Tuesday, July 12, 2016

Money And Doctors, Shame Or Pride - Guest Post by Dr Manoj Manikoth - Docplexus

Born to three generations of government employees, I was so full of ideology when I finished my medical school. I wouldn’t practice, I said. I would only serve the poor, I proclaimed; a good teacher would I become, I yearned. And so was it, over the next few years. I wasn’t unhappy at all. I had very few needs and no serious financial commitments. Life was good, and little things kept me happy. 
But over time, I started feeling uncomfortable. Was I doing enough? I fancied myself a good surgeon-to-be, and as and otolaryngologist, I needed technology to go a step higher. But that needed money. I decided to work for it, but also balefully remembered my classmate in school, a perpetual cynic, who told me once, without mercy- “soon, you will be just the same as everyone else- do things only for money, and rot inside”.  I so badly wanted to prove him wrong. 
Then, as if by sheer chance, I happened to watch a TV interview of the well-known psephologist. He said, and I felt it strike a chord inside me - “the middle class are often bought up thinking that making money is bad- we need to get out of it and understand that to make money well is actually satisfying and benefits a lot of people”. Voila, I thought- I can actually relate to that. 
Lets now fast forward thirty years. I now am a surgeon with considerable repute, have a really good, well equipped hospital, employ over a hundred people. No, I didn’t have any inherited wealth, I didn’t marry for money, neither did I have wealthy friends who would pitch in for me. I also didn’t, much to my childhood friend’s surprise, make money the wrong way. All of us here work to protocol, never prescribe a drug, or order a test unnecessarily, refuse more surgeries than we do and there’s a strict no-no to pharma funding of any kind. How was this possible? There’s no magic here, no providential hand. Just a formula that can just as easily be adapted by anyone else with reasonable skill and a little bit of guts. 
Let me try and enumerate what made me do well. We must remember that for most of us, our only earning comes from the patient. This money is never given thankfully- illness is a burden and the expense related to it’s alleviation is given grudgingly. Understanding this basic equation must make us strive to make each rupee of that money count for the patient. So, the first recommendation from my side to an aspiring entrepreneur is to make sure that you give value. We have long been caught in a vortex of trying to undercut our charges to gain practice. It is a losing game. We have to add value, albeit slowly, for everything we do. A better waiting room, more efficient patient management, transparency and education, everything counts for the patient, and they would actually like paying for it. It is simple economics. If you intend to spend an x amount of money to increase the facility in your clinic/hospital, you need to spread it over the patients that you see now, and look at the increase in patient flow due to the better system to make your profits. You just can’t work the other way, it is foolish to invest heavily and think they would come pouring it just because the waiting room rivals a luxury suite. The increase in your professional worth is what should give you profits. 
Let us take an imaginary scenario. There are often patients who present with a symptom that could be because of two different conditions. Doctor A, is cautious, ill trained and afraid of failure. He would investigate heavily, and when that too doesn’t give him enough clues, gives the patient medications for both conditions. The patient gets better, yes, but the doctor would never know which medicine has made him so. The spiral begins, and patients get investigated more and more, medicated more and more, side effects of treatment spirals and skill acquisition is minimal. Let us look now a doctor B. He is shrewd, well trained and is not afraid to experiment. He starts with the same uncertainty. He, by using an analytical, but yet unskilled brain, thinks in favor of one. He doesn’t investigate much because he trusts his instincts. If the patient gets better, he is elated- he is proven right. If he doesn’t, there’s always option 2. To prevent the discomfiture of an irate patient irked by the delay in treatment, he uses kind words and counseling to reassure the patient that he is only trying to avoid unnecessary medications and investigations. Over time, doctor B gets more and more skilled. He now has acquired that sixth sense which tells him what the patient might be having instead of over investigating. If the doctor B has entrepreneurial skills, he will now increase his charges. What the lab gets and what the pharmacy gets is now his. Money, now flows into the coffers, and a beaming patient praises the doctor. Doctor A is, unfortunately, still despondent.  
 The same goes for investing in surgical equipment. If you think that a particular instrument would greatly add to your results, buy it, but do not look at charging for it every time you use it to repay your loans. It creates stress and stress reduces your results. You would buy a Laser, simply because the salesman would pitch in with a formula “Sir, you might have ten laser cases a month, so x times ten times twelve, your loans are over in so many years” It is a gambit we fall for. I would buy a Laser only if it significantly improves my results. I would never even advertise or boast about it. I would use that in my counseling for a surgery if I think its absolutely necessary. But I would increase charges over my entire operation list for the month to make sure I am not pressurized to use it when I don’t really need it. Thereby I have only marginally increased charges; I have no stress if I don’t have any laser cases for a month, and if I do get one, I do a pretty damn good job. And this creates more patients, while shouting from the rooftop that I have an expensive laser would only have created suspicion, and sometimes, jealousy. We have to prioritize our investments- I would rather buy a good equipment than say, a fancy car or a palatial house that I can very well do without. If my choice of the purchase was founded on good grounds, it is often that the house and the car would follow, even if you can’t really count on it! 
Similarly, we must understand that a well run professional medical establishment offers far greater returns that those fancy stock market juggle. I was once told about this by some one who I consider my mentor and hold that close to my heart. My only real investment is my hospital- and if I retire, that should give me returns in decent terms for as long as I live. Another important lesson I received early on in life is from a senior neurosurgeon colleague. He once told me that it was a dangerous ploy to keep referral patients over 10%. It surprised me then, but the logic was irrefutable. Referrals are fickle. A doctor who refers to you can stop referring to you, even if he is not unhappy with you. But your patients, those who come to you for solace and comfort, are your real saviors. They bring more convinced patients who in turn, become your well wishers again. Many doctors spend a lot of efforts on placating the referees, little knowing that it is really not worth the effort. If you spend a quarter of that time with your own patients, the results are astounding. 
Nearly thirty years in practice, my referrals are still less that that magical figure. And I am in no way unhappy. A very good financial trick is to stick to the things you do best, or add someone to the team who would do something better than you. I have often seen people holding on to patients too long, and not referring out of fear of losing them. Referrals should be made early and to the appropriate person, not someone who calls you home for a weekend treat! Over time, you might lose friends, but keep only the good ones who value your intention. As I have surmised before, earning trust is worth its weight in gold, and nothing improves your stature more than the feeling you create that if you can’t do it, you will send them to someone who can. You also need to plan a retirement. 
For many doctors, this is unthinkable. To prevent burn outs, and to improve your family and social life, this is of paramount importance. A simple formula is to calculate how much you need now, once your loans are paid off and then plan to have that over the next twenty years, giving 10% to inflation. So, after you have reached the fifties and if you’ve been successful, you need to delegate your practice to deserving youngsters who respect your principles of practice and think about a system which gives you a share of the practice you have so painfully built up. You should, at that time, put yourself at a premium. Reducing your consulting hours and increasing your charges will allow you to work less for the same amount of money. And, for your social responsibility to be satisfied, you can also use your free time, involving your family too, to do your mite to the society, what appeals to your heart. 
Finally, you need to invest in your health. Eating properly, exercising regularly and reducing stress will help you to enjoy what you’ve reaped. And for those unfortunate times when ill health can strike without warning, it is important to be properly insured. An ideal health insurance should cover even the costliest procedure done, and should cover your family too. I am currently insured for 95 lakhs, and feel safe under its umbrella, even if I don’t even have a health issue at present. It might look an overkill, but considering the peace of mind it offers- priceless. Even more adequate should be your life insurance. This should give your family the same income even with you not being around. And do junk those policies that offer you a lot of investment benefit. The health and life insurance policies are useless for me if I am in good health and if I am alive- but I would rather be happy that I am healthy and alive! What made me want to pen this all down? Being a person who cannot resist being on social media for doctors, I see a lot of frustration and angst. I see many who feel that they are being hunted, victimized for no fault of theirs. I see people who feel that they do not receive their due. At the other end, I see the public who are critical, and out to malign the medical community for the wrong doing of a few. And there seems to be no way to make these radically different view points meet. It appears that the level of frustration is related to the failure of the medical profession to make it pay, and for the customers to realize what they are paying for. Let us not kid ourselves anymore- medical profession is just another profession, and it is no more noble than that of a lowly servant nor any worthier than that of a soldier. We have only one small difference- we aren’t in control of many things that we deal with. We deal with uncertainties and changing patterns of  ever increasing knowledge that rival most other professions. But we cannot, under the cloak of that nebulousness, neither wallow in self pity, nor puff out in artificial pride. We have to deal with this as a profession, and aim to give our very best, and by making sure we are doing so, to get in return what is due. Once we realize this, most our our helplessness should disappear. I do not consider myself a special person, and I do not ever want to think I am indispensable to many. I am here to do a job as best as I can, and with that, take my due. No one, I think, should ever suspect that I am taking more than I could, or attempting to do more than I should. This is all that I ever need.

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