COMMENTARY

My Market Value

Medicine and Endocrine, I never imagined that I would end up being compared to a Coke bottle.
Global Standards in Healthcare

Shoaib Mohammad

India has a rapidly expanding

healthcare industry with private
hospitals proliferating in every
big city. The health industry is
expected to reach nearly $200
billion by 2020. This article
talks about the authors
experience of working within this
industry which places market
value as the most important
quality a doctor may have,
irrespective of qualifications or
experience. Doctors often face
challenges to balance this harsh
market-driven environment with
the best interests of their patients.

Shoaib Mohammad (shoaibirfan@yahoo.co.uk)

is a senior consultant physician based in Delhi.

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ou are a product just like this

Coke bottle, which needs to be
marketed and sold. Though you
have good credentials, you dont have
any market value, and this hospital
needs only consultants with a decent
market value, explained the smartly
dressed senior human resources (HR)
executive with a practised nonchalance,
sipping from the cola bottle. Having
recently returned from England, with a
training and clinical experience valued
in most parts of the world, I was confident that my credentials would help me
easily join a corporate hospital of my
choice in Delhi. Listening to the HR
executive sitting in that swanky basement
office of a prominent Delhi hospital was
surreal. It was a rather shocking revelation, which brought my enthusiasm on
returning home crashing down. As a
doctor I have had my share of appreciation, adulation and failure, but 12 years
after my MBBS, during which I had
collected two postgraduate degrees and
a unique clinical experience in Acute

Delhi and the National Capital Region

(NCR) had changed while I was away.
New corporate hospitals had come up,
owned by industrial houses of various
backgrounds. Some were built on prime
public land given away by the Indian/
Delhi government at ridiculously low
prices (Kala 2013) on the promise that a
certain percentage of patients will be
treated for free and that they will thus
share the burden of the government
hospitals in treating those with limited
resources. These hospitals are now competing with each other for a healthcare
pie that is projected to be worth billions
of dollars, especially with the influx of
patients from countries like Afghanistan
and Iraq; these countries have managed
to destroy their healthcare infrastructure. Every hospital, big or small, claims
to offer world class standards in terms
of services provided.
By now, I was looking at the nearly
empty Coke bottle with almost great
admiration and envy. I did try to reason
that my experience in England, which
included working in a university hospital

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in London, should surely prove to be a

valuable asset to any hospital that is
striving to achieve global standards. I
explained that training in England
achieves high global standards not only
in medicine, but also in refining ones
communication skills and etiquette,
which would certainly be much more
acceptable to international patients,
particularly those from the West. Allowing someone with my credentials to join
would make very good market sense
since I would bring to bear a truly global standard approach to my work and
thus achieve good results through
patient satisfaction and trust. Perhaps,
once I work for a few months or years in
India, I will acquire the coveted market
value as well. Meanwhile, our know-all
HR man was now probably contemplating lunch having finished the Coke
bottle. He excused himself promising
that he would discuss my curriculum
vitae with the concerned head of department (HoD) and would call me.
I have worked in four Delhi hospitals
since then. This includes a two and a
half year stint as HoD Medicine and
Diabetes in a 150-bed multi-speciality
hospital. Many of these hospitals are
built to five-star hotel specifications. In
fact, the contractor of one of the hospitals is still my patient and is confident
that he can convert a hospital he built
into a five-star hotel in a few months
time. The lobbies and reception areas
are amazingly done with liberal use of
Italian marble. They have cafes, restaurants, book stores and sometimes many
other shops that one would normally
expect in malls. One hospital even has a
mini-theatre (India Medical Times 2013),
where, according to the manager, attendants can relax and watch movies while
their patients are being operated upon.
If you do not want to watch Bollywood
blockbusters, there is a spa option as
well. I wonder how many attendants
watch movies while their loved ones
undergo surgery. My experience suggests
that the thought of watching movies
may never occur to most in such situations. Perhaps a relative whose patient is
getting a nose job or breast augmentation
would not mind a movie, but someone
whose loved one is getting operated
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NOVEMBER 7, 2015

upon for brain tumour will more likely

be found in the prayer room, which is
usually hidden in a corner or basement,
difficult to locate. Or, it may not exist
at all.
Passion for Medicine
The next day I received a call from the
HR executive, inviting me to meet the
HoD who politely proposed that I should
work as a junior consultant (JC). Once I
have gained some experience in India
and people get to know me, I would be
eligible, he said, for the position of a
senior consultant. I discussed this with
my wife and others in the family, and
decided to join. The hospital was within
walking distance of my home. The job
would enable me to gain a foothold in
Delhi while continuing my search for a
consultants post.
I was introduced to the two senior
consultants with whom I would be working as the JC. I was excited to finally do
what I love and enjoy most in medicine,
that is, meeting patients, taking daily
rounds, and attending to medical emergencies, deciding what is best for my
patients. Over the next three to four
weeks, I noticed a subtle frosty change
in the behaviour of my consultants.
Immodestly, I interpreted this as envy
since I was more qualified in terms of
degrees, and the bonding I shared with
my patients was of a different kind than
what they had with the patients. One
evening, when I was about to leave, I
received a call for an urgent meeting
with the consultants. I found them in
their office looking very serious, discussing something animatedly in whispers. One of them excused himself and
left the room as soon as I entered. While
I pulled up a chair for myself, the other
declared that I have no passion for
medicine. I was worried now and started going through the list of patients I
had seen that day, trying to remember
details where I may possibly have made
an unintentional mistake. I asked the
gentleman the reason for his statement
and received the most astonishing reply,
which I can still quote verbatim:
You are too honest with our patients. Even
if we want to keep our patients longer,
after meeting you, they are reassured
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enough to demand discharge in two to

three days. Since you have joined, the
numbers of higher investigations and
procedures we generate have decreased
substantially. You can never become
a successful consultant in Delhi with
this attitude.

I do not remember my response,

which got clouded by my disgust and
shock, but I did say that I had not joined
this hospital to practise this kind of
medicine. When I came out of the
room I saw the other consultant talking
with someone trying to avoid making
eye contact with me. I realised that
this man just did not have the guts to
stay in the room; otherwise he was in
total agreement with his colleague. This
was the lowest point in my career as a
doctor. I had never imagined that my
most important and valuable asset
would be considered a weakness. Being
honest with our patients is something
that comes naturally to most of us and
has never troubled me. The only time I
debate honesty is when I break bad
news to my patients whom I end up
diagnosing with terminal illness. I still
do not know the best way to answer
the question, Doctor, how much time
have I got?
I never went back to that hospital; my
stint lasted only a few weeks. I received
a call after a few days, giving me an
opportunity to resign. No one cared to
ask me why I had abruptly left. I did
consider complaining to the HoD or
the chief executive officer (CEO), but I
rightly realised that it was useless, and
now I am convinced that the rot went
right up to the leaders and promoters of
that hospital.
The Healthcare Industry
In a nation of 1.2 billion (Government of
India 2013), the government seems to
have pulled the plug on healthcare
expenditure by contributing only 20%
of its total expenditure. The corporate
world has sensed the opportunity and
investment is pouring in, mostly from
private equity funds (Brady and Saranga
2013). I regularly hear how the Indian
healthcare industry is recession proof
(Singh and Shukla 2008), and how
India is now one of the most lucrative
health care markets, projected to
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reach $200 billion by 2020 (Healthcare Industry in India 2014). The industrial houses seem to be following
the United States (US) healthcare model
blindly with many scions of these
family-owned firms trained at US
business schools. Nearly 40 years ago,
J B McKinlay (1978) was concerned
about the entry of similar capital in the
US. He observed:
The industrial and financial capital institutions in medical care impose the same
logic (profitability through expansion)
on this field that they have been doing in
other sectors of the economy since around
the turn of the century. Their presence
has ramifications at all levels. Among
other things, it fosters fetishization of illness through an increased and intensified
sales effort.

Many in the US are convinced that

their model for healthcare is failing (if
not already collapsed). In fact, a recent
report by the National Research Council
and Institute of Medicine (2013) suggests
that despite spending much more than
similar high-income countries, the US
ranks the worst with regard to infant
mortality and low birth weight, obesity,
diabetes, heart diseases, chronic lung
disease, disability, adolescent pregnancy,
sexually transmitted infections including
HIV and AIDS, drug-related deaths, injuries and homicides. The report is aptly
entitled, US Health in International Perspective: Shorter Lives, Poorer Health.
Though I do not completely agree with
McKinlay (1978), I would also worry
about the future of our healthcare model,
which, with each passing year, resembles more and more like that of the US.
Industry advocacy groups have been set
up to influence our public health policies
towards this goal.
India has a unique opportunity of
building institutions, not merely hospitals, which could be centres of excellence in medical research and training.
The thrust for these centres of clinical
research should eventually come from
the private sector, since the Indian
government is not expected to contribute
much. India spends about 1% of its gross
domestic product (GDP) on public
health, compared to 3% in China and
8.3% in the US. The latest budget
slashed this further by 20% for 201415
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(Kalra 2014). I believe we need real

leaders in healthcare who are able to
build institutions of excellence, rather
than crass business models.
Nearly three years ago, a former CEO,
and a key opinion leader, agreed to
listen to my vision of a good and effective medicine department with various
sub-specialties. During the discussion
on poor quality of care, he said that no
one in the industry worries much about
the quality of care with the present
hospital bed ratio; perhaps, once it
improves the industry will start thinking about improving the average quality
of care. As per World Bank data of 2011,
India has one of the lowest hospital
bed ratios at 0.7 (per 1,000 people),
which is comparable to many other
developing nations, such as Cambodia
and Eritrea. Both the UK and the US
have this ratio at 2.9 (The World Bank
2011). This was a very cynical view,
especially coming from a self-proclaimed
industry leader, who happens to guide
the industry as a consultant and boasts
about being a pioneer in developing
new hospitals.
I am yet hopeful there will be institutions in the near future that will have
values which will make a clinician like
me flourish and share the same vision.
Leaders of these medical facilities will
have the patience and ability to follow
through the vision of truly world-class
hospitals that will make the medical
world richer through their research and
innovations, as well as teaching and mentoring young doctors to achieve their potential, and perhaps helping India achieve
its public health goals.
Market Value
It has been more than seven years since I
walked away from our market value
hospital. I started my own practice
three years ago with attachments to
two corporate hospitals where I admit
patients. The progress is more than satisfactory with the number of patients
increasing to a level where I am compelled to refuse appointments on some
days. I have found amazing colleagues
during this journey, valuable doctors
who are serving this profession with the
utmost sincerity.

What is my market value? Perhaps,

I have some, but I would not want to be
compared to a Coca-Cola bottle. This is
a vulgar and demeaning comparison
when you consider the science, skills
and experience a doctor brings in to
advise his/her patients. In any case, I
counsel my patients to abstain from
consuming fizzy drinks, including CocaCola, because of their long-term health
effects! I strongly believe that the terms
normally used in boardroomsmarket,
market value, business modelshould
not creep into our day-to-day clinical
practice because it may further dehumanise our profession, our individual
thought process, and we could end up
losing the all-important human touch
completely.
References
Brady, M P and H Saranga (2013): Innovative
Business Models in Healthcare: A Comparison
between India and Ireland, Strategic Change,
Vol 22, Nos 56, pp 33953.
Government of India (2013): Executive Summary,
Primary Census Abstract Data Highlights,
Census of India 2011, Office of the Registrar
General & Census Commissioner, New Delhi,
viewed on 23 April 2015, http://www.censusindia.gov.in/2011census/PCA/PCA_Highlights/
pca_highlights_fi le/India/4Executive_Summary.pdf.
Healthcare Industry in India (2014): India Brand
Equity Foundation, December, viewed on 23
April 2015, http://www.ibef.org/archives/
detail/b3ZlcnZpZXcmMzY5OTEmOTU.
India Medical Times (2013): Now Hospitals Will
Have Movie Lounge, Spa, et al, 3 March,
viewed on 22 April 2015, http://www.indiamedicaltimes.com/2013/03/03/now-hospitalswill-have-movie-lounge-spa-et-al/.
Kala, A (2013): Turning Healthcare into a Gift,
India Today, 31 July, viewed on 14 April 2015,
http://indiatoday.intoday.in/story/private-hospitals-supreme-court-concessional-land-ratesdelhi-advaita-kala/1/297203.html.
Kalra, A (2014): India Slashes Health Budget, Already One of the Worlds Lowest, Reuters, 23
December, viewed on 23 April 2015, http://in.
reuters.com/article/2014/12/23/india-hea lthbudget-idINKBN0K10Y020141223.
McKinlay, J B (1978): On the Medical-Industrial
Complex, Monthly Review, Vol 30, No 5, pp 3842.
National Research Council and Institute of Medicine (2013): US Health in International Perspective: Shorter Lives, Poorer Health, Steven H
Woolf and Laudan Aron (eds), Washington DC:
The National Academies Press, viewed on 23
April 2015, http://books.nap.edu/openbook.
php?record_id=13497&page=R1.
Singh, N and S Shukla (2008): Feeling the Meltdown Heat?, Express Healthcare, December,
viewed on 23 April 2015, http://archivehealthcare.financialexpress.com/200812/market01.
shtml.
The World Bank (2011): Hospital Beds (Per 1,000
People), Washington DC, viewed on 23 April
2015, http://data.worldbank.org/indicator/SH.
MED.BEDS.ZS.

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