Do we need mathematicians to take care of our hospitals?

Eratosthenes was a Greek scholar of the third century BC. He was a mathematician among other things. But what I find amazing about him was that he was able to calculate the cicurmference of the earth without leaving his home Egypt. It did not require computer based mathematical calculations nor the advanced technology that became available centuries later. These technologies largely confirmed his finding that was based on observations of the differences in sun's position in Alexandria and the town of syene further south. While we ourselves are unable to make such intelligent inferences from our daily observations of nature, we almost always use simple logic and rudimentary math to get through this complex world. But unfortunately such simple approaches don't seem to work for professionals especially medical professionals and that too with regard to assessing their own competence. They prefer to search for inferences that do not question their competence.

It was diwali of 2005 and I was not expecting a call from Eratosthenes. However that morning, I got a call from Dr. Jaggy (name changed) whom I had met some months ago in a conference in south India. He wanted to know more about one of the latest incubator models in the market. As we got deeper into the discussion, he told me that results from the IVF treatment cycles were not as good as expected and concluded that a better incubator would solve his problems. Sensing that there was an underlying issue that may have triggered the call, I was tempted to ask for details. This doctor like most others was in no mood to admit the need for help. And on the other hand I did not want to sound like I was looking for more work. I decided to remain in listening mode. This was not easy for me but I did not want to make it any more difficult for him. I decided not to ask for figures but I needed to decipher the numbers. There was no way I thought I could understand the problem without objective information. Erastosthenes came to mind and I decided to 'decompose' the problem. First I needed to know what the recent past meant. As my thought machine went to work, I expressed my wish that his diwali call should have brought better news than the 'lower than expected' results. The quick reply was indeed revealing as he opens up that he was hoping for the same since last Diwali. And at that moment, I felt like Eras who had just recorded the elevation of the sun in Alexandria. It was clear he had been struggling with this problem for more than a year. . A long standing problem that needed a solution also meant an opportunity for me. While I began calculating the money from a potential consulting opportunity presenting itself before me , I wanted to know what the embryologist on his team had to say about the problem. His reply was probably as illuminating as the sunshine over Syene. He said' "They all say that there is nothing wrong but the results don't improve." The word 'they' seemed to be louder and clearer than everything else. I couldn't control my curiousity any longer and I asked him ," what do you mean 'they'? I thought you had only one embryologist". His answer seemed to cover the entire circumference of the problem. I did not need to understand the science of deductive analysis to understand why changing members of his team did not solve his problem. In IVF the performance of a clinic is dependent on the competence of its doctors and embryologists and of course properly functioning equipment. A new clinic with new equipment that is deemed as functioning well by the continuously replaced embryologist is usually indicative of a problem with the third variable. But for a doctor who runs the show, it is easier to find an alibi in the incubator. This is a common problem with under performers especially professionals. Acknowledging their inability to perform a task within reasonable limits of acceptability is not easy. But when it comes to patient care, it is the obligation of hospital leadership to take remedial action when unnecessary suffering is observed.

A few days after that call that would bring me money, I was at the receiving end of under-performance. My wife underwent a caesarian in a hospital that had differentiated itself in the region for its higher standards of care. Prior to the caesarian, we expressed our preference for spinal anesthesia. But we did have question about the risks for which we were given very comforting answers. Unfortunately, my wife ended up in bed for several days suffering from severe spinal headache. For a complication that was usually rare, we were resigned to the fact that theory of probability did not work in our favor. However in the weeks that followed, I made some inquiries internally during my regular visit to the hospital as a consultant. I learnt that the spinal headache complication levels were alarmingly high and a couple of months later complaints from obstetricians led to the management instructing the anesthetists to reduce the use of this technique during caesarians. I found it quite strange that in a hospital doing about hundred caesarians a month, they could not zero down on the poor performer using simple math. I had to assume that an acknowledgement of incompetence and knowledge of basic mathematics is after all a rare combination in clinical care. Unfortunately patients are at the receiving end of this avoidable mix of poor self perception and selective ignorance.

Standard operating procedures for bed time stories

The school organized 'Storytime Saturday' for the children in junior kindergarten. Parents would need to accompany their wards and together experience a story telling session. So last saturday I took my younger daughter Noora to listen to the story about the toad princess. At the end of the story, there was a lively discussion on the benefits of bedtime story reading. The teachers led the session and much was said about how it can improve parent-child bonding, imparting of good values, improvising language and lots more. I was so impressed with the school's initiative and thought that we should do this more frequently at home. That Saturday after a long day of shopping, we reached home tired and wanting to jump into bed as soon as possible. With the inspiring morning session still in my mind, I suggested we should have a story session if the kids were not too tired. What should have happened then was to have me read out a nice story, the kids listening attentively and they would gradually fall asleep. But what happened was nothing of the sort. I asked my elder daughter to get one of the books, sit in her bed and read out the story. My younger daughter and myself made ourselves comfortable on the bed. Within a few minutes I was asleep. Parent-child bonding, language training and everything else went up in dreams. The intent was good, the benefits were clear and environment amenable but it things did not turn out the way they should. A similar combination of circumstances and unintended outcomes occur unfortunately in patient care.

I am reminded of this today as I try to think of the effectiveness of training in clinical organizations The objective of training is always to impart the knowledge and experience of the trainer to the trainee and in clinical environments it mostly involves skills training. It is expected that at the end of training the trainee will eventually be able to duplicate what he or she has learnt and that too in a real environment. It can go wrong and even the most well intentioned trainee may fail to competently execute a newly learned skill. Once we have mastered the skill, we are more confident to undertake the task but we still can go wrong because of several reasons. One could be due to an error in judgment while executing a task. The kind we can make when we try to discern the type and location of pain of a patient reporting at the emergency room. Another reason could simply be the inability to make a decision when overwhelmed with complex circumstances. This is the kind when you are confronted with a young boy brought in with multiple injuries from a car accident. You did everything you could towards the injuries but you pump in the antibiotic that he is allergic to. The patient was accompanied by his father but no one on your team remembered to elicit this important piece of information from him. The second type of error is not due to lack of competence or absence of knowledge. It is simply the result of failing to execute an activity in a careful sequence.

I believe that such errors can be avoided or at least the probability of it happening can be reduced by having standard operating procedures or SOPS as it is commonly referred to. It could even be a defined clinical pathway where in a clearly charted out sequential course of action is meant to be followed. The problem with SOPs (and in this discussion I will include clinical pathways) is not just who should create and issue one but most importantly how it should be written up. I will try to summarize my opinion and I must say that the same rules would apply for SOPs on virtually anything even outside healthcare. In my view, SOPs must be detailed yet not too restrictive and it should leave room for professional judgement wherever possible. But being detailed does not mean intuition is ignored. We do not need to answer the 'does the pant zipper need to be downed before or after' type of questions. Yet we should also remember that SOPs will be used by newly trained or less experienced persons. Hence we should never leave out the essentials, must be clear, lucid and most importantly easily communicable.

Communicability reminds me of an afternoon at the school playground. It was probably in grade 4 or 5 and we all seated ourselves on the ground in a circle. The teacher whispered something in the ears of one of my classmates seated next to her. There were about twenty of us and each one would have to listen carefully and then whisper what he had heard into the next one's ear. The words would travel the circular route and when it reaches the last person he was supposed to reveal to all what he had been told. It turned out be a very amusing experience when an unspeakable something was announced to our curious bunch. It was a good laugh that afternoon in the playground but when I think of it now I realize that it is not an unusual occurrence even in the most sophisticated of technical environments.

Who would you like to talk to?

A friend of mine got an exciting job with a huge business group that is now venturing into the hospital business. He had been assigned to look after their first project and this was more than he had expected when taken on board. Last week as I met him over an extended dinner he elaborated on the huge responsibilities ahead. I could feel the excitement and towards the end of the first pizza he looked at me wondering what I thought of it all. I did not have to think much about my answer. My mind was fresh with the experience of two calls I had made an hour earlier. The calls kind of summed up a lot of pent up feelings I had about the hospital business. And what better a way to express myself than to make a change where it is possible. Across the table was a friend who had the job of shaping up a new hospital from the ground up. If I could convince him to do something about it then I should be happy that fewer people would have the same unpleasant experiences.

The smiling waiter brings another pizza to the table and in a well rehearsed manner asks for permission before he begins to serve. As my friends watches the pizza loaf being placed onto his plate, he breaks into small talk with the waiter. Without knowing what the conversation in the local language is about, my mind wanders toward the 2 calls. An hour earlier I called up the travel agent to discuss options for my upcoming tour. Having some concerns on whether the weather would be enjoyable for my kids, I ask him what he thinks. In a very reassuring voice, he says "Sir, don't worry I have myself been there at that time of year and I am sure your kids will love it. All you need to do is be adequately prepared. My kids loved it." I also brought up some queries on the quality of the hotels. Since he had gone through with me in detail about my previous trips, he tells me the hotels he is suggesting are the ones that 'families like you' would love. "Don't worry, you will thank me for the choices" he says in a very confident tone. Fully satisfied with the conversation, I look up at the clock and with a quick thank you and a promise to call back I end the conversation. I had just remembered that I was supposed to call the nearby clinic for an appointment the next day. I dial and as a lady picks up I say "Hello, I need to bring my daughter to the pediatrician tomorrow. Can you ...” My request is interrupted with a quick and brief answer in the negative. Before I ask when it would be possible to see the doctor, the phone is shut at the other end. I call again and this time I get to the point quickly and say “I need an appointment...”. But the call is transferred to someone else and I repeat my request hoping to complete my statement before it is transferred again. This time I raise my voice slightly and ask again. The voice at the other end seemed as though her otherwise nice working day was being spoiled by my call. But she turned out to be more responsive and told me "Come between 10 and 12 tomorrow. We don't take appointments." I quickly jumped in "But tomorrow is a working day so can you tell me how to see the doctor without waiting too long". Now the lady is obviously irritated and in a raised voice "You have to come between 10 and 12" and with that the conversation ends abruptly.

These 2 calls are fresh in my mind as I look at the pizza in front of me. In both instances, the caller at the other end is being paid to serve the customer. I pay them both if I want to or I can choose not to use their services. But the people at the clinic seem to think they are doing us a favor. We pay them but they seem to believe that we need them more than they need us. This is the reality of life as a patient or somebody who cares for him or her.

Back to the moment at the table and now I know exactly what to tell my friend. In a manner that may seem like I was making a personal request I tell him there is one thing he should do and that would make a big difference to the patients. Curious, he looks at me and I advise him that it would mean a lot to patients and their families if he hires people from the hotel or travel industry for the front end. I tell him that there seems to be a distinct difference in our experiences in the hospitality industry compared to hospitals and clinics. The difference I reasoned lies in the training and culture prevalent in both these industries. In one the culture is about pleasing the customer enough for him to love the experience so much that he or she wants to come back. In the other, the equation is different; it is about the sufferer being at the hands of a care giver. There seems no need to please in ways other than through medicine or the scalpel.

Medicine in the stone age

I do not normally remind myself as being among a species that first lived in the caves. But there are moments when the inexplicable behaviors of the medical fraternity take me back thousands of year to an age when the first wheels were being perfected.
To understand this let us travel back in time and imagine you are one of the cavemen who came to hear of a wonderful invention, the wheel by which people are able to cover distances or move goods with less effort. You haven't seen it but you are excited and bring back the wonderful stories to your own tribe. Then you begin to create your own wheel based on the rumours that you have heard and of course your own imagination. With more than full confidence in your abilities, you begin to cut out wooden pieces and join them in a shape resembling a square. You fit them on a sledge or whatever and conduct the first trial runs in moving a not so heavy rock. Sadly the first time it doesn't work and you are a bit upset. Then you think harder and come up with a 'smarter solution', you are convinced it needs sharper corners. You try again, sharpening it as much as you can but again it doesn’t seem to get things moving. You go back in the cave, drink some more goat milk, think harder and then eureka, you believe that all you need is to punch some holes and try it again. And this can go on and on until you may just maybe get it right. All the while you could have just walked 2 nights to see it for yourself and replicated the invention. But no, no, no you would not do that for you don't believe you need to. You know that you are very clever after all you were the first one in your generation to catch a monkey by its tail. Or maybe you came from a proud tribe that did not have a tradition of looking for guidance from the other cavemen. Whatever your past, many full moons may pass not getting it right. Or you could be lucky with ideas and finally shape out a nice round wheel that can carry your proud lady to the yearly wheat festival in the neighboring village.

How stupid you might think! Well the truth is that this is what happens everyday in many clinics or hospitals around the world. And if you have worked in a clinical environment, I am sure you have seen what I am talking about but have not probably understood the implications. But I couldn't avoid the implications because my job often was to make it right. The wheel may have become IVF or angioplasty, the full moons have become the calendar on the PDA but unfortunately some of the caveman persist in scurb suits.

Over the last ten years I have been involved in starting up new clinics. There are always challenges like meeting budgets and spatial constraints. There are difficulties in hiring the right people, getting the equipment set up right and there are issues in coordinating the teams and people involved to get it all right. But to me these are the simpler challenges, the ones that we can overcome. What I find harder to overcome are the hurdles in human behavior, mainly the stubborn determination to recreate the wheel if I may say so. The doctor often refuses to walk the 2 nights or does not like to be told what to do by the other tribes.

We are fortunate to live in an age where there is knowledge and skill available in abundance yet some choose to behave as though they live in a vacuum. They prefer to learn by trial and error often ignoring the fact that error is costly. It is more than just not being able to roll the fat lady to the wheat festival. They ignore the reality that not doing it right means the unlucky patient is forced to experience the nice doctor’s extra long learning curve.

The queue of the blind and the one-gloved ophthalmologist

In the world of medicine there are broadly two types of people, the care giver and the cared for. For those of us who are care givers, being humans we occasionally are forced to do a role shift and be among the cared for. We have to submit to our medical colleagues and allow them to take control of our lives. For me, this occasional switch in identity has given me the opportunity to view medical science from both perspectives and this is often very revealing. On those days I try to take an outsider view and I watch as doctors and nurses go about their work controlling our lives when we are most vulnerable. The revelations in those moments are often troubling.

One such day was this weekend when my wife had a mild inflammation of the right lower eyelid. To me it seemed that it could be a developing stye. Not willing to take the risk of a misdiagnosis for an eye condition we went to see the ophthalmologist at a nearby clinic. Standing in the long queue for patient registration, I look around and see that the waiting and hoping crowd isn't really smaller on a Sunday morning. We move to the next floor where a short walk from the elevator is the waiting area for the ophthalmologist's patients. As we settled into our not so comfortable seats, we realized that we were surrounded by numerous cases of what looked to me as the seasonal conjunctivitis and of course other unpleasant looking eye diseases. We wait our turn trying not to touch any surfaces in case we go back home with the virus. After about 40 minutes, the nurse informs us we are next in line and that we can move into the short corridor from where the door to the doctor's room is visible. Another few minutes and she signals us to enter the room. As we open the door, we see that he is only finishing up with the last patient. Or this is what we gathered on seeing the boy's mother rising up from her seat while the doctor has his gloved hand on the eyelids. Embarrassed that the doctor may have found us intrusive, we quickly shut the door and wait. Soon the boy and his mother walk out and we slip in as quickly. My wife seats herself on the examination chair. And I sit across the table with ears wide open hoping to hear that this is nothing but a simple stye and would require nothing more than a few days of medication and hot fomentation. The gloved hands make a thorough examination of her eyelids and convinced of the diagnosis the doctor starts his explanation of the condition and the simple treatment measures for the stye. Happily we walk out of the room satisfied and then onto the street. As I enter my car, it suddenly dawned upon me that this doctor had not changed his gloves before examining my wife. It was hardly ten seconds between his gloves on the other patient and then on my wife’s. Recalling memories from clinical practice days, I thought to myself that this doctor like so many other doctors would not change their gloves nor even wash their hands between patients. The results are alarming as is evidenced from the thousands of cases of hospital acquired infections reported every year. These infections are often deadly with many such avoidable deaths routinely occurring in hospitals around the world. I do not for a moment believe that this is because they want to deliberately transmit disease. Instead I think it is because they have all the weakness of being human. They can be lazy, forgetful arrogant and everything else that humans can be. And I am not trying to justify this but I am trying to think from the other end, the patients, the victims of this humanity. But this is what patients don’t expect their doctors to be, they do not expect their doctors to be affected by human weaknesses. Thus in their world of make belief, patients are blind to the real problem of what we have nicely termed ‘iatrogenic’ infections. Much effort has gone into hospital campaigns to make physicians wash their hands when they have to but unfortunately the problem persists. As a result, patients continue to wait in the registration queues for care not knowing that once past the queue they may actually be the unlucky ones to catch a disease courtesy of the doctor, the one gloved ophthalmologist

Moments of truth

Jan Calrzon is a legend in the business world. Well known for having turned around the failing SAS airlines in the 80s, his strategy for success was simple....focus on what he calls the 'moment of truth' which is the few seconds when a customer or passenger interacted with the airline. He called it so because he believed that those few seconds were a unique opportunity for the airline to make a positive and lasting impression. His clarion call to every employee eventually led to a transformation of the organization which soon reached the top ranks in customer satisfaction. This kind of leadership with an obsession for patient satisfaction and a strong belief that this is achievable only through team work is hard to find in healthcare.

Finding the right match

I was going through a case study on the hiring process at SG Cowen, a successful investment bank. I found in their hiring process the reason for my encountering dissatisfied employees at all levels in every healthcare organization i worked with. Cowen's hiring process was based on using technical skills as merely a qualifying criteria. The rigorous process they had devised was instead focused on finding the 'right match". The right match almost sounds matrimonial...it had be love for the job/groom and a proper fit into the groom's 'family'. But look at the hiring in our hospitals and clinics. The degrees and the technical skills matter. The rest is mostly ignored.