any person living or dead or incidents current or historical are purely coincidental.

Warning: Legality could be injurious to health

It was the saddest day of his life.

Let us start from the beginning. Bill was a brilliant student at A levels, he was also a stickler for formality, rules and process. This stood him well and he was very highly thought of as a scrupulous, proper, law abiding young man. He went on to study medicine, completed junior general training and got into specialty training – all very smoothly. His specialty also involved working in the operating theatres.

Bill found within a few weeks of into his registrar job that his work never ever finished at 5 pm.  Bill being Bill, thought he will simply leave at 5 pm as long as there was no patient he was directly dealing with was acutely ill. He did that for a week. Bill then found his training was getting adversely affected. Consultant ward rounds continued after 5 pm, if he did not join in he cannot learn. Patients for elective surgery were admitted after 5 pm, if he did not see them he will not be ready for them for the next day. Theatres routinely over ran easily to 7 pm sometimes longer, if he was not there he will lose out on the training.

Bill discussed this with his consultants who looked at him as though he was an alien zombie. When he insisted on resolution they told Bill that he is free to leave at 5 pm if he wished to do so, some of them insisted that he leave at 5 pm so that he did not breach his hours. Bill’s logical argument was very simple, substantial training happened after 5 pm so to take consultants’ advice and leave at 5 pm means that he will never get the training he deserved. So Bill refused to leave on the grounds of training needs and claimed payment for extra time on the basis of actual time spent working at the hospitals. Boy, this was resisted by the management. Bill was born different, his documentation was perfect, they had no choice but to pay him. The managers gave the consultants a hard time because of this issue; the consultants did not take it lightly.

The time came to ‘assess’ and ‘report’ on Bill which were used at annual progress meetings. These used to be called RITAs before now called ARCPs. Bill’s numbers, performance, success rates, patient feedback and anything clinical were spot on average. Bill’s consultant reports were full of masked vitriol on how his attitude, behaviour, cooperation, et al were not compatible with a surgical career. This was pointed out to him and he made tremendous efforts to improve. Every time he was assessed externally he had no issues on any of the ‘soft skills’ assessments. But he would not stop claiming for staying after contracted hours. Every hospital that made him work after 5 pm paid up; the consultants from the hospital wrote badly about his approach to life.

After 6 years of completed training with same average clinical rating as his peer group, Bill was denied his completion of training certificate due to five reports that faulted his attitude. Bill cannot get into the specialist register; Bill cannot be a substantive consultant in the NHS. His colleagues with his level of performance and achievement and some with lesser performance and achievement were signed off.

All because he followed the country’s law and the NHS rules. The message his colleagues got from their seniors was that people who followed the law can be severely, career damagingly punished. The message other trainers and managers got was that they can break the rules and law with impunity and use their power to penalise the person who caught them out. Bill can go to employment tribunals and the like but when he has at least half a dozen consultants who have already written badly and a dozen managers willing to write badly – he faces a lost cause. In a world where the subjective decimates the objective - he is a lost soul.

Has he learned his lessons that legal and rule based behaviour does not win and not submitting to the whims of the powerful was harmful? We do not know yet. This sounds like a case of operation successful, patient died; only here it will be training successful, career died. Bill hit the target, its the ricochet and the debris that maimed him.

Bill is at a crossroad waiting to change careers.

Oh by the way he also happens to belong to a minority ethnic group.

I think this quote from John le Carre (in his book The Constant Gardener) will probably be very appropriate here "Nobody in this story, and no outfit or corporation, thank God, is based upon an actual person or outfit in the real world. But I can tell you this; as my journey through the pharmaceutical jungle progressed, I came to realize that, by comparison with the reality, my story was as tame as a holiday postcard."

©M HEMADRI 

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PS: The loose ends such as throwing in the ethnic minority, etc are there to be filled in, if and when I get to write this story in full

Blondes, pilots and doctors. Who should learn from whom?

Blondes, pilots and doctors – who should learn from whom?

The Malaysian Airlines plane disappearance remains a very sad mystery. Our hearts go out to the missing persons and their families/friends, it must be unbearable agony.

Now we hear in the papers that young blonde girls were entertained in the cockpit in 2011 by one of the pilots of missing plane. http://www.dailymail.co.uk/news/article-2578146/Young-blonde-says-missing-Malaysia-Airlines-pilot-invited-friend-ride-cockpit-entire-flight-2011.html

I am not taking any moral stand here, pilots or anyone are welcome to entertain blonde girls or any other type of women or men anywhere. My problem arises when these pilots put passenger safety at risk by such acts.

I heard this news on the morning of 12 March 2014 on my way to the CHFG conference in Birmingham. I would have normally laughed out loud, then stay angered for a while and then move on. But there was something else bothering in my mind. Then at the conference, as in any healthcare conference these days, I heard a number of people repeating what has now become a cliché that healthcare should learn from pilots and airlines. What was bothering me then surfaced to provoke me into writing this blog.

If you thought for a minute that this cockpit privilege is dished out only in Malaysia or in some other distant country, you are probably mistaken and it may be time to change your mind.

A few weeks ago a colleague who is a senior doctor with additional responsibilities in the UK told me about travelling in the cockpit of a major airline on a scheduled short haul international flight in Europe. It was obviously very thrilling for the colleague but as a safety enthusiast it was disturbing me. As a senior doctor it might have been appropriate to decline the offer on the grounds of ensuring safety; that is another debate. If that colleague lied to show off etc that is a personal probity issue.

Then the colleague said that this privilege was also offered to another family member a couple of months earlier, who took a flight in the same sector for stag or a hen night. This is even more unsettling since it seems such behaviour by pilots are not one off or localised but probably frequent and international. Update: Since this blog was originally published about 48 hours ago, I have had a very senior doctor now retired telling me that he sat in the cockpit while flying over the Alps on the way to Italy. Goes to show that it is not only localised and frequent, it is also chronic poor behaviour by pilots.

I think the constant bu*****t about healthcare learning from pilots has to stop. This blog has argued for healthcare to learn from all sorts of good sources. I have previously written about animal air transport. I have written on the pilot error rates not falling since 1950s and the very large variation seen in the 'ultra-safe' airline industry. I still believe that healthcare needs to learn from everyone including airlines. But it should not be one-way traffic. Perhaps pilots can learn from doctors who will not pick out anyone from a waiting room on the basis of hair colour or allow 'friends' to join them in operating theatres as a thrill of the day.

We should not also make the error of mistakenly attributing the improvements allowed by technology as advances in human behaviours and interactions.

©M HEMADRI 

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Scheduled airlines are safe – just like out patient clinics

http://successinhealthcare.blogspot.co.uk/2012/09/scheduled-airlines-are-safe-just-like.html

Healthcare is not similar to aviation but lessons can be learned http://successinhealthcare.blogspot.co.uk/2012/04/healthcare-not-similar-to-aviation-but.html

Kahneman, Colonoscopy and Goole

The Goole way of improving patient experience of colonoscopy

Colonoscopy and pain

All of us are well aware that despite our collective immense experience, colonoscopy can be a painful procedure for our patients. That is the reason we use analgesics. At this time influencing the experience happens by the sedation (midazolam) we give (influencing the perception, awareness and causing possible amnesia for the duration). Of course, the patient always has a better experience if our technique is good (minimum inflation, not going into loops, undoing loops early, change of position, abdominal pressure, lower total duration of procedure etc). Nevertheless patients can experience pain.

The pain obviously causes immense distress to patients, it also causes complaints. More relevantly pain may cause the patient to decline colonoscopy in the future. For some patients due to the nature of their disease repeat colonoscopy becomes essential and pain or unpleasant experiences puts these patients into distress even at the thought of considering colonoscopy. Patients may also colour the expectations of their family and friends regarding colonoscopy.

Kahneman and clinical psychology

The 2002 Nobel prize winner Daniel Kahneman has done important work on patient experience and its relation to the patients' willingness/readiness for further colonoscopy in the future if required. My understanding of what Kahneman says is that the total duration of the procedure, the highest rating of pain during the procedure or the duration of high levels of pain matters much less than the degree of the pain experienced at or towards the end of the procedure. For instance this means a patient with a 10 minute colonoscopy who was relatively comfortable for 9 minutes but had significant pain the in the 10th minute reports a worse experience than a patient who had a 20 minute colonoscopy with relatively severe pain for the first 17 minutes and no pain in the last 3 minutes. In fact in Kahneman's experiments they deliberately kept the colonoscope in place for extra 2 or 3 minutes so that the patient can have a pain free ending.

The lessons to us are of course self-explanatory - irrespective of the duration of the procedure or the degree of pain we should not take out the scope quickly and allow a pain/discomfort free period before the end of the procedure.

Kahneman explains this as the difference between experience and memory - with the message being what happens in the end is remembered more as the memory (rather than the totality of the duration of the experience even if that was painful/unpleasant).

The Goole Translation

We wanted to translate this into an even more tangible improvement of patient experience than just a slow withdrawal.  We wanted to go forward from the described lack of negative experience to the establishment of a positive experience. If Nobel Laureate Kahneman says the end of procedure experience is counted as memory we wanted to try to deliberately aim for and deliver a positive memorable experience.

At colonoscopy one of the main roles of the nurse who supports the patient is the reassurance role. Till the scope reaches the caecum the nurse has a reassurance role (‘you are doing fine’, ‘its nearly done’, ‘take nice and easy deep breaths’, ‘pass some wind out & you might feel better’ etc) - this is the normal role for the nurse in any endoscopy unit anyway and we do it as well. Once the scope reaches the caecum and completes the examination of caecum/terminal ileum, this reassurance role generally diminishes as the patient feels less pain, less anxiety etc. At this point I declare to the patient and the staff 'we have reached the end we should be getting out soon'. In Goole that statement would be the cue for the nurse to reduce the reassurance role and deliberately start a conversation with a high quotient of humour with the patient. The explicit aim is to try and make the patient laugh.

There seems no obvious downside or specific risks noticed yet. Important to remember that it is the nurse who supports the patient who engages in humour. The endoscopist and the nurse who supports the endoscopist remain extremely focussed and serious on completing the procedure safely.

We find that the patients end up in a really good mood when we are able to make them laugh. The trick is for the nurse-patient conversation to elicit a laugh. On the contrary, nurse-nurse or nurse(s)-endoscopist or even endoscopist-patient conversation eliciting the laugh from the patient is in my view is not as effective. The nurse-patient conversation resulting in a laugh is the crucial element; anyone else laughing may not be liked by some patients especially as the patient could be at the end of an unpleasant procedure.

In my conversations with people in the know, I learn that on the way to the caecum when the patient is experiencing distress/pain it could be okay to distract by attempting a social conversation but not with the intention of humour as that could end up as 'the memory' ('they joked while I was in pain'); the intention to humour is only after reaching the end point while making a slow withdrawal provided the patient does not have pain on withdrawal (if there was pain on withdrawal, then the reassurance role becomes important again)

It seems like common sense. Apart from a potentially great patient experience we find that the atmosphere in the procedure room becomes very enjoyable. It develops a good relationship between staff members. We have only just started doing this. I write my initial impressions and not any definite long term observations. This is not based on research, it is a simple description of what we do and what we feel about what we do on the matter of influencing patient's memory of colonoscopy.  I just wanted to share this simple and in my view, elegant humour based intervention to improve patient experience. You may want to try it with your patients, get your nurses to do this. Not every nurse will agree or be willing to go with this. That is okay, best to work with the willing.

Kahneman has proven the science - I have just added humour to it.

©M HEMADRI

Follow me on Twitter @HemadriTweets

Deliberate Redundancy and Intelligent Management

DELIBERATE REDUNDANCY AND INTELLIGENT MANAGEMENT MAY BE THE NATURAL WAY FORWARD FOR HEALTHCARE SYSTEMS 


Redundancy (slack in the system) is normal in the human body. Nature has provided the human body far too much capacity than what is needed for day to day living. Most of the capability of the human body lies unused for most of the time. Human anatomy is full of many muscles all doing small parts of the same movement and/or many muscles doing same or nearly same movements. There is often two of many organs. Two eyes may be needed for depth perception but two nostrils, two breasts, two ovaries, two testicles cannot be explained within the logic of efficient systems. It is also not just the anatomy, the way the anatomy works also reflects enormous over capacity of human systems. About one eighth of the kidney or one seventh of the liver is adequate for normal living. Similarly much lesser length of colon or much lesser sperm counts will still be abundantly compatible with digestion or reproduction. The scope of the surplus is truly amazing, for instance every part of the body is pain and pressure sensitive – we are used to it but is that needed or if we were building a system would we not consider that as wasted resource. There are many ways of providing energy and and many ways to eliminate end products. Well amazing is probably and understatement.

It is normal for the human body to have excessive capacity with only part utilisation at most times - i.e. functioning as though it was an inefficient system for the majority of the time. Even after doing so the human system needs significant amounts of rest and recovery at regular intervals at low utilisation levels and certainly much higher rest and recovery when systems are stressed (achy muscles and joints even after exercise and worse effects after fever, or surgery etc)

Interestingly that is how the rest of the nature is. There is more water than needed, more sun than needed, more air than needed, one could even argue that there is more food than needed (though it is distributed unevenly and too much is wasted).


My argument is that such a pattern is actually essential for healthcare systems. There is a lesson for healthcare professionals on how to manage healthcare systems which care for redundantly built humans. We should not be averse to a system with significant redundancy deliberately built into it and managed intelligently.



High reliability, high efficiency, narrow variation is valid for system architecture, system performance and output delivery in mechanised or electronic or technology based systems (i.e. machines). Humans dealing with healthcare will almost never be high reliability, high efficiency or narrow variation - they only give the impression of being so. In other words healthcare systems with human beings showing high 'efficiency' may well turn out quite simply to be an illusion. It is simply anti-natural, anti-anatomical, anti-physiological and anti-biochemical - humans are not built to perform that way. Well, most of the humans anyway with the few exceptions of outliers such as high end sports persons, highly narrow specialists, etc – even they need much 'down' time.




However, it is imperative to insist that a high redundancy system simply cannot mean that delivery, output and/or outcome can be all over the place in healthcare - that would to put it simply - kill the ill; apart from causing significant morbidity.



So while the overall infrastructure is 'poor' by technology standards the output performance by humans delivering healthcare has to be pretty slick. A 'poor' 'system' (with high level of redundancy/slack, over-capacity and similar) has to deliver 'great' results. That is exactly what the human body does for us human beings - poor 'systems' delivering 'great' results.



That can only be done by building deliberate redundancy, planned slack in the system, over-capacity by design with specific high intelligence management. A large system which only uses small parts of it most of the time to deliver great results. A large system which kicks in fully only occasionally to cope with specific pressures and then goes to rest again. A large system that under extreme crisis shuts off most of its activity and concentrates on the vital few to survive and once it survives goes back to its normal (for human) inefficient (as per technology definitions) self.

This will require a completely contrary understanding to the one that we currently possess, We will need a new kind of intelligent management that may be non-existent right now. We need to learn from nature about the need for redundancy and over-capacity to live a normal life. Any one who is unable or refuses to learn from nature will be defeated by it – we cannot afford that in healthcare as our failure will affect our patients more than us.

©M HEMADRI

Follow me on Twitter @HemadriTweets

Indian Health: Money and Doctors Cannot Solve It - Get the Engineers Out There

India's recent mission to Mars seems to have provoked questions mainly from non-Indians on the need to prioritise development in other areas such as healthcare. Most Indians seem to be proud of the Mars mission and live on hope that the great successes seen in space exploration may somehow be replicated one day in other areas. Many non-Indian commentators and overarching international organisations have asked for India to raise healthcare spending.

The numbers seem to be all over the place. For the purpose of this blog discussion we will assume the following for Indian healthcare expenditure:

Percentage of GDP spent on healthcare 4%

Percentage of government expenditure on healthcare 8%

Per capita spending on healthcare $60 (if you believe wikipedia its $124)

Out of pocket expenses is around 60%

This is when the arm chair commentators, the ones who have never been bitten by a mosquito in an area where malaria is prevalent, should get out of the discussion and get a dose of reality.

What can you get in western healthcare for $60? Not a lot. 

This $60 per person per year spent on Indian healthcare is mostly accounted for by the 20% of people who represent the middle class and above. Many of the middle class get much more than $60 spent on them leaving in theory and in practice, a large proportion of the population to have nothing spent on their healthcare $0 per year. A friend recently had a colonoscopy in a frightfully expensive hospital in India and spent Rs 70000 ($1111) this may mean this friend has used up 17 other Indians' annual healthcare spend. You get the picture.

70% of the Indian people live less than $2 per day (33% of people are below the official poverty definition of $1.25 per day). You get the bigger picture.

By how much should India raise its healthcare expenditure? Doubling it to $120? What would that get? Nothing in reality. Doubling that to $240? You would not even scratch the surface. If the entire per capita income of an Indian which averages $1100 is spent on healthcare India will still have a healthcare expenditure less than Lithuania. Even at that level no one can predict if healthcare benefits will be equitably distributed across the population. It may well be possible that the rich will get healthier and the rest may get unhealthier.

The US example is relevant here where 18% of GDP is spent on healthcare at nearly $9000 per person yet 40 million US citizens do not have healthcare cover and US has poor outcomes for many chronic conditions. Throwing money at problems does not necessarily solve problems. 

Ask for a better system. Ask for a different system. If that system costs a little more, then the money follows, do not ask for more money to be spent on the existing system - it just goes down the drain.

Copying the current western systems of the 21st century for healthcare delivery in India straightaway  is expensive. This means the benefits of any copied western systems will reach the small proportion of the wealthy population. Well worth remembering the Jaguar in India costs the same as in England and obviously the only wealthy get to use it.

Alternative medical systems (ayurveda, siddha, homeopathy, etc) are still unable to provide comprehensive answers at a population level.

So what is missing? What are the potential avenues to explore?

Cannot Escape Evolution

There can be no doubt health improvement at population level has evolved gradually over time from the early 1900s. Interestingly the earliest foundations of population level health improvement happened not by direct personal medical based interventions but by infrastructure based social living conditions improvement. I am talking about covering the drains, separating animals from human beings, providing clean drinking water and so on. Direct intervention based healthcare followed much later.

In India in 2013 there are still many areas even within all the cities greater boundaries where there are open sewers. In 2013 in one of the poshest areas of a very major city there are contaminated water supplies. The healthcare budget cannot not solve this; yet solving it will improve the health of the people.

A healthy population is the greatest boost to an economy but the population cannot be made healthy by primary, secondary or tertiary care based direct personal medical interventions - i.e. doctors, clinics, hospitals. Populations can be made healthy only by political will and civil engineers. That is the trick India is missing. Building more primary and secondary care centres with open drains around them is the opposite of a decent healthcare solution. India cannot hope to improve the health of the population by avoiding a well established evolutionary pathway.

It seems India and its well wishers may be looking for the magic injection that will solve major health problems. There may be magic injections for diseases but we will do well to remember that there are no magic injections for health.

Under the given current conditions, doctors cannot solve the healthcare problem of India. Get the engineers out there. Get them to cover the drain, clear the puddle, provide clean drinking water and keep the roads clean. You will find the population becomes healthier contributes effectively to the economy. Then and only then we can spend more on healthcare and expect to benefit from it.

©M HEMADRI 

Follow me on twitter @HemadriTweets

I have blogged previously about great areas of Indian healthcare which you may want to check out.

Dr Bang's remarkable achievement in rural India which gets the same results as cities  http://successinhealthcare.blogspot.in/2013/01/swadeshi-healthcare.html

My conversation with the Chairman of Aravind Eye Care a low cost superior quality system about their culture  http://successinhealthcare.blogspot.in/2013/04/my-conversation-with-dr-ravindran.html