Successful Medical Practice Winning Strategies For Doctors PTN Communications

Successful
Medical Practice
- winning strategies tor doctors
Dr.Aniruddha Malpani, MD
Dr. Anjali Malpani, MD
Successful Medical Practice:
Winning Strategies for Doctors
Dr. Aniruddha Malpani, MD

PTN Communications
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Dr. Aniruddha Malpani, MD

Copyright:
Dr. Aniruddha Malpani and Dr. Anjali Malpani
Cartoons Copyright :
Dr. Hemant Morparia
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Preface
The education of the doctor which goes on after he has

his degree is, after all, the most important part of his
education.
— John Shaw Billings (1838-1913)
Running a successful private practice can be hard work.

While medicine can be a very fulfilling profession, one
out of every three doctors reports that medical practice
leaves them dissatisfied because they have too little
time for themselves or their families. Doctors suffer
from depression four times as often as the general
population ; and many doctors hate their jobs and
dislike the majority of their patients. While most doctors
acquire a high degree of medical expertise during their
long years of professional training, unfortunately few
learn anything at all about the nuts and bolts of
running a practice. While some have a natural flair for
entrepreneurship, many end up doing badly in real-
life.
In fact, many doctors are now quitting practice
because of too much work, too much hassle, too much
competition, too much despair, and too little
reimbursement. They are increasingly feeling the
pressure of having to see more patients, do more in less
time, discount their fees sand face more competition.
vi I Preface
Like the White Queen in Alice in Wonderland, they find

they are having to work harder just to remain in the
same place. However, working harder (which is often
the only solution most doctors can come up with to
cope with this problem) is not the answer. After all,
there are only 24 hours in a day ! What doctors need to
learn is to work smarter, more efficiently, and more
productively—and with less hassle and more
satisfaction. The secret is to learn how to manage
yourself. The problem is that certain skills—especially
time management, knowledge management, and
relationship management—are not taught in medical
schools and most doctors have to learn them the hard
way. Unfortunately , the majority never do, and they
fail to live up to their potential, leading lives of quiet
desperation.
Like them, do you find that you are fed up of:

• Long energy-exhausting hours and crushing
workloads leaving little or no free time ?
• Demanding dissatisfied patients ?
• Inadequate payment for all your hard work ?
The purpose of this book is to help you find a truly

satisfying way of practising medicine which would:
• Give you control of your time;
• Allow you to do work which you felt was worthwhile,
for patients that you enjoy seeing; and
• Pay you well for your effort, so that you enjoy going
to work every day.
Many doctors feel they are very productive because

they see patients all day long. However, there is a
difference between being busy—which almost all
physicians are these days—and being productive. This
Preface I vii
is the difference between inputs, which is how busy

you are, and outputs, which is how productive you are
- and the smart doctor will focus on improving his
outputs. The better your practice fits with what you
really want to do, then the more productive—and
happier— you will be.
A hundred years ago , when life was much simpler,
the successful doctor was said to need three things; a
top hat to give him authority, a paunch to give him
dignity; and piles to give him an anxious expression.
Today, a doctor who wants to run a successful private
practice needs to be far more accomplished. He needs
to be :
• Clinician , who has polished medical skills, a

reassuring bedside manner; and a high personal
standard of medical ethics and professionalism;
• Academician, who is a constant learner , and keeps
up-to-date;
• Manager , who understands the business aspects of
running a profitable clinic, and is knowledgeable
about marketing and networking;
• Financial expert, who can manage his money and
his investments;
• CEO, who understands how to motivate staff and
lead people;
• Family provider, who is a good father and husband;
and a
• Self-care-taker, who know how to look after himself
and fulfill his personal needs .
While this may seem to be an intimidating list, there

are many techniques which can help you become more
successful. While many of these are based on simple
common-sense, this book will allow you to think about
viiil Preface
them clearly, so you can apply them to your own life.

The best practice management advice is disarmingly
simply : "Patients are the practice. Everything else is
just paperwork'."
All doctors have a different definition of success. For
someone, it may mean having lots of patients; for others
it may mean a new car every year; others may find it
in publishing high quality papers in academic journals,
while others find happiness in teaching students. There
are as many ways of having a successful private practice
as there are doctors, because everyone's definition of
success is very personal and private. You need to create
your own path, because success is internal and is
achieved when you reach your own goals. We are
privileged to be doctors - let's make sure we enjoy doing
what we do, so we can all be happy and successful in
our own lives !
— Dr Aniruddha Malpani, MD
— Dr Anjali Malpani, MD
Medical Director
Vital Signs,
Medical Practice Management Consultants,
Mumbai,
India.
Email:info@drmalpani.com
Owener- Bangladesh
Contents
Preface v
1. Planning Your Career:
Carve Out a Niche for Yourself 1
2. Beginning Practice:
Get Off to a Flying Start 10
3. Designing Your Clinic:
Make it Patient-friendly 27
4. Assessing Your Practice:
A Critical Look 36
5. Marketing Your Practice:
How to Get More Patients 43
6. Business Management:
Basic Skills 55
7. Financial Planning and Management:
Boosting Your Bottomline 62
8. Making Your Money
Work for you 69
9. Hiring the Right People 80
10. Creating Superb Employees 88
11. Good Medical Records:
Worth their Weight in Gold 95
12. Scheduling Patients:
Managing Appointments Efficiently 101
xI Contents
13. The Telephone: Your Clinic's Lifeline 107

14. Buying Medical Equipment:
Getting Value for Money 112
15. Going Digital: Using Computers to
Enhance Your Efficiency 118
16. www.doctor.com: Setting up
Your Virtual Clinic on the Internet 122
17. Information Therapy:
Educating Your Patients 128
18. Communicating with Patients:
Your Bedside Manner 136
19. Listening to Your Patients 143
20. Winning Your Patients' Loyalty 148
21. Improving Your Emotional
Intelligence: Honing Your People-skills 160
22. Keeping Up-to-date:
Learning How to Learn 165
23. Time Management:
Working Smarter 173
24. Managing Mistakes in Medicine 180
25. Steering Clear of Malpractise Threats:
How to Avoid Legal Battles 188
26. Crisis Management:
Coping When the Chips are Down 193
27. Risk Management: Keeping Problems at Bay 201
28. Health v/s Wealth: The Danger of
(Mis)managed Care 210
29. Making Your Marriage Work: Keeping
Your Better Half Happy 217
Contents | xi
30. Parenting - Bringing up the Next Generation 224

31. Retiring: From Medicine, Not from Life 233
32. Medical Ethics: How to Do What is Right 240
33. Preventing Burnout: Manage Stress 249
34. The Impaired Physician:
Healing the Wounded Doctor 258
35. Professionalism in Medicine:
Striving for Excellence 265
36. Physicians as Leaders 272
37. Spirituality in Patient Care:
Looking at the Bigger Picture 286
38. The Joy of Practicing Medicine:
How to be a Happy doctor 292
Chapter 1
Planning Your Career:

Carve Out a Niche for Yourself
If you don't know where you are going, you'll probably

end up somewhere else !
- Lawrence Peter
Many doctors naively believe that once they start earning

lots of money and have a long line of patients waiting
for them, they will have it made. Once they reach this
point, many are quite happy to cruise on their reputation
and skills for the rest of their lives. However, to judge
the health of your career, it's not enough to just look at
your income statement - you need to assess your
personal balance sheet as well. You are a professional
and your major assets are your medical knowledge and
skills. You need to keep on building these if you want
to remain successful. The Japanese call this kaizen, which
means constant improvement. If you do not actively
work at it, your career prospects will decline, even
when (or perhaps especially when) you are making lots
of money. In fact, the more "successful" you are in later
years, the greater the temptation to exploit existing skills
- and the harder you need to work to make sure that
you don't just rest on your laurels. You have to find
ways to continue to develop the knowledge that your
21 Succesful Medical Practice: Winning Strategies for Doctors
patients value. Doctors get paid for their time, but that's
not what we sell. We sell our medical knowledge and
skill, and left untended, these depreciate in value
surprisingly quickly. This is especially true in medicine,
where the knowledge base expands exponentially every
year, and new discoveries are being made all the time.
We all need a personal strategic plan for our careers,
and the sooner you formulate this, the easier it will be
for you to progress.
Most doctors' careers have the following five stages:
• Entry, when you are starting out;

• Establishment, when you have created a name for
yourself;
• Exploration, when you look for new fields to conquer;
• Specialization, when you settle down in your niche;
and
• Mastery, when you establish yourself as the expert
in your area of interest.
Whether you are 25 or 55, you always need to think

about where your career is headed. The one constant in
life is change - and as medical technology, governmental
regulations, insurance reimbursement policies and
patient expectations change, you will need to change
with them. As you think about your career, here are
some questions to ponder:
• In what way are you personally more valuable to

your patients than last year ?
• What specific new skills do you plan to acquire or
enhance in the next year?
• What is it that you want to be famous for?
Planning Your Career: Carve Out a Niche for Yourself I3
Traditionally, doctors have adapted themselves to

their jobs - and most have uncomplainingly and blindly
done what the rest of their colleagues are doing.
However, many are increasingly finding that this is a
difficult burden to bear. This is why, rather than change
yourself, it is better to create a job, which is especially
designed for you. A niche is " any position specially
adapted to its occupant", and if can find your niche
where you can practice effectively, this will help to make
your career in medicine enormously rewarding. After
all, we all have different interests and talents. Why not
use these to stand out and shine - you need to play
from your strengths. Find your special interest as soon
as possible. What turns you on? What do you enjoy
most? What part of your work would you be happy to
do daily without pay? The secret for success is to find
something you love doing and very good at - and then
to attract patients who will pay you to do this for them.
A niche does not need to be some new thing imposed
on you (unless you want it to be) nor does it need to be
a whole new aspect of your life (again, unless you want
it to be).
If you want to make yourself a truly valuable asset,
then you have to focus your attention on building a
highly specific set of knowledge and skills - you have
to carve out a niche for yourself. With ever increasing
sophistication in medicine, patients value specialisation,
and you have to consider what your patients define as
value. For your patients, your asset is valuable only if
you have technical skill as well as the ability to apply it
in a customized way to their situation. It is important to
make a distinction between knowledge and skill.
Knowledge is relatively easy to accumulate, but it
depreciates. Skills are harder to win, but keep their value
a little longer. For most doctors, technical skill alone is
rarely enough. To be a valuable doctor in the eyes of
patients, you need to learn a wide variety of

interpersonal skills as well, which allow you to
communicate effectively with your patients.
Each patient encounter can teach you - if you are
willing to learn. Many good surgeons will take time at
the end of an operation, for example, to ask themselves,
"What went well, and why? What didn't go so well,
and why not ? " . This self-imposed discipline allows
them to critically analyse their performance, so they can
come up with ideas that will help them get better the
next time. Keeping notes will also help you remember
and apply the lessons next time. Take every opportunity
to discuss your work with colleagues, so you derive
value when they ask "Why did you do it this way? What
would have happened if you did that?"
Although creating a niche for yourself can be a lot of
hard work, there are ways to make the job easier. For
instance, if you want to be known as an expert in a
specific area of medicine, it helps if you give professional
talks on the subject. Start locally and expand your
horizons as word of your expertise travels. If you are
inclined to write, publishing articles in peer-reviewed
journals or the lay press will help to further establish
your credibility as an expert. Join professional
organizations that can provide valuable information in
many forms, including publications, seminars and formal
coursework. For example, if you are interested in writing
on medical topics, you can check out the American
Medical Writers' Association (AMWA). If you are
interested in becoming a hospital administrator, you can
contact the American College of Physician Executives
(ACPE). Having a niche allows you to differentiate
yourself from other doctors, so that you can attract more
work . Being different can be very helpful in becoming
the leader, so don't waste time trying to be everything
to everyone and ending up becoming nothing to no one.
Planning Your Career: Carve Out a Niche for Yourself 15
The secret for planning your career is to pick a clear

focused personal professional goal. As physicians, we
aren't used to choosing our own professional goals
because they were usually chosen for us. Throughout
our training, we were told what we were going to do,
and when and how we were going to do it. But by not
setting our own career goals, we have no direction—
which is why, after 10 or 15 years of practice, some
physicians end up saying, "Is this really what I wanted
to do? Did I train 16 years to do this?" When you set a
goal, and every day do some work toward reaching that
goal, you begin to take control of your professional life.
That's why choosing a professional goal is the most
important single thing you can do—it starts to put you
back in control of your career. Each year, perhaps on a
specific date such as your birthday, you might want to
reflect on the path your career is taking. Think about
what things you can do in the coming year to further
define your niche. As time goes on, you will develop
new interests. At some point, you may even want to
move in a completely different direction. Taking the time
to reassess what you are doing on a regular basis allows
you to incorporate these new interests into your life ,
and to get rid of things that you really don't want to
continue pursuing. Discovering your true mission in life,
and then allowing that to frame a career that is specially
designed for you, can help to make you a true healer.
Both you and the people whose lives you touch will
reap the rewards of the careful thought and planning
that go into creating your own personal place in the
world—your niche.
The most important factor in your career design is to
shape your practice around your abilities. In doing your
self-assessment, five areas are key:
• Values: What motivates you? What would make you

feel you were devoting your time and talents to
something extremely worthwhile?
• Skills: What's your strong suit? Which strengths do
you have that complement your medical skills? Are
you skilled at something you don't enjoy doing? If
so, you'll want to de-emphasize it so you don't
gravitate toward something you won't like.
• Behavioral style: How do you approach problems,
people, rules, and procedures? What kind of pace do
you like to keep?
• Cultural preferences: Do you like the intimacy of small
medical groups or the anonymity afforded by a larger
organization? Are you a traditionalist, or an innovator
who prefers a fast-moving, entrepreneurial culture?
• Lifestyle: Are you a family- and community-oriented
person? An outdoor enthusiast who needs the right
setting to pursue other passions? A travel bug who
needs to take vacations on your own schedule?
Thus, if you are an orthopedic surgeon and find you

are technically clumsy in the operation theatre, it's better
to stay out of the OR and not botch up surgical
operations. Instead, you could choose to specialize in
medical legal work, by providing advise to lawyers in
medical compensation cases - a very remunerative field.
If you enjoy what you are doing, you will do a much
better job at it.
You don't have to limit yourself to medicine either.
Many doctors have successfully pursued careers in
many other fields, such as information technology,
writing, law and business management. Some start
coaching classes to teach medical students, while others
Planning Your Career: Carve Out a Niche for Yourself |7
serve as consultants to the pharmaceutical industry. In

today's world, your options are limited only by your
imagination. Other doctors have been even more
enterprising and have a portfolio of careers - after all,
there is no rule which says that you have to slavishly
do one job all your life. Having a career portfolio can
add colour to your lives , because it ensures you have
multiple interests to pursue, which keeps you on your
toes; and also allows you to create a financial buffer, in
case one career is not doing well at a given time.
Remember that you are your most important asset.
You can think of yourself as a small company - You,
Inc - which you need to nurture. It's no longer enough
to just become a doctor and work hard anymore. You
must do something you love, have outside interests,
participate in your community and continue learning
throughout your life. These are investments in your
future, which help you lead a life full of purpose and
meaning. Unfortunately, too many doctors (especially
those with successful careers) have forgotten that there
is more to life than just earning money. Finding a second
source of income, which comes from something you love
to do, will make life much more interesting - after all,
medicine can become very monotonous if you don't
explore new options. As you get senior, it's the quality
of your patients which counts, and you are not going
to be very excited about doing your 500th appendectomy.
Finding a mentor who can give you the benefit of
his experience can also help you achieve your goals. This
is why every athlete has a coach - to drive them, to
make suggestions, to help encourage them to better their
best. Coaches know exactly how to get their "stars" to
work a little harder, to stretch their horizons, to try
things that they ordinarily wouldn't have tried left on

their own. Many doctors hate the business side of
practice, but that is exactly where profits are made or
lost. So, what's a doctor to do? Simple - put a
knowledgeable coach on your success team, and maybe
you'll win the Olympics of success in practice ! How do
you find such a coach ? If you have a friend or relative
who is a successful businessman, ask him for help. Many
successful people are very happy to share their secrets
of success with others. Another useful source is your
patients. Pick your most successful patient, and ask for
help. Most patients are more than happy to help their
doctors.
In his book, Finding Your Niche, author Laurence Pino
suggests trying this exercise.
Visualize your own funeral. There will be four

speakers at the service: a family member, a friend, a
colleague , and an associate from your community.
What would you like these speakers to say about
you and your life?
This might seem a morbid thought to some, but it's

worth considering Pino's point. What exactly is it that
you hope to accomplish in your lifetime? You then need
to plan your life so that you can achieve these goals.
Planning backwards works much better than stepping
forward into the unknown. If you plan well, you can
lead a life which you can look back upon with pride
and joy.
Planning Your Career: Carve Out a Niche for Yourself 19
Chapter 2
Beginning Practice:
Get Off to a Flying Start
The starting point of all achievement is desire. Keep this

constantly in mind. Weak desires bring weak results, just as a
small amount offire makes a small amount of heat.
— Napoleon Hill
Starting practice can be difficult, because so many things

need to be done at exactly the right time, and it's easy
to get overwhelmed. Often, it's difficult to know what
to do and when to do it, because this is the first time
in your life that you will be handling a job of such
complexity entirely by yourself. A little advance
planning can go a long way toward giving you
confidence when your clinic actually starts. It's helpful
to have a timeline and use basic project planning
techniques to ensure that everything goes off smoothly.
A good start will boost your chances of long-term success
considerably.
When to start ?
When should you cut the umbilical cord of training

and start practice ? How do you know when you are
ready to start off on your own ? This depends upon lots
of factors, such as your career goals and your field of
Beginning Practice: Get Off to a Flying Start |H
specialization. Thus, while a family physician may be

comfortable starting within a few months of graduating,
many specialists will want to work with a senior
specialist for some years before starting out on then-
own. Other factors such as marriage and bearing
children can also play an important role in this decision.
Where to start ?
Deciding where to practise is one of the most important

decisions you will need to make. Sometimes you may
not have much choice in the matter - for example,
married women may have to settle down where their
husband chooses to locate. But if you do have a choice,
then how should you go about selecting the best location
for your practise ? Most new doctors mindlessly choose
to settle down in large cities, because this is where the
"glamour" and "action" is. However, often the
competition here is intense, and you may be much better
off looking for alternatives. Remember that the place
where you eventually practise will, to a certain extent,
determine the pattern of the practice. It may take
months of research and effort before you find a town,
which is not only suitable for your practice, but also
optimal for your personal life and bringing up a family.
There is an axiom in business that there are three
keys to success: location, location, and location. The best
location for your practice is in a convenient, highly
visible, and easily accessible office. The easier you make
it for potential patients to find and use your services,
the more quickly you will achieve the level of success
you desire. After all, if you want to deliver a service to
the public, then you will be most successful if you are
located where the public is willing to go. Selecting a
location should be done with the same care as selecting
a spouse - you want a long, healthy, prosperous and

happy lifetime together, so treat the decision with an
eye toward the long term. Chances are that you will
spend many years building and growing your practice
in the location you choose, so it's important for you to
consider where you would like to work and live for the
long term.
You should pay attention to the following points:
• The community's need for a doctor.

How many other doctors are there in the area ? What
are their specialties? Will the area support another
doctor ? What is the density of the population ? Is
there anticipated growth or decline in the
population ?
• Tour needs and those of your family

Are buildings or office premises available for
purchase? Will you lease or rent? Has the property
plenty of car parking space? Is there good access to
public transport? What are the recreational facilities
and social opportunities? Are there good schools
nearby? Will they suit the ages of your children?
Will the rest of the family be able to find work? Will
planning permission be necessary to convert the
property for medical use?
• The local medical facilities

Is there a good local hospital or health centre? What
other doctor are available for consultations and
referral? Are they likely to be cooperative?
Since this may be one of the most important decisions

you ever make, give it enough thought and attention,
Beginning Practice: Get Off to a Flying Start 113
and don't just accept the first opportunity which comes

your way. It might be a good idea to serve as a locum
or an assistant to get a "feel" of what practice in the
area is like.
Types of Private Practice
When you commence private practice , you will need

to decide which form your practice will take. There are
three main options:
1. Single-handed practice.
2. Partnership, and
3. A group practice.
Which method you choose will depend on your own

physical and mental abilities, financial circumstances and
personal aspirations. All the methods have their
advocates; it is up to you to determine and define your
aims in order to find out what you really want. It need
not be an irrevocable decision; you may decide to start
working single-handed, and then meet a colleague with
whom you feel you could work and form a partnership.
Single-handed Practice
This is by far the most popular type, and allows you to

be completely independent. You have to be dedicated
and confident, because you are responsible for everything
connected with the practice, including obtaining
premises, fixtures and fittings, decoration, practice
organization, financial planning and management; and
you will have to make all the decisions. Think of yourself
as being an entrepreneur starting and running a small
company. Independence can prove a little daunting,
particularly if you have been working in a hospital
where much of the support structure is provided and

the responsibility is mainly clinical. However, you do
have the satisfaction of knowing that the success of the
practice is all your own work and, of course, the patients
are entirely yours. This type of practice is very flexible
it can be started without legal formality and the
accounting requirements are fairly straightforward and
simple. It gives great freedom, but it brings great
responsibility. Many practitioners enjoy working on their
own and have highly successful and profitable practices.
You can make decisions yourself without having to waste
time on committees and meetings - and you can mold
your practice so that it is as efficient as possible.
The disadvantages occur when you are ill or you
wish to take a holiday, for unless you close the practice
or find a suitable locum, holidays become non-existent.
You might also find it harder to compete with larger
group practices which have greater financial muscle, so
you will have to work harder to attract new patients. If
you are ill and cannot practice, there is no income -
effectively, you are a "daily wages" earner ! Solo practice
is still the commonest form of private practice in India
today.
Partnership
If you want shared responsibility, a partnership with

one or more colleagues may be the answer. A
partnership is preferably a formal legal relationship
rather than an informal agreement with no legal
authority. A partnership consists of two or more people,
who join together with a view to making a profit. The
partnership is subject to certain legal formalities such as
the sharing of profits. Each partner is personally liable
for the debts of the partnership or of the individual
partners if they are unable to meet their own debts.

Therefore, there must be complete confidence and trust.
Partnerships have many advantages. Each partner
may contribute capital and will devote time and energy
to the success of the practice. Special skills and expertise
may be complementary, thereby expanding the range
of patients the practice can accept. Decisions,
responsibilities and management of the practice will be
shared. A partner may well bring in valuable referrals
and contacts. In addition, an older and more experienced
practitioner can be of considerable benefit to the practice.
A partner is invaluable if you are ill, have an accident
or if you have to give time to a family crisis. Whether
you personally are at work or not, the practice will
continue, the patients will be seen and you are relieved
of the worry of finding a colleague to cover for you
while you are absent. Partners should not only be
regarded as useful for the difficult times- it is also very
pleasant to share success with somebody else and to
plan for the future.
A partnership is, however, a close relationship and
entails a great deal of tolerance and understanding if it
is to be successful. A shared decision can mean one
which is reached only through compromise and possibly
argument. Disagreements are rarely over patients, but
usually center on management or financial matters.
Patients identify with a particular partner and there is
occasionally a cross over during holidays, professional
courses or sickness, so the attitudes and behavior of
the partners should convey an atmosphere of stability.
Take your time over entering into a partnership. It may
be a good idea to work together informally for a while
to see how compatible you are before signing any
agreements. A partnership, whether informal or formal,
is a social contract, and as in marriage, divorce can be

expensive and upsetting.
Group Practice
Group practise is becoming increasingly popular in India

now. Here, two or more practitioners' join together to
share expenses such as rent, rates, electricity and water
charges. In this type of practice, therefore, you would
have to access to all the facilities, such as the receptionist
but remain independent, responsible for your patients
and with complete control of your own finances. This
option has many attractions, particularly the shared
responsibility for the premises and facilities and the
contact and friendship of your fellow practitioners. This
can be very useful for referrals, on call duties and
holiday arrangements. In the US , after the advent of
managed care, most doctors have turned to group
practice, because they found it difficult to meet the
bureaucratic hassles and paperwork demands of HMOs.
Many US doctors want the protection of an established
practice, with someone else running the business, so
they don't have to cope with administrative hassles,
and can focus on providing good medical care to their
patients.
The ideal size practice is represented by the fingers
of one hand for specialists and the fingers of both hands
for primary care physicians. Specialists shouldn't try
to grow much beyond four or five because they start
acting like employees and refusing to compromise for
the good of the group. And, there's nothing to be gained
by getting bigger. All the sub-specialty skills can
normally be covered by four or five colleagues and there
are few economies of scale to be gained by further
growth. The statistics are clear: the larger the practice,
the higher the overhead.
Hospital Practice
There are additional options too. Many doctors now

prefer to work full-time for large corporate hospitals.
While this provides the prestige of being a consultant
in a reputed hospital, a steady stream of patients, an
established infrastructure, access to the latest medical
equipment, and no administrative responsibilities, you
need to pay a price for this. While the job satisfaction
can be tremendous, since you are working in a "state of
the art " medical facility which attracts challenging
patients from all over the country, and serves as a
referral center for difficult cases, since the hospital retains
the majority of the patient's fees, your financial benefits
are capped as compared to doctors in private practice.
Also, most hospitals are hotbeds of petty medical politics,
and the amount of backbiting and bitching which goes
on amongst the medial staff can be frustrating. You also
need to know how to butter up the hospital's
administration and trustees to keep them happy. Many
doctors find that not only does the hospital
administration retain the lion's share of the profits,
leaving them with chickenfeed, they also force them to
admit a minimum number of patients and to generate
a certain amount of income every year , as a result of
which they lose their medical autonomy. Since
competition for these hospital attachments is intense,
the fear of being thrown out of the job is always present.
Government Practice
Many doctors find practicing in a government hospital

satisfying. They do not need to worry about attracting
patients or raising money to start practice. They usually
have the pleasure of being able to teach the next
generation of doctors, and this interaction with medical

students and residents keeps them young. Job
satisfaction can be considerable, since the sickest and
most complex patients often end up in government
hospitals. One is also on many government regulatory
bodies and committees and can wield considerable
power in public health, government projects, and
professional medical societies. As professors, many
doctors are leaders in their profession . However,
dealing with the bureaucracy and government
machinery can be a uphill task. One needs to keep the
VIPs in power happy, and buying new equipment can
be a frustrating exercise. Also, promotions and
professional opportunities are restricted; you are forced
to live with limited budgets and miles of red-tape; and
many doctors find the chores associated with
administering a department very unwelcome.
Key Advisors You Need
When practicing medicine, you will need advisors to

help you with your various business, legal and
accounting needs . Rather than solicit informal advice
from friends, family or others, you will be better served
if you select professional advisors in the very beginning.
You may want to seek recommendations from other
physicians concerning these advisors. Interview each
of them. Once you are convinced that they have the
experience you need, determine whether you can
establish a rapport with them individually, and if they
can work with each other. Choose these advisors with
great care and forethought - they will play a vital role
in the future growth of your practice. Perhaps one of
the most important characteristics to look for should
be how well you can relate to him, because this
relationship requires a high level of trust and

understanding. Once you have found an advisor you
are happy with, you can ask him to recommend another
advisor in the other fields you need help. Thus, an
accountant you are happy with may recommend an
attorney, or vice verse.
The Accountant
The accountant will be responsible for the following:
1. Setting up and monitoring financial record keeping,

2. Establishing sound financial guidelines on
expenditure, salaries and pensions,
3. Advising on, analysing and projecting the growth
and development of the practice,
4. Preparing the annual balance sheet and income
statement,
5. Dealing with all tax matters.
The Lawyer
A lawyer is another necessary advisor. You must ask his

advice in connection with all legal matters. Lease
agreements, conveyance documents, partnership,
limited company and insurance agreements must all be
seen by him. A small legal practice with two or three
partners is usually the best option to ensure that your
lawyer has enough time for you.
The Bank Manager
A sympathetic and helpful bank manager is essential

in financing the initial capital expenditure and
providing you with a reserve to pay continuing expenses
until the practice begins to generate some income. It is

a good idea to have a talk with him before you begin
looking for premises or take the first steps towards
starting a private practice. He then knows what you
have in mind and can advise you on a number of
matters. He may even put you in touch with the other
professional people who may be of help to you. Banks,
on the whole, are kindly disposed towards applications
for professional practice facilities, because doctors
usually have a good track record in repaying their
loans, and are considered to be excellent credit risks.
Unless there is a serious problem, you will have no
difficulty in obtaining the money you need for the
practice.
There are other advisers you will need as well, and
one of the most important is an insurance agent. Don't
even dream of starting practice without ensuring that
you have a valid professional indemnity insurance policy
to protect you from malpractise claims. You will also
need to insure your clinic and the expensive medical
equipment you buy. Other advisors may include:
financial consultants, to help you manage your money
as your practice grows; and marketing consultants to
help you grow your practice. In the US, medical practice
management firms will often provide these services
under one roof.
Getting Referrals
The first few months after you start practice are usually
the most difficult for most doctors. You are full of
enthusiasm and your technical skills are finely honed,
but you may find that attracting patients is very difficult.
If you are fortunate and come from a family of doctors,
this will help you immensely in getting off to a flying
start - but what happens if you have no doctors in

your family ? Most doctors will go through three stages
in their professional life.
1. No work, no money, lots of time,

2. Some work, some money, some time,
3. Plenty of work , plenty of money, no time.
Unfortunately, many doctors who start practice end up

falling prey to the temptation of giving cuts and
kickbacks to referring doctors. They are so desperate
for patients, that they are willing to stoop to any depth
to allow them to make ends meet. They justify then-
approach by saying " Everyone does it anyway"; and
are worried that if they don't, they will starve. However,
this is a very short-sighted tactic, which will end up
hurting you in the long run. Not only will it reduce
your self-esteem because you are behaving unethically;
it will also force you to do things you are ashamed of
doing ( for example, unnecessary surgery, because the
referring GP insists you do it). Also, you could devote
the same energy more constructively to building direct
referral channels to your patients, which is far more
satisfying and rewarding in the long run.
So what can you do to get more patients ? Actually,
quite a lot. Sitting and waiting for patients to come to
you will not help - you are going to need to get out and
let people know about your skills, so they will want to
send patients to you. In order to get referrals , you need
to rely on an ever-widening circle of friends, colleagues,
and contacts. In order to do so, you need to learn to
"network", that intangible collection of skills that
successful businesspeople seem to use effortlessly.
Networking, when handled skillfully, is more art than
science, just like medicine is. Whether its simple rules
are followed by either a new doctor or veteran physician,

networking can produce decided benefits. You first need
to start by networking with colleagues. Unfortunately,
most doctors still treat colleagues as competitors. They
are seen as rivals, and petty medical politics often result
in rivalry and pulling each other down - energies which
could have been constructively used instead to build
each other up. 'United we stand, divided we fall' is as
true today as it was centuries ago. Networking allows
you to pool your skills with others, so that the sum of
the parts is greater than the whole. Just like some doctors
naturally acquire a polished bedside manner, others have
excellent networking skills. Most of these doctors are
politically very active, and their "people skills" are
excellent. You can learn from them how to network
efficiently. Treat your colleagues well and trust them.
Do not bad-mouth other doctors - word gets around.
Make it easy for them to get in touch with you and
update them about their patients. If you are computer
savvy, offer to help them update their skills, so they are
grateful to you. Attend medical conferences and use
these as opportunities to meet as many of your colleagues
as you can. At social occasions, instead of hanging out
with old friends, fraternise as much as you can so you
can develop new contacts.
Successful networking is about meeting people and
forming relationships - you help them so that they will
help you. Try to do as much good to others as you can.
If you want to increase the number of referrals to your
primary-care practice, interact with potential sources
of new patients. Determine who the relevant people are
- you need to perpetually scan your environment and
mentally tuck away the names of people and
Beginning Practice: Get Off to a Flying Start | 23
organizations that will eventually be of use to you. You

also need to be able to give them good reasons as to
why they would be better off sending their patients to
you, rather than anyone else. They key to networking
is to follow up and stay in touch. For example, sending
a personal note of thanks is one task that many of us
fail to do. The benefits of such a simple act are
incalculable.
Networking involves honing your interpersonal skills
and the following acronym will help you network more
efficiently.
N: Remember their names.

E: Eye contact is key.
T: Talk less and listen more.
W: Write follow-up notes on a consistent basis.
O: Be open and ask open-ended questions.
R: Become a resource to others.
K: Knowledge is power; know people and know
their work.
Your patients can be very helpful in your networking

efforts. You can capitalize on their goodwill to make
new contacts and explore new opportunities. Most
patients are grateful towards their doctors, and are more
than happy to help them. Many doctors have made
good use of their patients to build up their practice and
so can you. Learn to speak in the local language - this
simple act will help to set your patients at ease, and
increase your practice mainfold.
Here are simple techniques successful networkers
use.
1. Speak: Take every opportunity to speak about your

specialty - both on a one-on-one basis, to making
presentations to large groups. Be enthusiastic and
willing to talk - and have ready-made presentations for
those "last-minute" invitations. Eloquent doctors are
always in demand.
2. Participate: Join medical organizations. It is better
to belong to fewer organizations and take an active role
in them than to belong to many with superficial
connections to the membership. Truly participating
allows you to really get to know people and thereby
supports your desire to build professional relationships
with them. If there isn't an organization that fits with
your objectives, create one. It can be a physical
organization or a virtual one. Being the founder of the
organization gives you instant credibility with your
entire membership and gives you an opportunity to
define and mold it.
3. Publish: Write articles. While this can be difficult,
it will get easier as time goes by - and the more you
write, the more you will be asked to write. Doctors
who can express themselves clearly are always in short
supply.
4. Volunteer: Volunteering is a great way to build
professional relationships while giving back to the
community. Take a volunteer position that allows you
to use your skills and express your passion. Your
network will grow along with your sense of
accomplishment.
5. Socialize: Socialising is great way to build and
nurture your network . It's very useful to host an
event. This can be a party at your house or a recurring
event at a chosen meeting place. This will provide an
informal way to get together and connect the members
Beginning Practice: Get Off to a Flying Start | 25
of your network with each other. If each member

brings a member of their network, it will also help to
significantly expand yours. Remember, the secret for
success if often not knowhow, but know who !
As with any job, well begun is half-done, and while
your first few years in private practice can involve a lot
of hard work, this investment of time and energy can
pay off in spades for the rest of your life. Don't get
disheartened when things don't seem to be going well
in the beginning - remember that one has to struggle
to establish oneself.
Chapter 3
Designing Your Clinic:

Make it Patient-friendly
Always design a thing by considering it in its next larger

context—a chair in a room, a room in a house, a house in an
environment, an environment in a city plan.
— Eliel Saarinen
Most doctors starting practice have a limited budget, so

your options when constructing your clinic are likely to
be limited. However, since this is one of the most
important decisions you will make, you need to give it
a lot of thought. Don't hesitate to raise funds or take a
loan to buy more space than you think you can afford.
Not only will your investment in real estate be sound,
you need to leave yourself enough space for expansion
for the future as you become busier, since changing
your location is so difficult once you are established.
Unfortunately, most doctors' clinics are still very
depressing places - and most look just like any other
doctor's clinic. Spend some time and energy in
designing and building a better clinic - after all, you
will be spending most of your life here ! If you prefer
practicing medicine to going on weekly sightseeing
excursions to look at suitable sites, you need to find a
reputable, commercial real estate broker to help you
find space for your clinic. Based on an evaluation of
your needs and budgetary requirements, the broker

should produce three to five prime sites in your target
area—containing information on traffic, photos,
locations of competitors, and details on leases and/or
purchase options.
Try to locate your clinic in a site which is close to
public transport, so you are easily accessible to patients.
Most cities have their equivalent of a "Harley Street" ,
which is considered to be the "medical heart" of the
city where many doctors practice. If you can afford a
place here, this is a useful "high-profile' address to have.
Being located in a busy area will help to attract
patients, many of whom prefer doctors who are close
to where they live. Practising in a "medical office
building" along with a lot of other doctors will help to
put you in the heart of all the medical action, facilitating
networking with doctors, and getting and providing
referrals. Of course, it may also mean that patients
may go to your "competition" in the building, rather
than come to you.
Try to stay as close to your residence if this is possible
- commuting can be hell in many cities today. Many
young doctors start many clinics all over town, and
take as many hospital attachments as possible, in order
to attract as many patients as possible. While easy
availability is important, often this means that they
waste a lot of their time commuting. Not only does
this drain their energy, it also is frustrating for patents,
who may find it very difficult to get hold of the doctor
when they need to. Hospital attachments can be a
valuable source of patients , and also allow you the
opportunity to network with colleagues and establish
yourself professionally. The admission and operating
privileges they provide are essential for doctors in
surgical branches, who need theatre facilities.
Designing Your Clinic: Make it Patient-friendly 129
When you start your clinic, make sure you have all
the required permissions. For example, not only will
you need permission from the society if you practice in
a residential building, you will need to make sure this
permission is in writing, so you do not have problems
in the future.
While purchasing the premises can be expensive, you
can look upon this as an investment in real estate, which
will usually appreciate in time and is a valuable asset.
A less expensive option is to lease or rent a place to
start your practice . Young doctors who are just starting
practice may not be able to afford a clinic of their own.
In such a case, starting practice in a polyclinic is a very
useful stepping stone. Study the owner's policies and
decide whether they are good for you and your patients.
Does the polyclinic offer any services apart from a
consulting room? Do they have an efficient receptionist?
Is the receptionist capable of handling your patients?
After how many years will the rent increase? Are the
current doctors practicing in the polyclinic happy with
the owner ?
Be careful in selecting an architect for designing your
clinic. Remember, experience counts. It's a good idea to
actually visit the clinics the architect or interior designer
has built in the past, to ensure that his work is reliable.
Also, keep an open mind, and friends, doctors and
patients for suggestions for your new clinic - they may
have seen novel ideas elsewhere which are worth
incorporating.
Strategically placed sign boards outside the building
are extremely important in helping your patients find
your clinic. Illuminated sign boards are even better, since
they will increase awareness of your clinic in the
community. If you work in a large building, make sure
that the entrance to your clinic stands out in the maze

of doors and corridors. Keep your building security
guards and lift operators happy ( perhaps by providing
them with free medical care) , so that they take better
care of your patients.
In order that your clinic functions efficiently, rooms
should be built to allow optimal traffic flow of patients,
and medical and clerical staff The designer's goal
should be to make patient "flow and function" run
smoothly, with a minimum of disruption and noise.
Space is always at a premium, and you will need a
skillful architect to help you make the most of every
inch. Your time is precious, and your availability is often
the bottleneck in your clinic's functioning. This is why
it may be a good idea to have two or more examination
rooms, so that you can examine more patients in a
shorter time . Thus, while you are examining one
patient, your nurse can help the other patient get ready
for you in the other room. A time and motion study has
shown that three treatment rooms are the ideal number
for a medium-sized practice. Visiting the clinics of senior
doctors, especially those in large cities,as well as the
newer five-star hospitals will also give you lots of ideas
as to how you can create a pleasant ambience in your
clinic. If you can afford it, go abroad to see the world's
leading clinics, so you can use these as a model when
designing yours. Remember to wire your clinic for the
future, so that it is ready to accept the newest telephone
and computer networks.
Medical clinic designers have started to introduce a
new and exciting interior design format called the
"therapeutic environment." These designers feel that
healing and recovery are dramatically affected by colors,
finishes, lighting, views, furnishings, open spaces, and
even sounds and smells. These are referred to as

"positive distractions" and have actually been shown to
be healing agents. The practice decor must project a
professional image. Interior designers and decorators
are expensive but if you do not have a good, imaginative
sense of colour and design, then you will need the help
of a spouse, a friend or a professional. Pictures can be
useful assets in addition to the colour scheme, especially
in the reception room where patients are waiting, since
they provide a talking point with other patients. We
have put up the pictures of some of the test tube babies
which have been born in our clinic, and many patients
enjoy looking at these, since it gives them hope that
they can succeed to. You can put up patient educational
posters as well as a bulletin board, which has articles
on medical topics your patients will find of interest.
Attractive information signs are extremely useful since
they help direct the patient and save a lot of questions.
Many signs are mass produced by firms, or you can
have them custom designed. Such examples include:
no smoking, details of clinic timings and payment
schedules.
A good way of finding out how your patients feel
when they arrive in your office is for you to sit in your
own waiting room. Are you comfortable ? Would you
be happy to wait in this room ? Design your clinic by
always keeping the patient's viewpoint in mind, so that
you can build an office that maximizes your productivity
without losing the warm human touch that
characterises the best practices. Many physicians now
have TVs in their waiting rooms, so that their patients
don't mind waiting.
Provide for a welcoming atmosphere by positioning
your receptionist with direct eye contact with anyone
coming through the door. To make the reception area

seem more friendly, don't place the receptionist behind
a wall or behind glass. Pictures of you receiving awards,
and photos with famous personalities and celebrity
patients can reassure your patients ( and their family
members) that you are a competent doctor. Putting up
your medical diplomas and certificates will also help
to reinforce your credentials , ability and learning. You
might also want to put a file which contains
testimonials from patients about your services. A press
cutting file which contains articles by and about you
is also impressive. Keep your practice brochures and
patient education pamphlets in your reception area.
Encourage your patients to read these- and to take
them home - this is an excellent way of marketing
your service.
Patients expect the clinic to be clean, and you need to
be obsessive about this. Make sure all the cleaning is
completed by the time the first patient arrives. If you fail
to find anybody to do the cleaning, you will have to do
it yourself. The ambience of your reception area creates
clues for people about what they should realistically expect
from the care and service in your practice. Too elaborate
an area may send a message that care will be expensive,
while an overcrowded room full of grouchy looking people
signals a long wait and a rushed physician. The seating
and the size of your reception area must be adequate, not
only for the patients, but also for the relatives and friends
they frequently bring with them. As a rule of thumb, if
you see four patients in an hour, you should have twelve
seating spaces (three times the seating capacity for the
number of individuals you have scheduled to see in the
hour)
A telephone line should be available for the patients'
use, as they may wish to ring their office or home. The
best option is to install a pay-phone service, to ensure

the phone facilities are not misused. A rack or table
carrying an adequate supply of general interest
magazines is essential. Do not let your magazines
become dusty, torn and two or three years out of date.
Flowers and plants in tasteful arrangements have a
welcoming effect. Silk flowers and plants are a good
way of avoiding continual worry about watering,
providing they are not allowed to become drab and
dusty. Background music is popular and can provide a
pleasant and relaxing atmosphere for patients who are
sometimes tense when they arrive. Have a supply of
tea, coffee , biscuits , sweets and soft drinks for your
patients and visitors. A supply of drinking water should
always be available, as should toilet facilities. The toilet
is often the best indicator of a facility's focus on
cleanliness and hygiene. Make sure yours is spotless
and kept clean . It's a good idea to use it frequently
yourself to ensure this is done ! A collection of small
toys and children's books is a good idea to prevent
boredom.
If you can afford it, airconditioning your clinic is
one of the best investments you can make. A
comfortable environment will not only keep your
patients happy, it will also dramatically enhance the
productivity of your staff. Carpets have become more
affordable, and offer a touch of class to your clinic.
If you use assistants in your clinic, try to provide a
private seating area for them, where they can talk to
patients in private. Patients must have a small private
area in which to change. A simple curtained-off space
in one corner is adequate; or screens may be used if
curtaining is not possible. Some very busy doctors try
to improve their efficiency by seeing more than one
patient at one time. This is terrible, and should be
avoided. The least you can provide your patients is

your undivided attention - even if it is only for a few
minutes. Patients understandably hate talking about
their problems in front of other patients.
Your front office is your public face, but just having
a comfortable reception is not enough. Your staff is
vitally important, and they can literally make you or
break you. It's a good idea to provide uniforms for your
staff. Not only does this help your clinic look much
more professional, it also helps your patients identify
your staff members. Staff should wear name badges;
and having pictures of the staff with their names and
designations on your bulletin board can help to enhance
their self-esteem, because it sends a message that every
person on staff is a respected member of the team. It
also makes it easier for patients to approach a staff
member when they can recall the person's name. The
best feature of a good reception area is an immediate
acknowledgment of people as they arrive. A warm
welcome creates a positive expectation about the care
and service that will follow and builds trust and rapport.
You need to constantly motivate your staff to present
your practice in a positive light. Staff-patient interactions
are crucial because the reality is that your staff spends
much more time with your patients than you do -an
average patient spends 45 minutes to one hour in the
office and only five to 10 minutes with you. Every
interaction that patients have with the practice has to
be managed and made positive. Investing in good
employees involves more than wages — you also need
to provide them with the best tools for the job, including
computers and Xerox machines, depending upon your
practice needs.
It's a good idea to create an office manual which
describes commonly performed office procedures, such
as answering the telephone . It is useful to have "check

sheets" and reference pages, which summarise the
common queries patients have . While establishing these
systems may seem like a lot of trouble, having a defined
system will help your practice to grow. The primary
responsibility of the front office is to greet patients—
period. Remember that you never have a second chance
to make a first impression, so make sure you make the
most of your space, funds and staff to make the best
impression possible.
Chapter 4
Assessing Your Practice:

A Critical Look
Good criticism is very rare and always precious.
— Ralph Waldo Emerson.
After practicing for a few years, we tend to get into a

rut. This is why it's a good idea to step back and
critically appraise your practice every year . You can
use the following criteria in order to do so objectively.
If you can request another doctor to do this for you,
this is even better. Critical patients can also help you
improve , provided you don't get defensive when they
censure you. Use their feedback constructively to
improve the care you provide to your patients.
a. General Clinic Facilities
Is the area big enough ? What about the design,

atmosphere, cleanliness, maintenance ?
Are the waiting rooms comfortable ? Do the patients
feel pampered ?
Do the examination rooms offer privacy ? Are they
well-equipped ?
Are the toilets clean, easily accessible ?
Assessing Your Practice: A Critical Look 137
b. Telephone System
Are their enough incoming lines ?

Are phones answered promptly and politely ?
Are fax, e-mail sefvices available ?
Is there a scheduled call back time or other means of
returning calls ?
Is there a system to ensure incoming messages are
appropriately directed and acknowledged ?
Do patients know how to contact you after the clinic
is closed in case of emergency ?
c. Appointment System
Does it satisfactorily accommodate patients ? Is there a

very long waiting list ?
Do you keep to your appointment schedule ?
Is there a system to accommodate urgent or
emergency appointments ?
Is there provision for coverage after the clinic is
closed ?
d. Filing System
Is the filing system efficient and accessible ?

How are the charts coded ?
Is there a system to avoid mis-filing ?
e. Medical Instruments and Equipment
Is the equipment modern and up-to-date ?

Are appropriate sterilization procedures in place ?
Is there a system for managing biomedical waste ?
f. Drug Supplies and Samples
Are appropriate drugs available and properly stored ?

Is there a proper system for maintaining current list

of drugs on hand and monitoring expiration dates
Are narcotics and other controlled drugs stored
securely ?
g. Emergency Facilities
Is the emergency medical cart appropriately stocked,

centrally stored, and readily available ?
Does the staff know what to do in the event of an
emergency or disaster ?
h. Laboratory Investigations
What type of investigations are available ?

Are they accessible on-site or close by ?
Is quality control maintained ? Are the results
verified? checked ? recorded properly ?
i. Personnel
Is there enough staff for running the clinic smoothly ?

Are they well trained ?
Do they work well with each other ?
Are regular staff meetings held to troubleshoot
problems ?
Are there documented job descriptions and office
policies ?
k. Miscellaneous Observations
Is there a system for handling incoming medical reports

and test results ?
Is there a system for handling consultations and
referrals ?
Are educational and medical reference materials
available for the doctor ? For the patients ?
It is also a good idea to pretend you are a new

patient, and subject your clinic to the following First
Impressions Test. This can help you identify deficiencies
in your present practice, so you can work on improving
it.
First Impressions Test
1. Is the practice easy to identify from the street?

Yes No
2. Once inside the building, is it easy to find your

office? Yes No
3. When you enter the office, is the air fresh?

Yes No
4. If a glass partition separates the reception area

and the receptionist, does the receptionist open it
immediately when a visitor arrives?
Yes No
5. Is the reception area furniture free of stains and

tears? Yes No
6. Is there some individual seating in the reception

area? Yes No
7. Are there current issues of different magazines?

Yes No
8. Are patients greeted with a smile?

Yes No
9. Do staff make eye contact with the patient?
Yes No
10. Are first-time patients welcomed to the practice?

Yes No
11. Does a staff member ask the patient about the

name he or she prefers to be called? Alternatively,
are all adult patients addressed by their last names?
Yes
No
12. Are patients afforded privacy to explain why they

are there? Yes No
13. Are patient names and records accessible to staff

only? Yes No
14. Do staff - orient patients about what will happen

next? Yes No
15. Does the patient meet his or her physician before

disrobing, giving a urine specimen, having blood
pressure checked, and so on?
Yes No
16. Do staff or physicians apologize for waits longer

than five minutes?
Yes No
17. Do staff members listen without interrupting?

Yes No
18. Do physicians and staff appear to be happy in their

positions? Yes No
Don't get disheartened if your score is low - this

checklist can give you a goal you should aim for.
Benchmarking Your Medical Practice
While the term benchmarking may be unfamiliar, it is

something doctors do all the time to improve their
clinical skills. We compare and observe skilled and
experienced surgeons, for example, so we can learn their
superior surgical techniques - and in exactly the same
way, benchmarking is a business technique which
analyses successful competitors to determine the
indicators of business success, and then applies that
information to achieving business growth and
improvement for yourself. For doctors benchmarking is
a way of taking a critical look or "snapshot" of your
practice's health. It provides you with an objective way
to measure your practice's performance, and to compare
it with others', so that you can learn from the best
practices of the leaders.
Historically, physicians have not formally
benchmarked their practices. However, benchmarking
is not such a new concept, and it's something all of us
have been doing informally for years. For example, when
we compare our past year's income with our present
year's performance, we are using internal
benchmarking. Has your income gone up or down?
Have expenses remained steady, or have they spiked
up? Looking internally will show you how well you are
progressing.
Clinics have also used benchmarking to improve their
clinical protocols. Thus, leading IVF clinics collaborate
with each other and compare their techniques and
pregnancy rates, so that they can learn from each other,
and adopt the techniques which give the best results.
Benchmarking is an excellent tool for assessing the
health of your practice and detecting problems as early
as possible. Remember that you can learn a lot from

other successful doctors - and benchmarking will allow
everyone to improve. Thus, if you are reluctant to
share information with your local "competition", you
might want to benchmark with a colleague in another
city, whose specialty and practise size is similar to yours.
Rather than compete with each other, you can
collaborate to create a win-win situation.
Chapter 5
Marketing Your Practice:

How to Get More Patients
Everyone lives by selling something.

— Robert Louis Stevenson
The word marketing is still taboo for many doctors,

and many physicians confuse marketing with
advertising. We need to remember that the role
physicians play is unique, and that marketing
techniques adopted by other industries are not
appropriate for doctors. What you need to concentrate
on is "practice building"- which is a perfectly ethical
activity of promoting your practice that successful
doctors have been using for many years. Traditionally,
the only acceptable marketing allowed was "word of
mouth", but today doctors can use additional avenues
to promote themselves ethically. The purpose of
practise building is to let potential patients and referral
sources know who you are, what you do, and when
and where you do it.
Why should doctors worry about promoting then-
practice? After all, if you are good then won't the
patients automatically come to you ? If you are the only
provider of your particular expertise in the region, then
you may not need to worry too much about marketing.
But today, doctors compete for patients and if you

want to see your practice grow and flourish, you need
to market yourself.
Satisfied patients are the best word-of-mouth
marketing tool a physician Can have because they tell
others about the positive experiences they have had
with you. In fact, the major premise of this book is
that if you can make your practice patient-centric and
focus on keeping your patients happy, you will become
a successful physician. You should make every effort
to exceed your patients' expectations regarding their
health care. For example, if you phone patients at home
after surgery and check on their conditions, you can
create a "wow" experience for the patient. Patients
who receive a personal phone call from their physician
will almost certainly tell dozens of other people about
it, generating word-of-mouth referrals. This strategy is
easy, costs nothing, and is extremely effective.
Should you attempt to market directly to the public
? If you want your practice to grow, the simple answer
is - Yes. The real question is not "should we do it?,"
but "how do we market to patients?" Since doctors in
India cannot advertise , you need to select your
marketing tools carefully.
There are many avenues open to you. For example,
volunteering at the community level can bring positive
attention. As an advisor or board member for a public
service agency, your name can become recognized as
a resource for health -related information. Thus, the
local media are more likely to seek a quote or an
interview from an Indian Cancer Society board member
than from a less prominent oncologist in town. The
best way to market is to give something away everyday
- and giving away your time, services and expertise
for free can be very effective.
Marketing Your Practice: How to Get More Patients 145
One of the best and least expensive way to market

your practice is to attract media attention. This can
allow you to attract free public relations that would
normally cost thousands of dollars if you had to pay
for it and, more importantly, can attract even hundreds
of new patients to your practice. Remember that the
media are always looking for news - which means that
if you want them to cover you, what-you do should be
new. For example, if your clinic has bought the first
laser for tattoo removal in the city; or you have devised
and successfully performed a new operation, you have
a story that will be of interest to the readers of
newspapers.
You need to understand what the media wants when
trying to pitch your story to them - remember that
thousands of stories are competing for the limited space
in a newspaper. Try to Idok at things from the
reporters' point of view if you want to succeed in
getting coverage. You need to be aware of their job
and their needs (for example, what the difference
between a news story and a feature story is; and what
their deadline is). They are professionals too, and if
you help them to do their job well , they are much
more likely to turn to you when they need information
for a health story. Many doctors now also employ PR
(Public Relations) firms to ensure that their name
appears in the media as often as possible.
Creating an event can help to create a buzz if you
do it properly . Rather than just sending a press release
like everyone else, if you have a new state-of-the-art
piece of medical equipment, invite the media for a free
demonstration. Make it exciting by inviting local
celebrities . Whenever possible, have a patient who
has used or experienced the equipment or technology
- this makes it more newsworthy.
Contribute articles on health to magazines and

newspapers. The public is usually thirsty for well-written
information. If you can arrange to write a health column
for the newspaper, do so. A regularly contributing
author to the local newspaper can become a household
name.
Offer to give lectures to the public on your areas of
expertise . Forums like Rotary clubs and Lions can be
very useful. Print patient educational brochures on the
common medical problems you see in your practise.
Encourage your patients to take these home - this will
help to increase awareness in the community about the
services you offer . You can also publish a newsletter
and distribute this free to your patients. This will help
to keep them aware of what's new in medicine - and
about the new services you offer. In today's wired world,
your website can also be a very effective avenue of
marketing your practice.
If you are attached to a hospital, use the hospital as
a marketing partner. Since both doctors and hospitals
want to attract patients, you should develop the kind
of relationships that will allow you to share in the
benefits of hospital marketing activities. Hospital
marketing departments recognize that the best "product"
available for them to promote is their physicians. You
should want to be the one they call when they need an
expert to be interviewed on the local news. Being
interviewed as an expert in your field is one of the
lowest cost marketing avenues open to a practice. Learn
what your hospital wants and likes in a physician.
Volunteer to do screenings and public lectures. Keep
the hospital marketing director informed when you do
something noteworthy so they can promote your
actions, through their public relations efforts. Hospital
marketing and public relations departments struggle

to find material to promote to the press and to include
in their own advertising. By keeping them supplied
with this material which highlights your expertise, you
will become their "go-to" person, and their promotions
will benefit you.
Finally, if you are a consultant, remember that
marketing to your referral base - the doctors who refer
to you - is extremely important . Even with today's
educated and choosy consumers, tertiary care is still
largely driven by referral. You must work to retain your
referring relationships and to develop new ones. The
most important aspect after ensuring that referred
patients are returned to their original doctor's care is
promptly reporting the consultation results to the
referring physician. Referring physicians appreciate
hearing promptly from consultants and many are likely
to discontinue sending patients to you if they do not
hear back about their consults from you . Remember
that referring is often a question of building relationships
and once you receive the referrals, you need to ensure
that the relationship continues. Share your
accomplishments with your referring physicians. For
example, send a copy of an article in a professional
journal, with a personal note relating it to a referred
patient, if possible.
It is helpful to keep in touch with referring physicians
in a positive fashion, for example by sending a
congratulations note on something that the physician
did or even something the physician's children
accomplished. This creates positive name recognition
and will encourage the referring physician to continue
the referral relationship. Remember to be friends with
your referring doctor's office staff as well. It is a good
idea to give them a guided tour of your clinic, so they

are familiar with your practice . If you know their
names, this can help you considerably - so cultivate
them with care.
Marketing is a continuous process, and a true
marketing initiative involves educating patients, public
and referring doctors as to why you are their best
choice.
Branding Yourself
When we think of brands, we usually think of consumer
goods, such as Coke , Pepsi and Nike. Manufacturers of
fast moving consumer goods have learnt that letting
customers know who you are is critical to expanding
their position in the market place. While branding
strategies have long been used in large industries, they
are being increasingly employed by today's medical
practices. The large internationally renowned US
medical centers, such as Mayo, Johns Hopkins and the
Cleveland Clinic have done an excellent job in selling
their "brand", which is why rich Indians spend lakhs to
fly down to these centers for their treatment. In India,
corporate hospitals such as Apollo Hospital have started
following in their footsteps. However, you don't have
to be a large center to create a brand identity that
sustains your practice over time. You too can develop a
singular identity through branding and create an edge
over the competition.
Branding is the big picture view that a doctor
presents. It is who you are - and how you look to the
community, your professional colleagues, employees,
patients and future patients. Branding is about your
image, and developing and delivering a perception that
you create. Traditionally, a doctor's reputation has
always been his "brand ".As a doctor , your brand is
you, and branding is a marketing strategy that works

well if you follow these basic principles.
Focus on what you excel. The first step to creating a
brand is to identify who you are and what you do best.
Analyze the scope of services and explore your options.
What is it that your practice does best and who do you
want to attract? For example, in our clinic, we would
like to focus on infertile couples who need advanced
reproductive techniques such as IVF and ICSI. Not only
are these much more challenging patients, treating them
gives us more satisfaction, as we can use the cutting
edge of medical technology to treat complex problems
- a task few other infertility clinics can handle.
Understand the existing markets. When you have
clearly identified the service and image you want to
focus on, it is time to get a better understanding of the
market. If you are a primary care physician and care for
a large number of patients with addictive disorders,
this may be your brand venue, whereas another primary
care practice may focus on obese patients and nutrition
and diet.
Be consistent. Creating a branding strategy and
maintaining brand identify require an enormous long
term commitment. This is not a one-shot deal. Once
you imprint your brand on the public you must support
it consistently. It needs to become the overriding
philosophy of your practice. Remember that it takes
considerable time to penetrate the market and create
brand recognition - and once this is accomplished, it
must be continually reinforced.
Though branding has been used for large health
systems and corporate America, it is a new concept
for private practice physicians. It is a powerful tool
that will soon become commonplace in the future.
A number of enterprising individuals in India have

successfully branded themselves ( names such as
Amitabh Bachchan, Shiamak Davar, Anjali Mukherjee
readily come to mind) and doctors such as Dr R K Anand
are now following suit.
A strong brand identity that is built and protected
over time can create a long-term, consistent image of
quality and value. Inevitably, you will attract more
patients, based on how you have influenced them with
your branding strategies. Those doctors who take
branding action now will be tomorrow's leaders.
What about using advertising to attract more
patients? It is well known that the most effective form
of advertising is word of mouth. How we care for our
patients and how they perceive our care is what brings
us more patients. The next best form of advertising is
to our colleagues, by communicating our experience and
expertise via scientific presentations and/or publications.
In the past, this much was enough. The Code of Ethics
of the Medical Council of India still does not allow
doctors to advertise , and most senior doctors in India
look upon advertising with suspicion. After all, doctors
are professionals - why should they behave like
shopkeepers in order to attract customers ?
However, times have changed, and we need to
change with them. Gone are the days when patients
had a family doctor whom they could blindly trust, and
who would provide medical care for them from cradle
to grave. Today's reality is that medical care is often
provided on a fragmented, piecemeal basis by numerous
specialists, and the patient needs to learn to get the
best medical care for himself. This is why it is so
important that he has access to information on available
doctors, so that he can select the best one for himself.
Most doctors feel that advertising is unethical , but

we need to look at the reality more carefully. How are
young doctors who have just started practise going to
get patients ? How will patients know of their skills
and their expertise ? Many young professionals, who
have spent long years to qualify and taken loans to
start practise, simply cannot afford to sit back and starve
till patients arrive on their doorstep. This is why new
doctors feel they have to resort to unethical practices
like cuts and kick-backs today - many of which have
been institutionalized by their seniors. It is more honest
to allow them to attract patients by allowing them to
advertise - at least this is open and transparent.
Preventing advertising favours senior doctors - those
who have an established reputation, with many hospital
attachments, and lots of patients. They will do their
best to maintain the status quo by prohibiting
advertising - not to protect patients as they claim, but
to prevent new doctors from competing with them, thus
safeguarding their own interests.
Since senior doctors form the "medical
establishment" , which sets the rules for all doctors , the
Medical Council of India code on ethics still prohibits
advertising by doctors. However, this code was
developed many years ago, and needs to be updated so
that it is responsive to the needs of today's patients and
doctors. It is worth remembering that doctors were not
allowed to advertise by the powerful American Medical
Association ( AMA) in the US as well, many years ago.
The reason this changed is that some courageous doctors
took the AMA to court, and the Supreme Court ruled
in their favour, declaring that not allowing doctors to
advertise was unfair on them - and also unfair to
patients who need access to information on doctors,
so they can select the best for themselves . Today, the

AMA has promulgated guidelines for ethical advertising
by physicians, and these guidelines permit physician
advertising , provided it is not false, deceptive or
fraudulent. Maybe we could learn from them.
To keep readers abreast of new medical guidelines
worldwide, this is what the Council of the College of
Physicians and Surgeons of Alberta says about physician
advertising in its Code of Ethics.
The Council...believes that clear and accurate

information about physician services benefits all
parties in the health care system. Advertising falls
within the definition of "freedom of expression", and
any constraints to this freedom should be minimal
and reasonable.
They clearly specify what is acceptable and state that

"Advertising is just one of the professional activities
subject to the Code of Ethics".
It is true that advertising has a downside . For one,
advertising may cause doctors to start treating their
patients as clients or customers , rather than as patients
- and this is a shame. For another, some ads will be
dishonest, but at least they will be in black and white,
where they can be refuted and debated - and a doctor
making false claims, can be taken to task. This is far
better than making tall claims privately within the four
walls of a clinic and taking the patient for a ride.
What about the risk that patients would be lured to
the doctors with the fanciest ads, rather than the "best
doctors" ? To answer this, think about how patients
select doctors in India today . Usually they do so either
by reputation or referral , and neither of these are
reliable criteria. Allowing reputed and reliable doctors

to advertise will help to enlighten and educate
patients- and a good example of such educational
advertisements are the ads placed by the Cleveland
Clinic, USA in The Times of India. However, advertising
can be very expensive - and may not be cost-effective
at all. You need to experiment with different options,
and track how effective they are, so that you know
what works best for your practice.
We live in a fast changing global village, and we can
no longer afford to cut ourselves off from the rest of
the world. Since India has an abundance of qualified
and skilled doctors who can provide state of the art
medical care at a fraction of the cost which doctors in
the West charge, there is tremendous scope to export
our medical services. If we learn to advertise Indian
medical services worldwide effectively, we will be able
attract patients from all over the world , and medical
services can become a big foreign exchange earner for
India.
IMKAHTS
ACME
Chapter 6
Business Management:
Basic Skills
The conventional definition of management is getting work

done through people, but real management is developing
people through work.
— Agha Hasan Abedi.
Every medical practice is a small business, and being a

successful doctor is not just a question of having the
requisite medical skills or purchasing the newest medical
equipment. You also need to be an 'entrepreneur' and
to learn basic business skills in order to run a private
practice successfully.
Many doctors adopt a self-oriented rather than a
patient -oriented approach to their activities. This means
that they decide what medical services to provide, and
at what price to sell them, without analysing what
patients want and need. They try to sell their skills,
rather than try to provide what sells. They blindly follow
tradition rather than look for market opportunities -
and as a result , they are more likely to fail. They are
going against the law of business, which says that
businesses exist in order to satisfy demand, not to satisfy
their owners.
Physicians often fall into two distinctly different
profiles: "healers" and "dealers." The healers prefer to
practice medicine free of management, financial and

administrative demands; they see business as a necessary
but unappealing part of health care delivery. The dealers,
on the other hand, are energized by the business of
medicine; they apply their entrepreneurial energy to
building organizations that can compete for business in
a demanding market.
For many physicians, management is not a pleasant
role. They don't see management as being consistent
with their altruistic mission of helping patients. They
are simply not motivated to manage, since they don't
derive any satisfaction from being efficient
administrators. However, doctors must learn that they
need to manage their clinic efficiently, if they hope to
achieve their final goal of providing good medical care
to their patients.
Remember that it's not possible to provide good care
to your patients unless your employees are happy.
Instead of focusing solely on patients, you also need to
focus on the satisfaction and happiness of your
employees. Physicians can derive immense satisfaction
from knowing they have created an environment in
which their employees enjoy work - because this is the
sort of practice in which their patients will be well
looked after. As more physicians get the sense of
satisfaction that can be derived from caring leadership
, they will no longer perceive management as being at
odds with patient care but instead will recognize their
unique position to enrich the lives of their employees
- and through them, their patients.
The principal issue facing most medical practices is
simple: Will you succeed or perish? The business,
regulation, technology, and profession of medicine are
quickly evolving. Your medical practice needs an
Business Management: Basic Skills 157
advantage, and you need to act upon the advantage to

assure your continued success. A well thought out
strategic business plan will provide that advantage.
While most doctors just muddle along, and grab
opportunities as and when they come, strategic business
planning can help you improve your chances of
becoming successful. Use this basic business tool to help
improve your practice.
Typically, strategic planning is performed in five

stages.
Stage 1: Analyze Your Practice and Its Environment

You need to evaluate several factors, including :
Patients: Where do your patients come from? What
attracts them to your practice? What do they expect
from you? Are you satisfying all their needs, providing
all the services you should ?
Referring physicians: Visit your top referrers personally,
and find what they like and, more importantly, dislike,
about your practice.
Services: Know which medical procedures you offer
make money and which lose money. Understand where
your profitability lies and try to maximize these.
Competition: Find out what competing doctors are
doing for their patients and referrers. Know which ones
are forming networks and what kinds of deals they are
offering. Most importantly, know each competitor's
strategy and philosophy.
Regulation: Know what legislation has been recently
enacted, what is proposed, and how your practice may
be affected by it. Keep tabs on changes in practice
patterns and standards of care.
Stage 2: Analyze Your Strengths and Weaknesses

How is your practice different from anyone else's ?
You should assess your practice in the following key
areas: patient friendliness; referrer convenience;
"clinical" quality (outcomes); technology (state-of-the
art); price/cost (economic advantage); and allies and
barriers (competitors, financing, networks, etc.). A
candid analysis of these factors will help you determine
the strategy for your practice. You may be a technology
leader, or have an inherent price advantage. Whatever
your strength, go with it. If you have no strengths, seek
a way to obtain one. As for your weaknesses, instead
of ignoring them, do something about them.
Stage 3: Establish Goals

You must establish objective goals to monitor your
success. Establish practical goals in income, patient
visits, referring sources, and procedures performed.
Your plan should include: a prioritised timeline for
adding specialists, equipment, and administrative
support staff; a continually updated (every year) list
identifying possible expansion sites; and multiple,
contingent funding options.
Stage 4 : Implement Your Plan

Your plan is absolutely worthless if you leave it in
the computer or in a desk drawer and expect it to
implement itself. Most strategic plans fail because they
are ignored or forgotten. Involve your staff in the
planning, execution, and monitoring phases.
Stage 5: Monitor and Adjust Your Plan

Don't expect all your plans to become reality. Just
like complications can occur after surgery, often through
no fault of yours, you need to handle business

complications the same way - don't ignore them, but
correct them and keep going without altering your core
strategy.
If you are planning to offer a new service, you can
use the following formula to develop a business plan.
For (target customers - your main market segment

only)
Who are dissatisfied with (the current market
alternative)
Our product/service is a (new product category)
That provides (key problem-solving capability)
Unlike (the product alternative)
We have assembled (key whole product features for
your specific application/solution).
Here's an example of how it might work for an
infertility clinic, for example,
For infertile couples
Who are dissatisfied with running around from
gynecologist to sonographer
Our medical practice is a new personalised, integrated
infertility clinic
That provides couples with complete clinical services
under one roof
Unlike current gynecologic clinics
We have assembled a complete service including
sonography, specialists, lab tests and counseling.
Sometimes it's hard for a doctor to understand
business terms . Just like doctors use medical jargon,
administrators too use management jargon. This can be
easy to understand, if you remember that managing a
business is very similar to taking care of a patient. The
following " translator " can be a useful guide.
Management word Clinical synonym
Act Treat
Advise, recommend Consult
Audit Annual checkup
Bottom line Outcome
Delegates Refers
Difficulty Symptoms
Eliminate Cure
Gut feeling Hypothesis
Implement Manage
Pilot study Research
Organization chart Anatomical structure
Problem Malady
Reduce impact Reduce side-effects
Strategic plan Service plan
Goal Outcome
Thus, if you read: " The alternatives, as a result of

this audit, are to coordinate a plan, delegate to our
department managers or develop a solution on my own.
", in your mind, you can translate this as: " The
treatment options, as a result of our annual checkup,
are to integrate a service care plan, refer to specialists,
or to treat the situation myself."
If you encounter a business problem while running
your practise , think of it as a patient with an illness
and it will be much easier for you to develop a treatment
plan to solve it. Thus, if you are losing money, then
this is the illness, and your balance sheet is the
equivalent of the pulse and BP of the patient. Just like
you ask your nurse to monitor the patient's vital signs
to ensure he is getting better, you need to ask your
accountant to monitor your cash flows to ensure your
practice in improving. Think of a bank loan as the

equivalent of a blood transfusion for your practice's
financial health; and just like stopping smoking helps
to improve your patient's vital capacity, getting rid of
surly and inefficient staff can help to boost your
practice's profitability. One can carry the analogy
even further. If you have a patient with a difficult
problem and find that you are stuck, what do you do
? Ask a specialist for help, of course. Similarly, you can
use a tax consultant to help you to reduce your tax
liabilities. As a doctor, you are used to managing patients
with complex medical problems. You can apply this
expertise to managing your practice's business problems
as well!
Chapter 7
Financial Planning and

Management: Boosting Your
Bottomline
Money is a terrible master but an excellent servant.

— ET. Barnum
Your medical practice , like all businesses, needs to make

a profit to survive. All the idealism and medical skills in
the world are of no use if you cannot make both ends
meet. You cannot afford to be ignorant or careless with
figures , since you are self-employed. No one can run
a business without financial control, and private practice
is no different from any other business. Many doctors
are uncomfortable with financial figures, but you need
to attain basic financial literacy if you need to run your
own practice and grow it successfully.
A Profit and Loss Account
This account sets out the income earned ( patient fees)

and the expenditure of the practice, the difference being
your profit.
Financial Planning and Management: Boosting Your Bottomline 163
Budgeting
Budgeting is the process of estimating your income as
it is earned and expenditure as it is incurred. It helps
you to plan for the future, and to compare what you
achieve with what you had expected to achieve. Every
business experiences ups and downs in expenses and
income, so careful forecasting is essential, and it is
advisable to always allow a margin for inflation in the
forthcoming year.
Cash Flow
The cash flow statement sets out what is happening in
cash terms. It tabulates the money going out of the
practice to pay for expenses, and the money coming in
. If the outgoing is more than in the incoming, you
have a cash flow problem.
Balance Sheet
The final accounting item is the balance sheet. This
shows what the practice is worth and is usually set out
at the end of the practice's financial year, showing
what the practice owns and what it owes.
When you are starting practice, or when you want to

offer a new service , buy new equipment or expand,
you will need to raise money. The most convenient
source is your bank. Many banks do have special
schemes for doctors, in order to help them buy new
equipment or expand their practice. Doctors are usually
excellent credit risks, and most bank managers will be
happy to lend you money. Go well prepared with the
information your manager requires , and anticipate a
series of questions. The main questions will be as follows:
1. Why do you want the money?

2. How much do you want?
3. How will the money be repaid?
4. What securities are being offered against any loan
or overdraft?
5. What are the risks?
Make sure your documentation is complete and

up-to-date. If your paperwork is in order, your chances
of raising money are much brighter. You will need to
include details such as :
1. A short history and description of yourself, stating

your age, education, professional qualifications, skills
and specialisations. A prepared curriculum vitae is
always helpful.
2. A list of personal means, for example, property,
equipment, stocks and shares and any other asset
that may be held for collateral against a loan.
3. A detailed cash flow forecast and projected profit
and loss account.
4. The maximum amount of money you need to borrow.
The loan must be negotiated precisely with fixed
repayment details
5. References of your character. These should be from
people who have known you for a long time, who
are not family or friends.
Other approaches include borrowing money from a

financial company or finding a cash-rich sleeping
partner. A sleeping partner is one puts up money in
return for an eventual share in the profits, but does
not take any part in running the practice. Luck and
contacts can help you find a person who is willing to
risk money by backing your skills and talents. Having

a rich father-in-law can be very helpful when starting
practice !
Keeping Accounts
You must keep a careful record of all the financial

transactions concerned with the practice. This is
important, not only to check whether you are making
a profit or loss, but also for the legal requirements
involved in paying income tax. Accounts constitute the
financial memory of the practice, and it cannot be
stressed enough that you have to keep them in order.
It is largely a matter of self-discipline - do it regularly .
As your practice grows, you may need to employ a full-
time accountant to take care of your paperwork. Today,
many computer programs are available which make
keeping accounts much easier and manageable. These
will allow you to prepare a trial balance and submit
your income tax returns efficiently, and are well-worth
investing in.
Preventing Cheating
Since doctors earn a considerable amount of cash income

on a daily basis, there is considerable opportunity for
your office staff to cheat you - and unfortunately,
many do. Doctors are often too busy taking care of
patients, which is why they don't bother about "petty"
details. However, they often end up losing their hard-
earned money - something they can ill afford to do.
Some experts estimate that three out of four physicians
will suffer a significant loss due to employee dishonesty
at least once during their careers because they lack
sufficient checks and balances. The best way to prevent
this is by being strict about implementing cash controls
in your clinic. Unfortunately, the embezzler often turns
out to be a long-term, reliable employee, because

without proper controls, the most trusted staffer often
faces the greatest temptation. It usually starts small,
and then keeps on ballooning, so that a trusted
employee (but perhaps one who is resentful at what
seems like a low salary) , begins to siphon off small
amounts of cash until it becomes second nature.
Simple safeguards can help prevent fraud.
• Require documentation support (invoices or

statements) for all check requests.
• Mark each invoice "paid" and the date paid at the
time you write/sign the check.
• Schedule a specific time to sign all checks each week.
Your practice size will dictate how complex you can

make your cash control policies. Have your accountant
audit and revise your internal controls . You should be
involved in large financial transactions, and should
implement random spot checks to ensure honesty.
Try to minimise the opportunities and temptations
you offer to staffers to steal by having strict control
systems in place. Often thefts come to light when the
employee who is cheating takes a vacation, so make
sure all your staff members get an annual vacation.
• Make deposits daily, so that there is not too much

cash on hand in the office.
• Reconcile bank statements monthly .
• Occasionally track a random sample of cash receipts
through your whole system, from the appointment
register all the way to the computer ledger to confirm

no payments are missing.
• Never allow financial records or insurance claims to
be taken home.
Demonstrate your awareness of what is going on in

your office. That doesn't mean you need to hover over
employees day in and day out. Rather, set up and use
good controls, and make a point to talk to your staffers
about what they're doing. Be visible and ask questions
when you verify cash balances or review reports. If your
staff realizes you are careful with your money, they will
treat it with the respect it deserves.
681 Succesful Medteal Practice: Winning Strategies for Doctors
Chapter 8
Making Your Money

Work for You
That man is richest whose pleasures are cheapest.

— Henry David Thoreau
Doctors are usually financially well off. While they may

never become filthy rich, they have the ultimate luxury
in life—they get paid for doing what they like. However,
remember that you are also a daily wages earner—and
you earn only when you work.
When most doctors think about money (which is a
lot of the time) they only think about how to earn
more. However, in addition to earning money, you also
need to learn how to save it, invest it (build wealth),
spend it, and give it away.
How to Earn (More) Money
The most important source of income for most

doctors is their medical practice, and you need to spend
time and energy on building this. While many doctors
are medically very competent, most do not know how
to run a practice efficiently.
For example, how much to charge a patient is a
thorny issue for the doctor who is just starting practice,
especially since residents are used to working for

free during their training. It can be hard to ask a
patient for money and many doctors feel uncomfortable
initially, though most of us learn how to do this
quite quickly. This is often one of the most difficult
questions a doctor who is starting practice needs to
answer. If you charge too much, you will end up
twiddling your thumbs, with nothing to do. If you
charge too little, you may not be able to make ends
meet. Most doctors just charge what other doctors in
the neighbourhood charge, but this is often not the best
way to set your fees.
It can be helpful to work as an assistant to a senior
for a few months before starting on your own to get an
exposure to ground realities. You usually need to charge
what the prevailing market rate is—and we learnt this
the hard way. When we started our IVF clinic, we
charged our patients much less than current rates, and
patients felt we were not good enough. The moment
we increased our charges, our workload increased.
There are two key areas in any practice, no matter
what its size. These are: (1) medical treatment; and
(2) managerial functions, which include: executive tasks
(delegation, leadership and planning); personnel (hiring,
training staff and human resource activities); financial
(billing and collections); public relations; and quality
control (ensuring patient satisfaction and improving staff
performance). Of these, the medical treatment area is
the only one in which doctors are adequately trained.
The remaining areas can therefore become sources of
problems and difficulty as the practice grows. These
problems cost the average doctor thousands of rupees
Making Your Money Work for You 171
per year, cause a decline in the doctors' quality of life

and result in stressful work and home environments.
While even a poorly run practice can earn enough
money to get by, this is often more of a curse than a
blessing because 'just getting by' often takes up so much
of a doctor's time and energy that he will wind up with
a problematic and stressful practice. The real reason a
practice stops growing is because the doctor has reached
his level of management skill. It is a fact of life that the
medical competence level of a doctor has nothing to do
with how successful his carreer will be—and we all
know brilliant doctors struggling to make ends meet
while less skiled doctors are making their fortunes.
While most doctors do not like managing the business
aspects of their practice, either because they don't know
how to or would rather concentrate on treating then-
patients, the fact remains that what you do not or can
not control costs you money and causes stress. Doctors
have to learn to acquire business management skills—
after all, running a medical practice is very similar to
being an entrepreneur. As a doctor, you have a lot of
independence, but you need to be able to utilise this
freedom intelligently. Unfortunately, most doctors never
learn how to take control of the business side of their
practice.
In today's cut-throat world, junior doctors who are
starting practice are so desperate for patients that they
will often resort to underhand means such as cuts and
kickbacks in order to solicit patients. These unethical
practices have ended up giving the entire medical
profession a bad name. It is just a matter of time that
'marketing' a medical practice will become as
commonplace in India as it is in the USA—and
hopefully, this will remove the undersirable middle-men.
721 Succesfnl Medical Practice: Winning Strategies for Doctors
You don't need to feel guilty about charging for

your services—after all, if you don't make ends meet,
how will you be able to continue running your clinic?
But knowing how much to charge and how to collect
your fees can be a fine art, which can take years to
master. Should you charge variable fees? Many doctors
use a sliding scale, and charge more from rich patients
and less from poor patients. However, you first need
to learn how to do a 'wallet biopsy', so you can judge
how much the patient can afford to pay—and
remember, that appearances can be deceptive. What
do you do with the patient who wants to bargain and
reduce your charges? And how do you deal with the
patient who does not pay? There really are no easy
answers for any of these questions, and each doctor
needs to find a system which works for him. Some
prefer offering package deals, so they don't have to
hassle about the charges with each patient; and they
insist on payment in advance, so they don't need to
worry about collecting their fees. However, this can be
difficult to do for the doctor who is just starting
practice, and you will often find that some patients
may cheat you in the beginning. Put this down as a
learning experience—and don't make the same mistake
twice. Try to do some charity work— the amount of
satisfaction this can give you far outweighs the money
you will be 'losing'. There is nothing which can match
the joy one gets from the blessings and gratitude of a
happy patient!
The only way to increase you profits is to either
increase your gross income, or reduce your expenses.
Since the majority of your income is derived from
seeing patients, you need to learn how to either see
more patients (for example, by employing assistants or
opening a satellite clinic) or discover new ways of
Making Your Money Work for You | 73
charging your patients more (for example by

performing additional services, such as lab tests; or
offering new services, such as a new medical
procedure.) As a doctor, remember you are a daily
wage-earner, and this will limit your ability to earn
money. As time goes by, you should develop atlernative
ways of making your money earn for you by investing
it wisely.
Accountants and Taxes

Most doctors will need an accountant, who will help
prepare and file the tax returns. A good accountant will
analyse the previous three years' returns, look for ways
to reduce the tax bill in the coming year, and help plan
for the future. Money spent on a good accountant is
usually money well spent. He will check your
accounting systems, and present you with financial
reports, such as profit and loss accounts and balance
sheets—the financial equivalent of the pulse and BP of
your practice! Never hesitate to ask about items you
don't understand—after all, it's your money.
Your accountant will ensure that your accounts are
up-to-date, and that you maintain the legally required
records. Accurate paperwork is important and will help
you to keep your income tax officer happy. Accounting
software and computers have helped to make this much
easier.
Other Sources of Income

Many doctors do have other sources of income, and
these often include a family business. There are other
sources you can explore as well—for example, by
writing, or by developing new health-related products
(such as cosmetics, medical software or health websites).
How to Invest Money

Many doctors believe that the only way to earn more
is to work harder . However, you only have 24 hours
in a day ! You need to learn to work smarter, not
harder - and financial planning is vital. A financial
plan is like- a connect-the-dots puzzle -you can't finish
the picture without connecting all the points. To
improve your chances of reaching your goals, you must
first define as many of your goals as possible, then
prioritize them and establish a timetable for reaching
them. If you know where you want to go, you have a
better chance of getting there.
Pick your own targets, but make them specific. It's
not enough to say - " I'd like to save more money"?
How much do you want to save ? By when? Where
will you keep that money? Put all the particulars down
on paper. Once you get beyond meeting your daily
needs, a sensible investment strategy is an absolute
necessity for reaching many goals, especially big long
term ones, such as your child's education or your
retirement.
When should you invest?
Because of the magic of compounding, starting early
is vital. So is patience. It's an investing adage that you
can only get poor in a hurry; getting rich takes time.
The idea is to invest well, and then allow your
investments time to grow. Don't make decisions about
your portfolio on a daily basis - it's far more effective
to devote your day-to-day attention to your practice,
instead.
Besides investing early and for the long term, you
should invest regularly. This concept-called systematic
investment or rupee -cost averaging relieves you of
worrying about buying at the "right" time and tends
to lower your average cost.
What should I invest in?

Most investors need a mix of investment types, and
you need to diversify to reduce your risk. If you are
investing for the long term, carefully selected shares
should play a big role in your portfolio because they
provide the best returns. The idea is to produce your
desired result while exposing yourself to the least risk.
However, doctors rarely have time to evaluate the
risk factors in countless stocks, or the know-how to
quantify value and compare it with price, and so on.
Most would like a portfolio of well-chosen stocks without
the headache and responsibility of putting it together.
For them, the easiest alternative is mutual funds.
However, many doctors can't resist playing around
with shares! Many enjoy dabbling in the market, and
end up spending more time talking to their brokers
than with their patients. Others act on "hot insider"
tips from their patients - and as with anything hot,
often end up burning themselves. If you like
speculating, go ahead, but do so with a small portion
of your portfolio .
An important tool of financial risk management is
called asset allocation, and the key is diversification.
The goal is to own a portfolio of assets that don't move
up and down together. You need to balance risk, return
and liquidity - based on your income, age, long-term
goals, financial needs and risk-taking ability. Thus, if
your risk tolerance is low, a suitable mix might be
25 percent of your capital in equity (shares) , 35 percent
in debt (bonds), and 40 percent in bank accounts (fixed
deposit) . Your emotional profile can be as important as
your bank balance in designing the right financial
prescription for yourself - and just like you tailor the
treatment regime according to which kind of patient
has the disease, you need to design a plan which suits

you. Do also remember to review it regularly, as your
goals will change with time.
However, remember that your most important
investments are : in yourself (medical conferences,
continuing medical education, medical journal
subscriptions), your staff (salary hikes, perks) and your
clinic (updated medical technology, new office
equipment) - these investments will give you the best
returns.
Financial Advisers
While doctors don't like patients who ask for free

medical advice, most are very happy to take free
financial tips from those of their patients who are
stockbrokers or accountants. However, listening to the
wrong person could lead you astray. Just as you
wouldn't go to a psychiatrist for brain surgery, you
shouldn't rely on your banker to advise you on which
shares to buy - he's not the expert you need.
Before you can select an appropriate adviser, you
must decide what type of guidance you want.
Depending on your income, you may need several
advisers, such as a share broker, money manager,
personal banker or financial planner. Financial advisers
now come in many shapes and sizes - and you need to
select the right person, depending upon your needs.
There are now a number of websites which will offer
you tons of valuable information on investment and
personal finance management. Useful ones include:
www.myiris.com,www.equitymaster.com, www.sharekhan,
com and www.fool.com.
Making Your Money Work for You | 77
Insurance
To protect your family, you need to invest in a life-
insurance policy as well. While this may not provide a
profitable return on your investment, it is a valuable
safety anchor to protect your family against an
unexpected crisis.
Making a Will
It is advisable to make a will as soon as possible. Dying
intestate can make life difficult for those left to sort out
the affairs of the deceased and leave the intended
beneficiaries with potential legal wrangles and
unnecessary inheritance tax. Professional advice should
be sought because a poorly written wil may be worse
than none at all. A will may be revised at any time to
take account of changing circumstances.
How to Spend Money
While most doctors become quite good at earning

money, few know how to spend it well. Spending
money well is as important as earning it—after all, what
is the use of the money until you do something with it?
You need to be able to spend on yourself and your
family—there's nothing wrong with enjoying life!
How to Give Away Money

This is perhaps the most difficult skill to learn. As doctors,
we have a special responsibility to society because we
come in contact with so much suffering and misery,
and we need to use our special skills to develop more
effective ways of making good use of our money during
our lifetime. For example, we have started a charitable
trust, which runs a free public health library,
HELP—Health Education Library for People in

Bombay-which has now become the world's largest
health library. This allows us to promote health by
making effective use of both our money and our special
medical knowledge and skills. Earning money feels
good, but putting it to good use is the ultimate joy.
Chapter 9
Hiring the Right People
When you hire people that are smarter than you are, you
prove you are smarter than they are.
— R. H. Grant
Most doctors take a very casual approach towards

employing staff. Vacancies are filled as and when they
arise, and employees are left to muddle their way
through, till they either learn to do the job, or walk
off. Most doctors can get away with this , because
labour laws in India are still very primitive, and there
are few safeguards for employees working in doctors'
clinics. However, not only is this very wasteful of the
doctor's time and energy, it is also very shortsighted.
After all you need to remember that just like you spend
a lot of time and money and energy before buying an
ECG machine , you need to spend a lot of time before
employing a new staff member. Remember that your
employees are an investment in a successful practice
and you need to build a high-quality staff to keep your
practice running smoothly so you can spend your time
practising medicine
The basic rule is hire tough - a simple, yet powerful
principle, because hiring the right employee will reduce
staff turnover. Your formula for managing your staff
should be: Hire tough - Manage easy. If you are a good
Hiring the Right People 181
manager, you should be able to go on a two-month

vacation and come back to a clinic which is functioning
as efficiently as when you left. A good manager is one
who has truly learned to manage:- to get the work
done through other people. You need to teach your
employees a sense of responsibility for their tasks , and
should not need to constantly monitor whether they
are fulfilling their duties. The secret is to hire a person
with the right attitude, and then teach them the skills
they need to get the job done.
Each employee represents a major investment.
Unfortunately, doctors only consider how much they
actually pay each employee , and since this is usually a
small amount, they tend not to devote much thought
or energy to hiring the right candidate. However,
remember that hiring the wrong employee can prove
to be very expensive. If you lose even one patient thanks
to the inefficiency of your staff, this can be a major
financial loss to you. Your employees are your public
face - they represent you to your patients, so select
them with care.
The quality of your clinic can never exceed the quality
of the people who make it up. You need to have a
systematic method towards employing staff, and you
can learn a lot from the techniques employed by the
HRD departments of large companies. Losing an
employee can cause havoc in your practice, because
training a new employee is a time consuming affair. To
avoid costly staff turnover, hire the best personnel
possible - and then make your medical practice a place
they won't want to leave.
Prepare Job Descriptions : Start by writing a job
description - what duties does this job entail ? You also
need to write a person specification, which describes
the type of person you want for the job, detailing skills
required, qualifications needed and personal qualities

necessary. Advertise appropriately, then screen resumes
to find those applicants with all or most of the necessary
skills, education and experience to meet that position.
You can also ask your present staff to suggest people
who they feel would make good employees.
Pre-screen Probable Candidates by Phone: Pre-screen
those candidates by phone who look best on paper. A
brief conversation can help judge the candidate's
telephone manner. If you don't get a positive feeling,
neither will your patients. Just a few minutes on the
phone can eliminate some candidates and save time
that would be wasted in an interview.
Use an Application Form: Develop an application for
your practice or use a commercially available one. Do
not just accept the applicant's resume. Having the
applicant complete the form also allows you to judge
his handwriting and spelling skills.
Interviewing: When interviewing, watch for clues that
the candidate will mesh with your practice philosophy
and culture.
Consider Testing: To give you an idea of how the
applicant will perform on the job, develop some basic
skills tests or use commercially available, standardized
tests for English, spelling, math and keyboarding.
Checking References: When calling for references,
provide the applicant's name and dates of employment
shown on the application and mention the position for
which she has applied. Ask open-ended questions and
encourage the person to keep talking. Suggested
questions are: Was the candidate reliable? What were
her strongest and weakest points? Why did she leave?
Would you rehire her?
Hiring
When you find that perfect candidate, hire her. Be sure

your salary and benefits are in line with those in your
area. A qualified candidate may have several job offers
and you don't want to lose that individual for a few
dollars. Hire qualified people and give competitive
compensation. Many doctors take pride in paying the
absolute minimum to their receptionist - and this
explains why staff turnover is so high. Turnover
generates hiring costs and undercuts efficiency, since it
takes time for employees to get to know your patients,
your idiosyncrasies and the system of patient flow.
Consider offering a few thousand rupees more than
the average salary for your area. If that's what it takes
to have a first class person representing you at the
front desk, it's well worth it.
All new hires should be given a probation period
during which time you can assess their on the job skills.
As your interviewing skills are honed, this period should
just be an affirmation that you selected the right person
to fill the job. Once the probation period is over, it's a
good idea to sign a formal employee contract. This gives
your employee the job security they need - and also
helps to give you peace of mind that they are likely to
stay with you for at least the period of the contract.
Just hiring a new person is not enough - to make
the most of them, you need to train them as well, so
they fit in well into your office. Unfortunately, most
doctors simply employ a new person, and then expect
them to learn on the job itself. Training new personnel
can be a source of frustration for medical practices. It is,
after all, quite an undertaking to try to remember all
the tasks related to a particular position and then to
train the new employee to perform that mountain of
tasks .Unfortunately, in many practices, new employees
are forced to learn their duties on the job, often by

trial and error. While this method has long been in
use, it is less than optimal and can lead to poor
performance, poor patient-care, low job satisfaction and
high employee turnover.
A simple way of having a formal training process is
to have a checklist of the duties a new employee is
supposed to master, and then to provide training in
each. When new employees know what is expected of
them, they can take a more active role in their training
and feel they are truly succeeding. In turn, this can
boost job satisfaction for all employees in the practice,
increase efficiency, improve patient care, reduce the rate
of employee turnover and decrease long-term practice
expenses.
A four-step training approach is recommended when
you are breaking in a new employee.
1. Demonstrate the skill as you want it performed: As
you demonstrate, point out the important aspects so
that your employee understands why each part is
important.
2. Role play with the employee: Always give the
employee an opportunity to practice with you first.
Don't force your staff to experiment a new skill on a
patient.
3. Give the employee feedback on what was done
correctly: Too often managers only correct mistakes.
Positive feedback is much more important in training
new skills. Once you have explained what was done
appropriately, give feedback on what needs to be
improved.
4. Supervise the skill in a real-life setting: This last step
gives the employee an opportunity to ask questions if
necessary. After you watch the skill, give feedback. Be

sure to point out the strengths before you point out
areas that need improvement.
A procedure manual is a useful tool for training. It
simply sets the standards that the entire clinic lives by
in writing. Since procedures are formalised, they guide
the performance of everyone in the clinic and help to
keep things uniform and consistent. Every clinic should
have a procedure manual, but sitting down to write the
manual can be dull, dry work, so ask your staff to pitch
in. Each can write down how they perform their own
duties, and you can then correct this.
Some of the details a procedure manual should
contain include:
1. Telephone procedures —answering techniques, calling

missed appointments, scheduling new patients, handling
problems.
2. Regular patient procedure—<sign in, filling treatment
rooms, scheduling next appointment.
3. Collecting money—what to say, handling unusual
problems, sending statements, phone call collections.
Since writing procedure manuals is a new experience

for most people, there is one important technique that
makes it easier. Each step should be an action step - it
should describe a specific action. If you start each
sentence with a verb, you will have an action step. Here
is a simple example of the procedure which needs to be
followed when opening the clinic in the morning.
Writing all this down might seem like a lot of trouble,
but if you set up systems , you will find they save you
time, energy and money.
Opening the Clinic
1. Unlock doors.
2. Turn on lights.
3. Turn on air conditioner.
4. Check messages on answering machine.
5. Put on computer.
6. Check for cleanliness.
7. Check bathrooms for toilet paper, towels.
8. Check appointment schedule.
9. Pull out patient charts.
Remember that working in a doctor's clinic is a stressful

job, with constant distractions, and the need to handle
multiple jobs at a time - greeting patients, collecting
money, answering phones, putting patients on hold,
and ensuring the doctor's workflow is running
smoothly. However, most doctors still treat their staff
as ordinary clerks , as a result of which they still
overwork and underpay their front desk employees.
The time, money and energy you invest in hiring the
right person will pay off hundred-fold.
Chapter 10
Creating Superb Employees
Example is not the main thing in influencing others, it

is the only thing.
— Albert Schweitzer.
To a large degree your employees are your clinic. While

it is true that your patients come to see you, the quality
of the interaction of your staff with your patients is just
one of the many areas your people can either make or
break your business. Your staff also has a huge effect on
the quality of your life, because dealing with people
can be agony or ecstasy - the source of your greatest
frustrations or your most gratifying accomplishments.
You need to enhance your ability to effectively interact,
direct and work with people. Unfortunately, most
doctors never acquire good people handling skills, let
alone management training , along the way. One
problem is that most of us don't intuitively know what
makes people tick and as a result we get involved in all
sorts of counterproductive and self-defeating approaches
in managing and dealing with our employees.
The commonest mistake most doctors make in managing
their staff includes micromanaging and overmanaging.
You need to be able to trust your staff to do things their
own way. This may be different from your own way -
and may actually be better !
Creating Superb Employees 189
Managing human resources often gets a low priority

in medical practice. Busy physicians usually find
themselves hiring employees chiefly in crisis situations—
when a spot needs to be filled—rather than as part of
a carefully considered staffing plan. But developing a
strong staff doesn't happen by accident, and practices
can learn a lot from organizations with a stronger
tradition of human resource management.
Remember that helping employees learn and grow
also boosts the development of your practice. When
staff members are content, they're more friendly and
responsive to the needs of patients and happy staffers
improve your patients' experience with your practice.
High-functioning employees cope with problems
better, keeping the entire office running smoothly but
it takes more than just good pay and benefits to keep
employees motivated and satisfied.
Workers who are most likely to be satisfied with their
jobs:
• Know what's expected of them.

• Have the materials and equipment they need to do
their work properly.
• Have the opportunity to do what they do best every
day.
• Feel their opinions count.
• Have been recognized or praised for doing good
work.
• Feel that their supervisor or someone else at work
cares about them on a personal level.
• Receive encouragement for their professional
development.
• Feel the clinic's mission or purpose makes their job
important.
• Feel their colleagues are committed to high-quality

work.
• Have a best friend at work.
• Feel they've had opportunities to learn and grow
within the past year.
In general, there are three managerial styles. Many

doctors have a managerial style which is based on a
police cop mentality - the " authoritarian " model - "
find things that are wrong , and fix them the way I tell
you to " . Following this model, many doctors try to
force their staff to perform, but this approach works
only if you are there to monitor your staff all the time.
Others prefer a "hands-off" approach - the "laissez-
faire" model, because they prefer not handling staff
problems at all . Unfortunately, taking an ostrich-in-
the-sand approach will not make the problems go away
- and they may often fester till they become
unmanageable. In this age of service, a more appropriate
management style is " participative " - based on the
coaching philosophy. Coaches look for strengths - they
see what talent they have to work with and devise a
game plan to win with the skills they have available.
This is far more effective - both for you, and for your
staff.
Remember that the way you treat your staff is the
way they will treat your patients. You cannot ill-treat
your staff, and then expect them to go forth and deliver
inspired, compassionate service to your patients. What
they see is what you will get. You are the role model
whether you want the job or not. If you want your staff
to treat your patients with respect, treat your staff with
respect. If you want your staff to listen to your patients,
you need to listen to them. If you want your team to
report to work looking sharp, pay attention to your
own grooming habits. If you want people to be on

time, schedule an arrival time for yourself and be at
work when the schedule says you will be.
Today's business climate means physicians must act
as coach and counselor to improve morale, reduce
turnover, and energize employees. More than ever,
physicians are seeing the value of a motivated office
staff.
How do you create an atmosphere like that? Some
tips from experts:
Thank them : Saying 'thank you' to your staff when
they do something right is the single most powerful
motivator you have, a recent survey shows. Yet doctors,
perhaps because they tend to be self-motivated, are
notoriously stingy with praise. They don't realize that
the people who work for them need to be given verbal
thanks to feel good about what they've done. If they're
not recognized by their boss — the office manager or
the doctor — then they'll definitely lose motivation.
Be quick to pass on compliments: When a patient says,
'I'm really glad your billing person dug in and found
out what the problem was with my bill,' then make it
a point to go and thank that employee , preferably in
public. It's a good idea to pick a worker every week
and go out of your way to catch him doing something
well.
Adapt your style over time: Have a few stock phrases
that are bound to be useful at some point. Here are
some lines that Pitts burgh-based organizational
consultant Sam Deep recommends to help keep office
staff motivated and on the right track:
"Here's one way to do it." Those five words tell
your employee you're willing to teach him, but won't
force him to do things your way.
"That looks great!" Employees want to feel

appreciated, and surveys show they don't think they
get thanked enough. The good feeling a worker gets
from a compliment from the boss can last a week.
"What'll it take to keep this from happening again?"
This is a clever way to accomplish at least four goals at
once. First, you get your employee to make a
commitment to do the job right next time. Next, by
letting her tell you how she plans to fix her mistake,
not only will she be more committed to making the
remedy work, but she may well come up with a better
solution than you would. Third, you give her some
practice at problem-solving, which will help make her
more effective and confident. Finally, she won't forget
that you treated her with respect — even though she
fumbled.
Interestingly, you can dramatically increase your own
productivity by listening to the members of your care
team . Ask them, "How would you do this?" or "How
could I do this better?" Most doctors are so used to
knowing everything and doing everything, that they
forget to ask for advice and guidance of the real experts
- those whom they work with every day. You can be
much more productive if you share ideas with your
coworkers and listen to their ideas - your staff wants to
be listened to, and will be very happy to contribute
ideas and effort - if only you will give them a chance
to do so.
A common mistake most of us make is giving the
most work to the best employees, because they are the
most efficient. Ironically, we reward poor performance
with less work, and end up driving away our best
employees because they are overworked and burned
out.
Knowing how to work efficiently with your team is

the "hidden secret" of physician productivity; conversely,
an inefficient doctor makes the whole team inefficient.
Turnover in the clinic is a constant challenge for all
doctors. Thanks to low pay, poor organizational
structure, improper staffing, and the overall high-
pressure environment in a medical clinic, nurses,
receptionists and other staff often leave after only
months on the job, keeping the front office in a constant
state of turmoil. Worse, steady turnover can cause a
vicious cycle of employee paranoia. Plagued by what
seems to be a revolving door of worker replacements,
practices stop training (why waste the time?) and
maintain low wages (why waste the money?). As a
result, morale drops, other employees leave, and the
turnover in the front office just‘keeps feeding on itself.
Smart doctors should put staff first and patients
second. They know that when they take extraordinary
care of their staff, their employees will take extraordinary
care of their patients. Successful managers combine
the five "R"s and the one "F": Recognition, Reward,
Responsibility, Rules, and Respect, and Fun to create a
work environment that few choose to leave, even for
more money.
Recognition: Do you give your employees the
recognition they deserve? Recognition is simply giving
praise where it's due.
Rewards: Do you reward employees for superior
performance ? This does not always have to be a bonus
- you can also offer gifts in kind, or an extra holiday.
Rewards add incentive to the workplace.
Responsibility: When you give employees the
responsibility of making decisions and suggesting
improvements, they are empowered to do a better job
- and they may pleasantly surprise you.
Rules: Do you have rules in place that are fair and

reasonable? Do your employees know the rules they
are supposed to follow? Too few rules result in anarchy,
because your employees don't know what to do and
how to do it . Too many stifle creativity and flexibility.
Respect: Do you respect your employees? Your staff
will respect you, one another, and your patients only as
much as you respect them. Respect creates an
atmosphere where good relationships thrive. No one
stays long in a job where they can't enjoy relationships
with others.
Fun: Is your clinic a fun place to be ? Providing good
quality medical care can be a very satisfying job, and
your staff should have fun doing so. While it is true
that no patient enjoys going to a doctor, clinics which
are happy places will attract far more patients than
sterile boring clinics.
Your staff should be proud to work for you. If you
want good employees, learn to become a good employer.
Chapter 11
Good Medical Records:

Worth their Weight in Gold
Record what you have seen; make a note at the time; do not
wait.
— Sir William Osler.
Most doctors dislike paperwork - especially that

involved in entering information in medical records.
Thus, while most surgeons enjoy operating, many treat
documenting the medical details in the record as a
painful chore which they would rather not do. This
often means that entering data into the medical chart is
delegated to a junior or inexperienced assistant, as a
result of which it is often not done well.
Remember that the medical record serves many
purposes, and its primary function is to plan for patient
care. However, from the risk management perspective,
the medical record is a crucial element in preventing
and minimizing malpractice litigation. Ultimately, it
serves as the basis for the defense of malpractice claims
and lawsuits. Medical records which are poorly
maintained, incomplete, inaccurate, illegible or altered,
create doubt about the treatment given to a patient, and
can be a major medical-legal liability. By contrast, proper
documentation in the medical record creates a legal
document which accurately and completely reflects the

care provided to a patient and, in a courtroom setting,
it may be likened to a witness whose memory is never
lost.
While keeping good records is simply a matter of
common sense, the mnemonic OLFACTORY, which
stands for : Original, Legible, Factual, Accurate,
Complete, Timely, Objective, Rationale and Yours, will
help you to define a "good" medical record.
It is helpful to follow a system when making notes
in the medical record, to ensure that all important
information has been recorded. The SOAP system
(which stands for Subjective (the patient's history);
Objective ( examination findings), Assessment and Plan)
is popular in many hospitals, and is easy to implement.
Preprinted medical records can help to establish
consistent documentation , ensuring you do not forget
to record important information. They can also help to
save your time when entering data.
When writing orders in the chart, it can be helpful
to remember the following headings ( the mnemonic
being ADCA VAN DILMS) , to ensure that important
orders are not overlooked. Every doctor should develop
their own systematic method to ensure completeness.
• Admission
• Diagnosis
• Condition
• Allergies
• Vital signs
• Ambulation
• Nursing care
• Diet
• IV fluids
Good Medical Records: Worth their Weight in Gold 197
• Lab tests
• Medications
• Special orders (such as occupational therapy or
consultations requested)
Each and every page of a patient record should be

clearly labeled with the patient's complete name and
medical record number. Anyone making an entry in a
patient's chart should do so only on hospital approved
medical record forms and then only with pen rather
than pencil. Use only hospital accepted medical
abbreviations and terminology. Associated records and
tests such as EKGs, EEGs, fetal monitoring tracings,
etc., should all be properly labeled with the patient's
name, medical record number, the date and time.
All entries in the medical record should be dated,
the time they were made noted, and should be signed
by the person making the entries. Progress notes should
indicate that the patient was kept informed of his or
her condition, as well as the treatment plan. Document
all instances of patient non-compliance or refusal of
recommended treatment and that the patient was
informed of potential consequences. Many courts take
the view that if it an event is not documented, it did
not happen.
Patient records should never be altered. One should
not erase, obliterate or attempt to edit notes previously
written. All corrections, late entries, entries made out of
time sequence, and addenda should be clearly marked
as such in the record, and should be dated and timed
on the day they are written and signed. Draw a single
line through any erroneous chart entry and write "error"
with the date and time, as well as your initials.
Don't forget that the information you enter on a

patient's record is open to public scrutiny. Good medical
notes are an excellent way of showing other doctors
your clinical skills and competence. It's also a good idea
to go over the medical record with your patient, so
that he/she understands exactly what you have entered
and what it means.
It is helpful to ask patients to fill out their own
medical history form before they see you. This allows
them to review their own medical history, and also
ensures that they do not forget important details. Such
a structured patient interview form can help to improve
the quality of medical care you provide. Many clinics
mail such a form to the patient so they can fill it at
home before coming in; while others now offer such
forms online, so they can be emailed and checked before
the actual visit. This helps you to make more efficient
use of your time. Busy doctors often ask their assistants
to take the history; and while this saves your time, it's
important that you review the facts carefully with the
patient yourself.
While some doctors still laboriously hand-write all
their medical notes, it's very cost-effective to have pre
printed medical record sheets or templates. You can
design these yourself, customised for the medical
problems you see most commonly. This will allow you
to improve accuracy, because you record all the
important clinical details for each patient; ensure
legibility; and save you time, because it minimizes your
handwriting.
You need to develop a system of keeping your
patient's records safely and securely. While this can be
an additional burden, it's well worth your while. Not
only will it make it much easier for you to provide
Good Medical Records: Worth their Weight in Gold 199
better care to your patients, your patients will also feel

much more comfortable, knowing that you have all their
medical details at the tip of your fingertips. The
following suggestions will help you store your patient's
medical records safely.
1. Implement an efficient filing system . Charts can be

filed by the patient's last name, date or code - use
whatever works for you.
2. All records must stay in the clinic. Don't bring charts
home - you are likely to leave them in your home or
your car.
3. Practise what you preach. Your staff should have
full permission to let you know when you are remiss
in your chart duties.
4. Adapt to new technology. Computers and voice
recognition systems are great for simplifying
documentation.
5. Discipline yourself - charts should be completed by
the end of the day.
By taking an organised approach to the problem, you

and your staff won't be spending half the day looking
for missing or misplaced records. Many lawyers
recommend that medical records be kept indefinitely.
Older records can be archived and stored on microfilm
or CD-ROM. However, do remember that even though
the medical record is the property of the clinic, patients
have a right to see their own records.
In the USA, doctors often dictate their findings onto
a tape, which is then "transcribed" by a medical
transcriptionist. This is very useful, and many Indian
companies are now rushing to offer this service . Right
now, it's mostly hospitals in the USA which use this
service, but many Indian hospitals will start using this

soon. However, voice recognition software will most
probably make most transcriptionists redundant very
soon.
Keeping rqedical records on computers ( Electronic

Medical Records, EMR has been a major advance and
many software packages are available now which allow
doctors to do this efficiently. Not only is the information
much easier to fill in , it also ensures legibility and
completeness - and the records are easier to retrieve.
Computer-based records are also very useful for medical
research, since it's easier to analyse them. However,
many doctors have poor typing skills, and many are
still computer-shy. The introduction of sophisticated
voice recognition programs in the near future will soon
allow doctors to "talk to their computers" , making data
entry for medical record-keeping much easier for them.
However, computerised medical record handling does
also carry certain downsides, such as the issues of
privacy and confidentiality, and these still need to be
resolved.
Chapter 12
Scheduling Patients:
Managing Appointments
Efficiently
Time is the coin of your life. It is the only coin you have, and
only you can determine how it will be spent. Be careful lest
you let other people spend it for you.
— Carl Sandburg
When you first start practice, you may see only a few
patients each day , and you may decide not to bother
with having an appointment system at all. In fact, you
are likely to be so glad to see any patient at all, that you
will see them at their convenience. However, it's
important to get into the habit of planning efficiently
right from the beginning, and if there are just a few
patients, give them appointments close together, so that
one patient leaves as another arrives. It will then appear
to your patients that you have a busy, thriving practice.
Of course, as you become busier, an appointment
system is essential to help you plan your day.
The appointment system you choose will affect your
entire practice management. Appointment books or
diaries can be bought with timed appointments already
set out, and the following guidelines may help you run
your practice more smoothly and efficiently:
1. Be on time. If you are always late, the patient will

go elsewhere.
2. Allow additional time for elderly or disabled patients,
who may take a long time to get dressed or
undressed, and for those who are very talkative.
3. Patients attending for the first time will take longer
as their history must be recorded, an assessment
made and treatment may be necessary.
4. Emergency patients will derail your scheduling, and
you need to factor this into your appointment system.
5. Check the appointment book regularly to make sure
a helpful member of staff or enthusiastic receptionist
has not overbooked your time.
Even if you have an excellent appointment system, the

sad reality is that staying on schedule has never been
easy. An emergency hospital admission , a traffic jam
or a family crisis can all wreak havoc with your
appointments. One of the commonest complaints
patients have about their doctors is the long waits they
are forced to endure - and many patients refuse to put
up with this delay, and are quite prepared to find
another doctor who is more respectful of their time.
Managing appointments is especially hard in India.
Indians are notoriously unpunctual, and Indian
Standard time means anywhere from 10-60 minutes
late, depending upon the part of the country you
practise in. This often sets up a vicious cycle, because
when the doctor is always late, patients too start
showing up late for their appointments, making a bad
problem even worse.
Of course, many patients don't even bother to take
an appointment, and dealing with unscheduled "walk-
ins" can be tricky. Others will take an appointment, and
Scheduling Patients: Managing Appointments Efficiently 1103
then not bother to turn up (" no-shows") , so that the

doctor sits twiddling his thumbs, and wasting valuable
time. In order to prevent this, and protect their time (
after all, a doctor is a daily wages earner !), many doctors
will "overbook" - and if all the patients turn up, then
everyone gets upset.
We need to respect both the physicians' and patients'
time. No one likes to be kept waiting. It is very expensive
for you to sit and have no patients to see. It can be even
more expensive when your patients, faced with
unreasonably long times to see you, decide to find a
new doctor.
While most doctors would be only to happy to be in
the happy position of having a long waiting list of
patients to see them, and an appointment book which
is fill weeks in advance, having too many patients can
be as difficult to manage as having too few. Having few
patients is easy to manage - you just see them when
they want to see you. However, when starting practice,
many doctors adopt a very disorganised approach, with
the result that as their practice grows and they become
busier, they remain as disorganised as ever. But as the
volume of patients you must work with grows, the result
is predictable: chaos leading to reduced efficiency and
increased stress on you and your staff, not to mention
angry patients. If you have an efficient system, you will
help yourself - and your patients to make more effective
use of your time.
Waiting patients get stressed out and angry - and
this can be stressful for the doctor too. An overfull clinic
can be difficult for the staff to manage as well - and
tempers can easily get frayed. While some busy doctors
take pride in the fact that patients need to wait for
weeks before they can get to see them, I think this is a
symptom of poor appointment management practices.

Remember that patients can get fed up and easily go to
your competitor. It is useful to develop techniques to
ensure that patients can get an appointment to see you
when they want to.
Remember that not all problems need a face to face
visit - and many can be resolved on the phone or by
email. Try to reduce the number of visits your patients
actually need to make to your visit. Not only will this
free up your time for more productive activities, your
patients will also appreciate the fact that you have saved
them the hassle of coming to see you.
What if you deal with a class of patients who do not
take appointments ? It is possible to teach them to follow
a system. Thus, you can schedule a time slot for pre
booked appointments, and leave the rest of the time for
"walk-in" patients, who can be seen on a first come-first
served basis. What about emergencies ? You should keep
a few slots every day for same-day appointments.
Exactly how many depends on your previous
experience, but two in the morning and two in the
afternoon is a useful starting point. That may sound
like it will cut into your productivity, but if you plan for
same-day visits — and you will get them — you'll
handle them and the rest of your workload more
efficiently.
Physicians can easily evaluate the efficiency of then-
practices by conducting a time-and-motion study, which
involves placing a sheet on the front of every patient's
chart for about 10 days. Record the time of each
patient's appointment, the time each one is directed to
the exam room, the time the patient leaves the clinic,
and the time the patient spends with the doctor. You
may be surprised to find that some of your patients
may be spending 60 to 120 minutes in the clinic but
only about five to 10 minutes with you. This simple
Scheduling Patients: Managing Appointments Efficiently 1105
technique allows physicians to identify problems and

find solutions to them. Track your appointment activity
for a month, and pay attention to fluctuations in days
of the week, so that you can tailor your clinic hours for
your patients' convenience. Thus, if you find that you
are very busy on Saturday evenings, you can start your
clinic at 3 pm ( instead of the routine 5 p.m., for
example). And if you find that few patients come in on
Wednesday mornings, you can use this time for another
activity, without affecting your productivity.
If you have many poor patients, it may be a good
idea to run a free clinic once a week. You can then see
a lot of patients at this time- leaving you with more
time for demanding patients, who do not mind spending
more money to spend quality time with you.
Dealing with patients who take appointments and
then do not bother to show up can be very frustrating.
Practices that remind their patients of their upcoming
appointment will generally have fewer no-shows and
have less need to overbook. Each patient should be
contacted by phone a day or two in advance of the
appointment. You may also choose to mail them
postcards as a reminder service. It's a good idea to
request them patients themselves to fill up their
reminder post cards at the end of each visit to reduce
the administrative burden on your staff.
It is also helpful to have specialty clinics on a
particular day of the week - for example, immunization
clinics every Saturday at 10 a.m., rather than give
vaccinations whenever the patient turns up. This is
much more efficient , since everything ( staff, supplies
vaccines, doctors and patients) are geared up for this .
Similarly, gynecologists can have a menopause clinic at
a specific day. Since patients with similar concerns are
seen together this encourages interaction amongst

patients with similar problems while they wait in your
clinic.
A clever trick to avoid empty "holes" during a typical
day is to schedule morning appointments from noon
backward and afternoon appointments from noon
forward, thereby filling in late morning and early
afternoon appointments first and gradually booking
early and late slots. This way, if a day is not fully booked,
early morning hours can be used productively for a
staff meeting or permit the doctor to come in later. An
empty slot in the middle of the day is generally wasted
time.
When the doctor is faced with emergencies or is
running significantly behind schedule, take the
opportunity to partner with the patient. Patients already
in the office as well as those scheduled for later in the
day should be told of the approximate wait time and
offered options. If the physician appears unable to see
all of the scheduled patients, start calling immediately
to reschedule those who likely have not yet left for
their appointment.
To make the wait less onerous for patients, many
practices are implementing innovative amenities. In
addition to the reception room staple of magazines
(current, please!) consider adding these: library of
relevant medical information ; health-related videos ;
internet access ; a telephone for local calls ; coffee, tea,
water ; television ; piped-in music. An efficient
appointment system will ensure that your clinic runs
smoothly and well - and will keep you, your staff and
your patients happy and smiling.
Chapter 13
The Telephone:
Your Clinic's Lifeline
Let your fingers do the walking. American Telephone

& Telegraph
(AT&T)
The one instrument doctors use more frequently than

their stethoscope is the telephone. While most doctors
are expert at starting intravenous lines, they forget
that the telephone is their clinic's lifeline, and
unfortunately, most have still not learnt to make the
best use of the telephone. This is one of the most
important tools in your clinical practise, but most
doctors do not bother to ensure that their telephone
system works properly. However, this carelessness can
prove to be expensive - after all, if a patient cannot
phone you, how will he be able to fix an appointment?
Remember that your phone is often the first point of
contact of your patients with your clinic, and it's vital
that you create a good first impression. To many
patients, how your practice manages its telephone calls
is an indication of how well your practice manages
patient care , and patients tend to judge the efficiency
of a practice by how well phone calls are answered.
Patients who have difficulty making appointments,
contacting a doctor or obtaining care for an urgent
problem are more likely to change their doctor.
It is certainly an advantage if you can afford two or

more lines. If one is engaged, a worried patient or
relative can use the other, and the telephone will not
sound constantly engaged if you use one line only for
outgoing calls. Some clinics have a special number which
they give out only to their existing patients, so that
they can access the clinic easily.
A good way to assess your practice's phone skills is
to put yourself in your patients' shoes and call your
practice. Can a patient schedule an appointment easily?
Are doctors readily accessible by phone? Are emergency
calls processed quickly? Are other calls returned in a
timely fashion? Can referring doctors get in touch with
you easily ?
You can assess your practice's phone skills by making
test calls periodically. How efficient is the receptionist
in answering, screening and directing the calls of
patients seeking appointments or demanding to speak
to a doctor? Let your staff know that you plan to test
the system periodically by making test calls, then meet
with the staff after each test to discuss your findings.
Telephone systems have become more sophisticated
and you should consider investing in the best one you
can afford. Most doctors take a penny-pinching
approach when buying a phone system - but this is
short-sighted. There are many choices, including
EPABXs, key-telephone system, and computer-based
systems. Many allow you to play messages or music
while the patient is on hold and these are useful because
they give the impression that your practise is
professional, modern and well-organised. Others offer
automated options, which can direct callers to the right
person. However, do remember that no matter how
sophisticated your machine, it's only going to be as
The Telephone: Your Clinic's Lifeline 1109
good as the people who actually answer the calls.

Employ the best receptionist you can find - she can be
worth her weight in gold Staff members who answer
the phone should be trained to answer phones, so that
they can do so efficiently. You need to teach them to
sound caring and helpful. It's useful to teach them a
standard protocol for answering the phone - for
example," Good morning, this is Malpani Infertility
Clinic and I am Ms Sunita. How can I help you ?" To
provide better service over the phone, develop a list of
the most frequently asked questions and their answers.
All messages - both incoming and outgoing - should
be logged in. This will help to ensure that your system
works efficiently.
For smaller practices, simpler options like a recording
machine are very valuable, so that patients or referring
doctors can leave messages for you. *You should also
explore the newer telecommunication options, such as
pagers and cellphones. Mobiles allow you to be "on-
call" round the clock - but be careful to whom you give
your number. Pagers are useful , because they allow
you to screen calls, and return them at your
convenience.
Many patients will insist on talking to the doctor
every time they call. However, this is not an efficient
use of your time, and you need to be able to screen
calls. Administrative matters , such as fixing
appointments should be handled by an assistant or a
receptionist. Triage protocols can help practices manage
calls for urgent, same-day or next-day appointments.
It's a good idea to teach patients how to use the
telephone well when do they call you. For example, tell
them to keep a pen and paper ready so that they can
write down the relevant instructions; identify
themselves properly, giving their full name as well as

their diagnosis ; and to report specific symptoms. Let
patients know when you are easily contactable for
routine calls - and request them to call during this
time.
Make it a point to return calls efficiently. It's helpful
to set aside 15 minutes a day, during which you can
do this. Patients appreciate doctors who call them up
- it's a sign that you care for their well-being, and
since it's something which such few doctors do, your
calls will stand out for their thoughtfulness. For
example, it's a good idea to call patients at their
residence 24 hours after they have been discharged
from hospital, to check that they have no complaints.
As technology advances, phone systems are going
to become even more sophisticated, and you should
be prepared to make use of this valuable tool . The
simplest example is telemedicine, and videophones for
teleconferencing may soon become commonplace - and
call centers which offer patients pre-recorded health
information are now popular in the West.
How your telephone is answered can make or mar
the reputation of your practice and here are some
guidelines to help you improve your telephone
reception.
1. Have a standard printed form on which to put the

name, address, telephone number and a brief outline
of the patient's problem. These are quite helpful, as
it is possible to see at a glance the substance of the
call.
2. Screening calls is a problem. You should not speak
to a member of the family, another doctor or patient
when you are in the middle of a consultation. The
The Telephone: Your Clinic's Lifeline 1111
patient is paying for your time and attention, and

will not like interruptions.
3. An emergency call must be dealt with as soon as
possible. Establish what the problem is, and decide
what you are going to do about it.
4. Train the receptionist or secretary to distinguish
between urgent and non-urgent calls.
5. Leave your own calls, either personal or business, to
a time set aside for the purpose.
6. You might want to "schedule" time for telephone
consultations for complex problems. Many doctors
in the US do this - and charge for it as well.
7. Have a script in front of every phone, telling the
staff member how he or she should answer the
phone. This facilitates positive phone manners and
also ensures your phone are answered consistently
and pleasantly.
8. Tell your staff to smile and be enthusiastic while on
the telephone. Place a mirror in front of every
telephone - the smile can be heard on the other end
of the line.
If you hate being put on hold or talking to rude

telephone operators, imagine how much worse it must
be for your ill patients when they try to get in touch
with you ! Making effective use of the telephone can
help to save both you and your patients' considerable
time, effort and money - learn to use it well.
Chapter 14
Buying Medical Equipment:

Getting Value for Money
One machine can do the work of fifty ordinary men. No

machine can do the work of one extraordinary man.
— Elbert Hubbard.
Modern medical practice uses technology liberally, and

you may need to buy quite a lot of medical equipment,
depending upon your area of specialisation. Since this
equipment can be quite expensive, it is important that
you have a system to maximise the cost-effectiveness
of the equipment you purchase. You are likely to be
faced with lots of options, including: What to buy ?
When to buy ? New ? Second hand ? How to raise the
money ? Buy ? Rent ? Lease ? Imported ? Indian ? and
you must do your research well. Don't buy a major
equipment item without a cost-benefit analysis. You'll
need to make assumptions about anticipated patient
load and the cost of delivering the service, but don't
shy away from the work.
Uptil now, most medical equipment needed to be
imported and doctors were forced to buy what was
available. After sales service was usually poor and
doctors often smuggled in medical equipment, to save
customs duty. Today, however, the situation is much
better. Medical equipment manufacturers have realised
Buying Medical Equipment: Getting Value for Money 1113
that India is a huge market, and most have distributors

in India today, so that doctors can pick and choose. In
a buyer's market, you must demand excellent customer
service - remember that your patient's life can depend
upon it.
Cost out the equipment you need and develop a list
of priorities. The most essential items must head the
list followed by the equipment you will want to add as
your income becomes more supportive of the practice.
Shop around. It is a good idea to compare prices from
local sources as well as national companies, in order to
establish which firms are the most competitive. You
may be swamped initially with brochures of equipment,
followed by frequent calls from representatives and
medical suppliers, hoping to sell their company's
products. These representatives provide an important
and valuable service since they will keep you informed
of what is new on the market and give you some
research statistics which will back up their product's
claims . They will also educate you about their
competitor's drawbacks and limitations.
Articles in medical journals can provide valuable
information on the newest trends in technology. Most
manufacturers have their own websites as well, which
are packed with information. Medical conferences also
usually exhibit medical equipment, and visiting these
exhibitions is a good way of seeing a lot of the competing
products at one time, and will allow you to compare
features and prices with ease.
Bank loans are usually easily available to help you
finance your purchases; and options include leasing it.
Often the manufacturer will help you arrange for
financing as well. In order to make your purchase cost-
effective you will need to let your patients and referring
colleagues know about the special features of the new

equipment you have bought, and how it can help them.
Being the first doctor in the region to buy the newest
technological advance can help get you considerable
publicity, thus helping you to promote your practice.
However, remember that newer is not always better -
and a number of doctors have wasted lakhs of rupees
on buying equipment which either did not work
properly, or did not perform as promised.
For expensive equipment, you may want to use "
requests for proposals " or tenders, in which you can
invite competing vendors to bid against each other. Try
to seek at least two competitive bids using the same
specifications, and let vendors know they are competing
on price and value. Unfortunately, the medical
equipment industry in India is still not doctor-friendly,
so while supplies will promise you the earth when
selling the equipment, their after-sales service will often
leave a lot to be desired. If you want to avoid having
your fingers burnt, don't buy the cheapest equipment
available - this may actually turn out to be much more
expensive in the long run. Check out the track record
of the supplier and ask for a client list, so you can
interview doctors who have bought equipment from
them in the past.
If you are planning to buy expensive equipment,
insist that the manufacturer let you try it out in your
clinic for some time. What may perform extremely well
in another doctor's hands may not be the best piece of
equipment for you. While it's not always necessary to
buy new equipment, specially when finances are limited,
you must take care to ensure that any second-hand
items are sound.
Service is vitally important. Make sure the length

and coverage of the warranty is clear, and whether this
is comprehensive (includes both labour and spare parts)
and on-site ( or do you have to take the equipment to
the manufacturer ?) Read the fine print carefully.
Good companies should be able to offer a 24-hour
service. A friendly service engineer who comes
promptly can save your practice time and money.
Preventive maintenance done on a regular basis can
help to prevent expensive breakdowns. Good
companies must be able to provide replacements in an
emergency, if yours is being repaired. An annual
maintenance contract will ensure that the equipment
is maintained in an optimal condition for its lifetime
and is very valuable for your peace of mind - don't
scrimp on it. Keep a log book, which describes the
history of the machine; the problems it had; when it
was serviced; and when the next servicing is due. It's
also a good idea to insure expensive equipment - this
is very cost-effective. Technology changes so rapidly
these days, that you may soon find that your equipment
has become obsolete. Try to buy machines which are
modular and upgradeable, so that the equipment
remain state-of-the-art. You may also find it worthwhile
to sell your old equipment to doctors in smaller towns
when you need to buy a new model. A good supplier
will be willing to buy-back your old equipment, when
you plan to upgrade to the newer model.
When you buy medical equipment, make sure that
you also get the training needed to use it properly ! For
very expensive equipment, companies may be willing
to send you abroad for advanced training, and you
should explore this possibility to ensure you are
comfortable with the new technology. Make sure at

least one member of your staff knows how to operate
the equipment.
Investing in high quality equipment is one of the
most important investments you can make in
improving the quality of the medical care you provide
- spend your money with care.
Chapter 15
Going Digital:
Using Computers to
Enhance Your Efficiency
Artificial Intelligence usually beats natural stupidity.
Why use a computer in the first place ? You don't have

to. But then you also don't really have to use a telephone
either. The truth is that a computer can tremendously
improve the quality of your practice - and actually give
you more quality time to spend with your patients.
Most doctors even in the US have still to realize this,
although almost 75 per cent of physicians use computers
in some form or the other. In India, the number is
growing rapidly but we are still far behind the
Americans. However, you cannot afford to remain
computer-phobic anymore, and for most doctors, the
question should not be, " Should I buy a computer ?"
but rather, "Which computer should I buy " ?
Just for example, do you know the precise number
of patients that you examined and treated last Thursday
? Would you able to find out how many of them have
paid you, and how much? And who should have come
for a follow up visit this week, but didn't show up?
Most of us would have no clue—or it would take
several days of wading through old notebooks, receipts,
Going Digital: Using Computers to Enhance Your Efficiency 1119
prescriptions, rough notings on slips of paper, and

God knows what else. Is it better to go on doing that
for the next twenty years or would you like to switch
to a computer? The same thing applies to your clinical
research and analysis, whether it comes to collating your
data or preparing your presentation. And then there is
today's "killer application" - the Internet. This is such
an important area today, that we have devoted a full
chapter to this subject.
Computerising your clinic is not an easy task. If
you run a disorganised clinic, the computer will
multiply this disorganisation a hundred-fold. Make sure
you have paper backup records for at least the first
year, and that you have data backup and storage systems
to deal with the inevitable computer glitches which
plague all computer-users. Since this is such an
important investment, buy the best computer you can
afford; and ensure that you have efficient and reliable
technical assistance which is a phone call away. There
is ■ no substitute for having a comprehensive
maintenance contract for your computer - if the system
goes berserk, it can paralyse your clinic, and you simply
cannot afford this. Decisions as to which system to
buy and whether or not to go in for a local area network
(if you have a large clinic ) should be made only after
talking to other doctors who are happy with the
computer system you are planning to go in for.
Of course, a computer is just a dumb box, and you
need software programs for it to perform useful
functions. Generic programs such as word processing,
spread sheets, databases and presentation software are
useful to everyone , including doctors. Most doctors,
for example, still use their computer primarily as a
glorified word processor, for printing out patient's
discharge summaries or referral letters. Others have

been more innovative, and use their computer to
automate some of their office functions - for example,
to record the telephone numbers of incoming voice
mail; or as a FAX machine. However, a computer really
shines in. helping you manage your medical practise
when you equip it with a practise management
program, also called Electronic Medical Record ( EMR)
programs. These are meant to cater to general medical
practice tasks , like keeping patient records, scheduling
appointments, and billing patients. These maintain
accurate & detailed medical records which you can
retrieve at the touch of a button. You can also analyse
your practice, for example, to find out how often you
see patients with a particular medical problem, and
what their response to treatment is. Many of these
programs also allow you to instantly print out
customised patient educational handouts which you
can give to your patients. Many of these programs are
"intelligent" and will check your prescriptions for drug
interactions, for example. Which programme to buy is
a very important decision; and the more user-friendly
your EMR programme is, the more likely it is that you
will use it to improve your productivity. Insist on a
working demo in your clinic which you can try out
for a week before making a final purchase decision.
It's also a good idea to talk to other doctors who have
been using the program for some time, to ensure they
are happy with it. A good program will minimise the
typing you need to do; and should be able to adapt to
your practise's needs. While these programs are often
quite expensive, the good news is that many computer
programmers and doctors are now developing "open
Going Digital: Using Computers to Enhance Your Efficiency 1121
source software" for medical practice management.

These programs often run on Linux, and are free, so
you don't need to pay for them.
Unfortunately, the sad fact is that even doctors who
do have computers in their clinic do not make optimal
use of them. While buying the computer is easy, training
your staff to use it properly is a difficult task. Hopefully,
the new generation will be more computer-literate , and
doctors will be able to integrate the power of computing
into the medical clinic more efficiently.
Many doctors now also use handheld computers or
PDAs. These act as portable brains, and allow them to
improve their efficiency considerably, because they can
carry important data with them. If you need to travel
to different clinics or various hospitals, this can be an
excellent investment.
The best way to decide about how to use a computer
in your practice is to talk to a colleague who uses
computers extensively. Ask him to convince you how a
computer can help to improve the quality of your life.
Chapter 16
www.doctor.com:
Setting up Your Virtual Clinic
on the Internet
I used to think that cyberspace was fifty years away. What

I thought was fifty years away, was only ten years away.
And what I thought was ten years away... it was already
here. I just wasn't aware of it yet.
— Bruce Sterling
In the past, getting on the Net meant learning how to

surf the Web, and having your own email address was
considered to be a status symbol. However, today, this
is no longer enough - you need to have your own
website. This rapid pace of change is symbolic of how
quickly things are changing in today's world - and
doctors who are not proactive are likely to get left
behind.
You are a busy doctor, so why should you take the
time and trouble of setting up your own website ?
Every good doctor knows that keeping your patients
happy and providing excellent patient care is key to
success. Your website lets you provide value-added
services for your patients, by providing details as to the
timings of the clinic ; the specialized services you offer;
answers to commonly asked questions, and post
wuw.doctor.com: Setting up Your Virtual Clinic on the Internet 1123
procedure instructions as well as directions as to how

to get to the clinic. This means you can use your website
to serve your patients round the clock without requiring
them to call or visit, making your website a valuable
support/contact center.
Your website allows you to answer routine patient's
queries by e-mail. Patients are thirsty for information
about their illness, and many will use the Net to find
information. However, most patients would much rather
get information from their own doctor , and if you
provide this information on your website, your patients
know they can trust it. Your website will also save you
a lot of time. Most doctors have now started seeing
patients coming with Net printouts of pages and pages
of unreliable and irrelevant information. If you put up
your own website, you can guide your patients to
reliable sources of information - thus saving your
patients the frustration of wading through pages of
garbage and misinformation. Remember that Indian
patients want information about diseases common in
India - so they want information on malaria rather than
cystic fibrosis. By providing this information, you
establish yourself as a credible expert. You can "refer"
patients to your website at the end of the consultation,
so they can educate themselves . Patients appreciate
this - and word of mouth will help you get more
patients.
Your website can help you to attract new patients .
Indian medical care is very cost-effective, and a website
is very valuable for informing NRIs of your medical
expertise. Soon, it will become as routine for patients in
India to do " research " about their doctors, as it is in
USA, and your website can help patients to find you.
At our website at http://www.DrMalpani.com, we answer
over 10 queries a day, as a result of which we get

direct patient referrals from all over the world.
Remember that internet positive patients may be slightly
different from your average patient. They are well-
informed, used to getting second opinions, and can be
quite demanding. Most are affluent, and know exactly
what they want.
Your website is an excellent form of continuing
medical education for yourself. Because you need to
update your website all the time, not only do you need
to source the latest medical information, you also need
to keep upto date with web technology.
However, website benefits are not restricted to
practise promotion only. We put up a new website at
www.TheBestMedicalCare.com to publicise our book, How
to Get the Best Medical Care - A Guide for the Intelligent
Patient. We now get orders from all over the world -
and get paid in US dollars too for this. Our first website,
www.healthlibrary.com is a purely educational site, and
by putting up over 20 full-text books on ayurveda and
yoga online in our reading room, we are helping to
promote Indian healing systems internationally.
Patients all over the world are very interested in
alternative medicine , and websites can allow Indian
doctors to treat patients from all over the globe.
Putting up a website has become very easy , and
many companies provide free webhosting. However,
it's well worth spending about Rs 10000, to get your
own domain name and a commercial webhost. This lets
your patients know that you are professional and serious
about the services you offer.
You need to have realistic expectations of what your
website can do for you. In India, the number of Internet
users is not yet as high as in the USA, so don't expect
patients to start pouring in the day your website goes
www.doctor.com: Setting up Your Virtual Clinic on the Internet 1125
live. Just having a website is not enough - remember

that there are over a million websites out there. You
need to promote your website actively. Online
promotion usually means registering the site with all
the relevant search engines, so people can "find" you.
Offline promotion is even more important, and you
need to tell everybody about it. Print the website
address (URL) on your business cards and your
stationery - and display it in your waiting room .
Encourage patients to use your website - most will be
happy to follow their doctor's orders. And if your
website has content which is useful to them, and which
is updated on a regular basis so it is fresh and new,
many will happily visit it regularly - and even refer
many of their friends to your site as well.
You can also design a monthy e-zine, to keep patients
coming back to your site. Your staff should constantly
be on the lookout for interesting pieces for the next
month's issue. This creates a direct link to your web
site, but does require commitment to keep the content
fresh.
Are there are any downsides? The major one for
doctors in the US is that of legal liabilities. Protecting
patient privacy and confidentiality is a major concern,
and while this is still not an issue in India as yet, it is
likely to become important as the world shrinks even
further.
It is true that putting up a website - and updating
it - can be time consuming , and you might want to
consider outsourcing it. Your website is an image of
your clinic - make sure you do a professional job.
Typing errors, poor grammar and deadlinks all create
a poor impression. Also, make sure you reply promptly
to queries and e-mails. It's a good idea to check out
competing websites so you can see what they are doing.
This can also provide you with an incentive to upgrade

your own services. Your website can help to keep you
on your toes - both professionally, because you need to
update your knowledge to provide fresh content for
your website and to answer queries received by email
from patients in all parts of the world; and
technologically, because you will need to keep abreast
of computer and internet technology.
The Indian government has started encouraging
doctors and hospitals to export their services, and
medical services can be a major area of foreign exchange
revenue for the future . By encouraging doctors and
clinics to put up their own websites, the Indian Health
Ministry can help the Indian medical industry to export
their specialized medical services and knowledge -
without contributing to brain drain. This can be a
valuable source of foreign exchange for the country,
and our hospitals can be actively promoted as medical
centers of excellence. Indian doctors have the expertise
- we just need the infrastructure and the promotion.
Some doctors are worried that having their own
website may be misconstrued as a form of advertising.
However, the internet is a very valuable means of
educating patients, and doctors need to be in the
forefront of providing reliable information to their
patients. After all, if we don't take responsibility for
educating patients, then who will ?
The future of medical care is e-healthcare, with the
promise of online medical records, online pharmacies,
telemedicine, patient education, and an ever-expanding
list of exciting opportunities. The opportunity to help
our patients navigate the wealth of information on the
World Wide Web and better educate themselves is now
in our hands. We owe it to ourselves and our patients
to meet the challenge that lies before us all.
OMR SVTE I
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wmo.doctor.com: Setting up Your Virtual Clime on the Internet
1127
Chapter 17
Information Therapy:
Educating Your Patients
Information is the best prescription.

— Dr Koop
The commonest complaint patients have about their

doctors is that they never explain what is happening.
It is true that doctors no longer spend enough time
talking to their patients, and this leads to a further
widening of the doctor - patient communication gap.
You need to share information with your patients and
educate them about their problem, so that they can
make informed decisions for themselves.
Today patients are aware of their rights. This has
had its effect on medical practice as well - especially in
the U.S.A, where it is mandatory to inform and educate
the patients about their choices. With the introduction
of the Internet, medical and health information has
become much more easily available to the lay person in
India. Today, the intelligent patient can do free Medline
searches sitting at home, and explore advanced
treatment options available at the world's best medical
centers. Patients are going to start demanding
information , and rather than see this is a problem, it's
actually an opportunity for you to promote your
Information Therapy: Educating Your Patients 1129
practise. Smart doctors are proactive , and by providing

this information freely on your own, you can become a
leading expert in your field.
Remember that educating your patient is in
everyone's best interests, including yours. Patient
education is important as a practice promoter - patients
appreciate your taking the time and effort to inform
them. This helps you to stand out from the other doctors
he may have visited, so that when he finally decides
which surgeon to select, he will be more likely to pick
you.
It is well known that patients forget over half of
what the doctor tells them because of the stress of the
consultation. Giving them printed materials to read at
home will help them to remember. This will help to
prevent midnight calls about unimportant issues - and
ensure peaceful nights for both patient, and doctor,
because the patient will not need to trouble you about
trifles. Printed educational materials also help to increase
patient compliance and the printed word is useful in
reinforcing your advice and instructions. It helps to
educate the rest of the family as to what is happening
- and this is important in India, where it is often the
family, which makes decisions regarding medical
treatment.
Doctors learn a lot from the intelligent patient. After
all, physicians are not veterinarians and the inquiring
and well-informed patient can teach you much more
about medicine than any textbook. A patient's questions
will make you think about things you may otherwise
have taken for granted. Also, reading patient
educational literature can teach doctors to look at things
from the patients' point of view. This helps to increase
your empathy - a very desirable goal. Your patients
may also help to make you aware of advances which
are occurring in other parts of the world - which you

may otherwise have overlooked.
Some doctors feel threatened by a patient's questions
- and may feel that the patient is challenging them by
asking questions. This is not the right perspective at
all. Remember that both doctor and patient have a
similar goal - to make the patient better - and questions
should be encouraged and answered, rather than leaving
doubts to fester - a situation, which can create
unnecessary problems later.
Patient education is likely to reduce the risk of
inadvertent complications. After all, we are all human,
and may make errors - for example, prescribing drugs
which may have an unwanted interaction. Intelligent
patients are highly motivated to look after themselves
and the informed patient can sometimes point out
possible problems with your treatment plan which you
may have overlooked (for example, a patient with G6PD
deficiency should know which drugs are unsafe for
him).
Educating patients will help to prevent health fraud
and quackery in the community. This is especially true
for chronic illnesses (such as arthritis), and medical
problems for which we do not as yet have effective
solution (such as cerebral palsy). If you teach your
patient about what can be done to help him, as well as
the limits of what medicine can offer him, he is unlikely
to be cheated by quacks.
It is important to document that you have informed
the patient of possible complications and risks - and
educational handouts offer proof in black and white
that you have done so. Taking "informed consent" is
important, but for most doctors it simply means taking
the patient's signature on a standard form - more as a
medico - legal formality, without really "informing" the

patient about anything. Patient education is an integral
part of" risk management" in medical practice today,
and will reduce the risk of your being sued if
complications do occur.
There is some thing special about the printed word.
Patients who are anxious about their health will seek
more information on their illness - and doctors have
only a limited time in which to answer all their queries.
Rather than force patients to turn to unreliable sources
of information (e.g. the Internet , or sensationalised
media reports), because these are readily available,
doctors need to intelligently use a variety of printed
materials to both educate existing patients, and to attract
new patients to their practices. I first realised what a
wonderful service this was to patients when I was a
medical student at the Johns Hopkins Hospital . The
reception area was filled with brochures, newsletters,
and fliers that covered a plethora of diagnoses. The
materials were all professionally produced and the
information was easy to read. A patient who is anxiously
waiting to see the doctor might pick up one of the
brochures - and have more confidence that the doctor
he was about to entrust his health with was indeed an
expert in his particular condition. Most successful
physicians have all developed unique ways of
communicating with patients - and written materials
are extremely valuable.
Brochures are generally inexpensive printed
materials that can be read at a glance. They can be
effectively used to educate patients. For instance, in our
practice, we routinely perform a number of procedures
including laparoscopy and hysteroscopy. We use
brochures to educate patients about these procedures.
Once they have read the appropriate brochure, I review

the risks and benefits of the proposed treatment. These
brochures expedite the consent process and give patients
something to take home in case a family member has
questions. In my experience, patients are often relieved
to read the brochure, because it signifies that although
this is a new procedure to them, I have done lots of
them. A brochure helps establish my credibility and
experience with a proposed procedure , and at the same
time educates the patient.
Effective brochures are easy to read in a short period
of time. Brochures in the waiting room can alleviate
patients' fears and anxieties before their scheduled
appointments. Brochures also offer the opportunity to
present references and to provide details about your
training and credentials. It is now possible to buy pre
printed brochures from medical societies, and a number
of commercial publishers in the USA and UK. Many
Indian medical associations and pharmaceutical
companies have also started publishing these. The
benefit of these is that they are often very well designed,
attractive and have reliable content; however, they may
not be customised to your own practice and philosophy.
This is why many doctors prefer to produce their
own custom brochures. Desktop publishing makes it
easy to create brochures for a fraction of the cost of
having them designed and produced by a professional.
However, marketing experts are loath to recommend
this route, because poorly designed brochures may
produce exactly the opposite effect from what you want.
Poorly designed materials can damage your image and
may discourage patients from seeking your care, so it
may be worthwhile to hire a professional to design and
produce your personalised brochures. As with all
printed materials, both the content and presentation of

the brochure are critical.
Some common mistakes that will sabotage your
brochure include : using too much running text and
not enough bulleted information, using too many big
words or complicated medical terms, and forgetting to
put in contact information.
It is worth using commercially published brochures
as models, and copying them when
starting to publish your own. Try to have a consistent
design and logo, so your patients can easily identify the
printed educational materials you produce. A simple
inexpensive trick is to use the same background light
colour (for example, lilac), for all your brochures.
If you get more ambitious, you can also decide to
publish a newsletter on a regular basis, to help update
your patients about the recent advances in your
specialty and also inform them about the new services
you offer. Many doctors find that this is a very cost-
effective way of marketing as well, because patients
will often pass on a newsletter which contains
educational material about health to their friends and
relatives - all of whom are potential new patients for
your practice . And don't forget that in this digital age
a website can be very effective in educating your
patients without having to cut down a single tree.
A common question doctors ask is: isn't this is a
hassle? Who has the time to sit and teach patients?
However, just like you prescribe drugs, it important to
prescribe information as well. It is important that you
then discuss the results of this information search with
the patient, so that you can help him to determine which
information is relevant to his particular problem.
Remember that patient education is a worthwhile
investment of your time - after all, the best patient is

a well-informed one. You must aim to empower your
patients , by providing them with the information they
need to promote their health, and prevent and treat
their medical problems in partnership with you - their
doctor.
THE PATENTS KVXO'AJ MORE AftoO'T
their. dxseases than me . \ mvst
Information Therapy: Educating Your Patients
-<T
1135
Chapter 18
Communicating with Patients:

Your Bedside Manner
Patients don't care how much you know until they know
how much you care.
Today's patients want to play an active role in their

medical treatment. How can you help to encourage their
participation and improve your doctor-patient
relationship ? The answer is simple - learn to
communicate with them. Even if you are very busy,
it's possible to be an effective communicator — you
simply need to communicate "smarter" by making
better use of the time you've got. Communication with
your patient is an art - what is often referred to as
bedside manner.
For most doctors, good communication is a skill like
playing a musical instrument, which needs to be learned,
and then practiced repeatedly to be perfected. The best
communicators have an open mind, a receptive ear and
an empathetic heart. Their good bedside manner is
perfected through practice, experience and feedback
from patients and other doctors. For these doctors,
bedside manner comes naturally, and if you know a
doctor with good communication skills, try to adopt
him as your mentor and copy him.
Communicating with Patients: Your Bedside Manner 1137
You can also work on improving your interpersonal

skills by following these tips.
Remember your manners. Patients are more likely to
follow your advice if they have a good relationship with
you. How you enter a room is very important. Walk in
with a smile, shake the patient's hand, call the patient
by name (first name or surname, whichever the patient
prefers), and sit down. Make it a point to always
remember the patient's name - and if you have a bad
memory, instruct your staff to prompt you. You can
also help to put the patient at ease by starting off with
a simple " How can I help you ? "
Don't appear rushed, even if you are. Patients get irritated
when their doctors appear hurried. Make each patient
feel that they are in the center of the universe - focus
all your attention on him. Sitting down and talking is
far more effective than talking while standing up - and
takes just a few seconds more.
Keep conversations on track. Helping patients stay on
track is key to increasing efficiency and maximizing the
value of the time you have with them. You need to
guide them so they don't wander off on a tangent.
Listen without interrupting. While your tendency may
be to ask your patients a lot of questions up front, you'll
get more information and save time in the long run by
actively listening to the patient without interrupting.
Studies have shown that the patient normally speaks
for an average of 18 seconds before the doctor interrupts.
However, if you let them speak for three to four minutes,
they tell you 90 percent of what's wrong with them.
Organize your interviews. To make the most of your
interview time, structure your patient interview. For
example, if you want to explore the psychological aspects
of a patient's complaint you may want to try the "BATHE
technique" , which divides the patient interview into

the following components:
• Background ("Tell me what has been happening.");

• Affect ("How do you feel about that?");
• Trouble ("What's upsetting you most about it?");
• Handling ("How are you handling the situation?");
• Empathy ("That must have been difficult.").
Teach your patients how to communicate with you. Since

communication is a two-way process, it's very useful to
teach your patients how to discuss their concerns with
you . You can teach them to use the simple formula,
PREPARE, so they learn how to communicate with you.
P — Plan ( what they want to discuss)

RE — Report (what they have experienced and
what they feel about it)
P = Participate ( so it is a 2-way discussion)
A = Agree ( make a joint decision)
RE = Repeat ( so you can ensure they have
understood correctly).
Use computers creatively. You can use e-mail to answer

patients' questions and avoid getting tied up in lengthy
telephone conversations.
Educate your staff. Communication isn't just a doctor
patient issue. Your nurses and clinic staff also represent
you to your patients .To strengthen the staff-patient
relationship, hold staff training sessions on patient
communication.
Do the unexpected. Keep in contact with your patients
by routinely calling two or three of them each day -
they will treasure this gesture.
Be sensitive. The vulnerability of the patient is

something that doctors can forget too easily. Patients
are frequently anxious, unaware of their diagnosis, afraid
of cancer or death, worried about pain, and scared about
the future. Sensitivity is vital in all your dealings with
them.
Good communication with worried relatives is also
a necessity. Anxiety and grief sometimes manifest
themselves as anger. Often, when relatives complain
about the treatment a patient has received, their distress
could have been alleviated by talking to them and
explaining things coherently and honestly.
All of us have our own preferred communication
style, depending upon our personality. Analytical
doctors focus on facts and figures, while emotional
doctors focus on feelings. You need to look at yourself
objectively, so you can determine what your preferred
style of communication is. There is no right or wrong
style - it's just important that you be aware of what
your preferences are - and your weak points as well, so
you can work on them. Communication is a two-way
street, and for communication to be effective, you need
to attune your style to the patient's style . Patients have
different personalities and communication styles, and
you should be able to adapt your style according to the
patient's needs. You can become an expert on doing
this if you learn NLP (Neuro Linguistic Programming)
which teaches you how to mirror your patient's
behaviour, so you can mold their behaviour effectively.
Just like doctors, patients too have styles they prefer,
depending upon their own personality. Some are
emotional, and communicate through feelings. They
respond to stories of other patients you have treated
successfully. Analytical patients communicate

objectively with logic and rational thinking. They need
facts and figures and data, and are interested in your
success rates and statistics. Scholarly patients need
references and papers, and will respond to books and
articles which support your recommendations.
Socialisers are name-droppers, who are likely to be very
influenced by who your other patients are. Pictures of
you with famous personalities will impress then - as
will your framed medical certificates and diplomas.
Doctors who can communicate well with their
patients have happier patients; busier practices; greater
income; and higher self-esteem. This is why learning
how to improve your communication skills can be one
of the most important investments of your time and
energy. Communication is more than just words.
Psychologists estimate that only 7% of any message is
the spoken word; 38 % is voice quality ( tone, tempo,
intonation); and 55% is body language. This means that
most of what we communicate is non-verbal, and you
need to be aware of your non-verbal communication
cues, and those of your patient as well, so you can
respond to them.
Since you communicate 55 percent of the time
without ever saying a word, you ought to be paying
attention to what your non verbal signals are saying to
patients. If you think you're simply too busy for a lesson
in nonverbal communication, take heart: If you can
spell SOFTEN, you can begin to perfect your nonverbal
signals right now.
S is for smile. A smile helps set patients at ease and
generates positive feelings about you and your practice.
This, in turn, breaks down barriers so you can uncover
issues more quickly and openly.
O is for open posture. Open posture, which means no

crossed legs, arms or hands, says you are approachable
and willing to interact. Arms drawn together across your
chest, on the other hand, can be intimidating or even
condescending to patients
F is for forward lean. A slight forward lean toward the
speaking party says, "I'm trying to get closer because I
really want to hear what you have to say."
T is for touch. As you introduce yourself, shake your
patient's hand in a warm and friendly manner. In
addition to the nonverbal message the handshake sends,
you will learn a lot about the patient's psychological
state. Is the hand warm, cold, jittery, sweaty? All are
clues that may save you time.
E is for eye contact. Eye contact is probably the most
important non-verbal communicator after smiling. If
you maintain eye contact with your patients 85 percent
of the time, you will be branded as an expert
communicator and physician in the patient's view. Eye
contact conveys that you are paying attention to the
individual, not being distracted by the chart or your
notes or something else on your mind
N is for nod. As your patient speaks, nod occasionally.
This simply means that you are listening and
understand, not that you necessarily agree. Your
nodding helps the patient move forward with
complaints, rather than hesitating because he or she
feels uncertain whether you are listening.
Remember that the single most important criterion
by which patients judge you as a physician is the way
you interact with them. It is therefore vital that you
develop your understanding of your own communication
style and adjust that style to meet the needs of various
patients. If you include your patients as fully informed
partners in their care, they'll pay you back by sticking

with you through thick and thin. And as an added
bonus, you'll discover more satisfaction in your work,
renewed motivation and increased productivity.
As with everything, the best way to develop a great
bedside manner is to practise. By ensuring that you try
and put every patient at ease and alleviate their
anxieties, you will find your communication skills and
natural empathy rise automatically. And when your
patients smile at you and appreciate the way that you
have treated them, their gratitude gives you a warm
glow and reminds you why you went into medicine in
the first place.
Chapter 19
Listening to Your Patients
There are people who, instead of listening to what is

being said to them, are already listening to what they
are going to say themselves.
— Ibert Guinon.
One of the commonest complaints patients have about

doctors is that they are too distant and uncaring.
Perversely, many doctors still pride themselves on their
detachment and equanimity - and distancing oneself
from the patient is one of the first skills we learn as
medical students. However, medical practice is not an
either-or situation, and doctors need to practise both
science and art, reason and intuition, attachment and
detachment, equanimity and empathy. These are not
mutually exclusive - and the good doctor needs to find
the right balance.
Unfortunately, we do not encourage our medical
students to develop their emotional skills, and medical
college usually drains whatever natural empathy
students have. Students get marked for their academic
excellence, cramming ability and surgical virtuosity -
not their ability to establish a rapport with their
patients. Medical college professors rarely demonstrate
empathetic skills - so who are students going to learn
from ? By overworking residents and forcing them to
cram tomes of scientific information, we often end up

dehumanising them . This means that after 6 years of
medical college, instead of producing doctors who
should be able to understand a patient's pain and
suffering, we turn out unfeeling surgical automatons -
what a shame.
Some doctors are naturally blessed with empathy ,
while others need to learn it. However, it can be learnt
and taught - and is as important as learning to tie a
surgical knot and to start an IV line. Time , age and
experience often bring empathy along with serenity -
and doctors who have suffered themselves ( or whose
family members have experienced suffering) are much
more likely to be empathetic than others.
One of the best ways of developing empathy is to
become a patient yourself. When physicians fall sick
themselves, they learn the value of empathy the hard
way. Seeing things from the other side can be very
educational - and many doctors are quite shocked to
realize how badly the medical system treats patients in
general. Unfortunately, they only learn this when they
are at the receiving end, but many do improve their
own bedside manners as a result of this experience ! In
fact, a medical school in the US admits their medical
students as patients in a hospital ward for 2 days, so
that they can experience firsthand how it feels to be a
patient in a strange , hostile and threatening
environment.
Reading books written for patients can also be very
educational. The consumer health literature has now
become voluminous, and unlike medical text books,
these extensively cover the emotional effects of the
illness and how to cope. Since these books have been
written for patients, they are patient-centric, and
Listening to Your Patients 1145
eloquently present the patient's view point. Books

written by patients which describe their first-hand
experience are particularly valuable, and can serve as
an eye-opener if you try to feel the story as the patient
feels it. Just as artists learn to see by drawing, so doctors
can learn empathy by putting themselves in their
patients' place. " Pathography" - the stories of illness
from the inside - can help nourish empathy.
The internet is also very valuable, since there are so
many personal websites which present the patient's
experience with his illness. Online bulletin boards ,
chats, mailing lists and newsgroups which invite patient
participation are all very useful as well. Not only can
you contribute your wisdom as a medical professional,
if you keep an open mind, you can learn a lot about
what it feels like to be in the patient's shoes. Unlike
Indian patients, many in the West are very articulate
and demanding - you can learn a lot from them.
Is there a downside ? Empathetic doctors can
sometimes lose their objectivity, and when you get
attached to your patients , their grief becomes your
grief, and their sorrow becomes your sorrow. Is this
bad? I don't think so. I think this is part of being
human, and we should allow ourselves to experience
feelings ! As a doctor, we have the unique privilege of
sharing our patient's innermost thoughts, and we
should try to make the most of this privilege, rather
than try to wall ourselves off.
Learning empathy is very valuable in improving the
medical care you provide. Just talking to the doctor can
be therapeutic for many patients, and conveying
empathy lies at the heart of a physician's supportiveness.
We need to remember that doctors are active healing
agents - and often far more potent than an antibiotic.
It is true that there will be some days when you will

find it much easier to respond to your patient's feelings
- and some days (when you are feeling burnt out) when
you couldn't care less. Also, some patients are much
easier to empathise with than others. However, if you
do try to consciously develop your empathy skills, this
will help you to take better care of your patients, become
a better doctor - and even more importantly, become a
better human being.
Listening to Your Patients 1147
Chapter 20
Winning Your Patients' Loyalty
I don't know what your destiny will be, but one thing I
know: the only ones among you who will be really happy are
those who will have sought and found out how to serve.
— Albert Schweitzer
For many doctors the idea of treating patients as

customers is repugnant. For many doctors, "consumers"
is a dirty word, partly because many doctors are still
angry about the fact that their services have been
included under the consumer protection act. Doctors
regard themselves as being above traders and
shopkeepers, because they feel that the doctor-patient
relationship is special. However, rather than get upset
at the idea of treating patients as customers, we should
focus on how learning customer service skills can help
us to improve the medical care we provide to our
patients.
In the final analysis, the health care industry is the
ultimate service industry, and we can learn from the
billions of dollars the hospitality (Taj Group of Hotels),
leisure (Walt Disney parks) and retail industries
(upmarket departmental stores) have invested in
improving the services they offer to their customers.
It's even possible for low-budget outfits to provide
excellent quality customer care, as evidenced by the
Winning Your Patients’ Loyalty 1149
worldwide success of McDonalds, which offers

excellent quality service to all its customers, with no
bells and whistles. You may not like the food, but you
have to admire their service. Even when they are very
busy, they will greet you with a smile.
The right attitude is to regard all your patients as
discerning customers who expect, and demand a high-
level of service. You need to realise that giving patients
excellent service is critical to ensuring that your practice
thrives. Customer service simply consists of listening
to, understanding and responding to your customers'
needs . Patients today expect the same quality of service
they get in a 5-star hotel. To meet these demands,
many hospitals in the US teach their staff the
importance of positive, service-oriented interactions with
patients. You too can improve your practice's customer
service , right from the time a patient makes the first
telephone call , to the actual visit itself , to any follow
up visits.
You first need to learn to improve your own patient
handling skills. While your medical treatment skills may
be superb, unfortunately few of us are taught how to
treat patients well. Remember, that patients care more
about how much you care for him, rather than about
your technical competence, and it is important to let
your patients know that you do care about them as
individuals. This is actually surprisingly easy to do, if
you just remember the golden rule - treat your patients
the way you would like to be treated. While this may
be easier said than done, if you make a conscious effort,
it's easy to learn the skills which patients often refer to
as good bedside manners.
It's not enough to just improve your own skills -
you need to improve those of your staff as well -
remember, that they are your public face ! You then

need to train your "front-office" staff - your receptionist,
peon, clerk and nurse . Unfortunately, the key role these
staff members play is undervalued by most doctors,
with the result that even though the doctor may be
very polite and professional, his staff isn't. Remember,
however, that your staff are the representatives of your
practice -they are the ones your patients turn to for
information regarding appointments, referrals,
medication refills, and lab tests. For example, telephone
calls are the lifeline of your practice. Yet, most
receptionists, who serve as the link between the practice
and its patients, are often untrained , and yet are
expected to answer the phones, make appointments,
and greet patients and answer their questions.
It's important to train your staff in basic customer
service skills. Here , for example, are some telephone
policies and protocols your practice could consider
adopting.
• Always answer calls by the third ring.

• Prepare a script for answering the phone in which
staffers greet the caller, identify the practice name
and themselves, and ask the callers how they can
help them. Do not transfer a caller more than once.
• Take down the patient's name, number and request
or question and have the appropriate person call the
patient back within a specified timeframe.
• If an answer is not available, return the call and tell
the patient when someone will be able to get back
with the needed information.
Of course, you need to start by recruiting the right

staff, and the trick when looking for clinic employees is
Winning Your Patients' Loyalty 1151
to “ hire the smile and then teach the skills". If you find
a helpful clerk in a departmental store, she is likely to
make a good employee - and individuals who have
spent a summer working at a McDonalds are much
easier to teach, since they have already received basic
training in keeping customers happy . A simple question
to ask each prospective employee is - " Who is the
most important person in this clinic ? " - and the right
answer is - the patient. Pay your staff well - while
good staff members can be expensive, the wrong staff
members are much more expensive in the long run.
You get what you pay for, and pay for what you get.
When you deal with patients, remember that your
staff will emulate your behaviour. Rude doctors usually
have rude staff members, who are adept at turning
patients away. How do you know you and your staff
are doing a good job ? Simple - just ask your patients.
It's easy to carry out patient satisfaction surveys - and
these could be as simple as asking them to fill up a
form. We encourage our patients to fill in a Complaints
and Compliments book ( anonymously, if they wish),
which we read religiously in order to identify problems
and solve them. Most patients are happy to provide
feedback - after all, their input allows you to improve
the services you offer them.
The First Law of Patient Service is :
Patient Satisfaction = Perception - Expectations.
If your patient perceives service at a certain level but

expected something more or different, then he will be
dissatisfied. Remember that both perception and
expectation are states of mind, and you need to consider
these if you want to keep your patients happy.
You can learn a lot from the unhappy patient. While

it's not much fun to deal with complaints from an
angry patient, this is far less painful than losing them
to another doctor because you could not be bothered
to listen to them. Learn to see each problem as an
opportunity for improvement - "every complaint is a
gift". In fact, difficult patients are often the ones that
will make your practice better, because they are a
challenge to you and your office staff. If you can
successfully deal with a difficult patient, then you can
successfully deal with every patient. Here are some
steps in dealing with difficult patients:
1. Don't box yourself in. Choose the best time of
day to deal with a difficult patient. If you are
tired or preoccupied, the patient will feel as if
you do not care about his or her concerns.
2. Don't downplay the seriousness of the patient's
complaint. Let the patient tell you his or her side
of the story without interruption.
3. Apologize after you have heard the complaint.
Whether you are right or wrong, the patient is
seeking an apology. Offer it so the patient can
move forward.
4. Express empathy. Let patients know that you
understand the problem and are concerned about
their feelings.
5. Establish a rapport with the patient. Patients need
to hear that you are on their side and are willing
to do whatever it takes to solve their problem.
6. Do not go on the defensive. You are certain to
lose the patient if you become confrontational.
7. Take control of the situation. Once you have heard
the patient's side of the story, take the appropriate
action to resolve the problem.
8. Ask the patient what he or she wants. You may

be surprised to find out that the patient's solution
to the problem is both fair and simple.
9. Once the plan of action has been established, sell
it. Explain to your patient how the plan will solve
the problem.
10. Ensure that the plan has been carried out and the
results are acceptable to your patient - follow up
to ensure your patient is happy with the way
you have handled the problem.
By following these simple steps, your most difficult

patient can become your most valuable. Statistics show
that satisfied patients will tell three other people of then-
experiences, whereas a dissatisfied patient will tell 20
others. However, if you can satisfy an unhappy patient,
he will tell at least 50 others, and become your most
valuable ally.
Learn from other doctors. Visit well-run patient
friendly clinics - for example, "upmarket" clinics which
offer esthetic surgery, since their survival depends upon
keeping their patient happy - they can teach you a lot!
A patient-friendly clinic must be designed for the
patient's convenience. Pamper your patients as much
as possible. For example, if you are a pediatrician ,
make sure you have enough clean, unbreakable toys
for your children to play with, so they are happily
entertained while waiting for you.
Most patients want easy access to their doctor , and
you can use modern technology to ensure that it's easy
for your patients to get in touch with you. We encourage
our patients to access our website at
www.DrMalpani.com, which has extensive information
on the services we offer , and encourage them to stay
in touch with us by e-mail.
Remember that providing high-quality service is not

expensive - and in fact, not providing quality service is
much more expensive, since you will lose your patients
to someone else who will. Most of it is applied common
sense - treat your patients the way you would like
your wife to be treated by her doctor. If you treat all
your patients as VIPs, not only will you enjoy your
practise much more, you will also have lots more
patients.
A good way of looking at patient satisfaction comes
from the research done at Texas A&M University. The
researchers described customers' experiences of service
quality in 5 dimensions, summarized with the acronym,
RATER.
Reliability: This is defined as "the ability to provide

what was promised, dependably, and accurately."
Assurance: "The knowledge and courtesy of staff
and their ability to convey trust and confidence."
Tangibles: "The physical facilities and equipment,
and the appearance of personnel."
Empathy: "The degree of caring and individual
attention provided to the customer."
Responsiveness: "The willingness to help customers,
and to provide prompt service."
You can use this as a useful framework when trying to

assess how satisfied your patients are with you.
Remember that patients prefer to be treated as special
human beings, not just as a number. Here are the 10
commandments for patient relations which you and
your staff should live by.
i. The patient is never an interruption to your work

- the patient is your work. Everything else can
wait.
ii. Greet every patient with a friendly smile. Patients
are people and they like friendly contact. They
usually return it.
iii. Call patients by name. Make a game of learning
patients' names, and see how many you can
remember.
iv. Teach your staff members that for patients, all staff
members are as important as the doctor.
v. Never argue with a patient. The patient is always
right (in his/her own eyes). Be a good listener,
agree with him/her where you can, and do what
you can to make him/her happy.
vi. Never say, "I don't know." If you don't know the
answer to a patient's question, say, "That's a good
question. Let me find out for you."
vii. Remember that the patient pays your salary - treat
him like your boss.
viii. Choose positive words when speaking to a patient
- this is a valuable habit that will help you become
an effective communicator.
ix. Brighten every patient's day. Do something that
brings a little sunshine into each patient's life, and
soon you'll discover that your own life is happier
and brighter.
x. Always go the extra mile, and do just a little more
than the patient expects you to do . For example,
make it a habit to phone the patient after discharge
from hospital, to ensure he is doing well.
Exceeding patient expectations is the best way of
keeping your patients happy - and keeping them
your patients for life.
How do you know if your patients are satisfied with

the care they receive at your clinic? The answer is
simple - ask them! Patient satisfaction surveys are an
easy tool you can use to answer this question , and they
can help you identify ways of improving your practice
- which translates into better care , happy patients -
and a happier doctor.
To perform a formal patient satisfaction survey, the
first step is to prepare a flow chart which follows the
patient when he enters the clinic.
For example, one sequence might be:
1. Phones clinic for appointment;
2. Approaches receptionist;
3. Provides necessary information;
4. Waits in waiting area;
5. Goes to exam room;
6. Provides information to nurse;
7. Waits for physician;
8. Meets with physician;
9. Pays the bills and
10. Leaves.
Based on this flow chart of a patient visit, the satisfaction

survey needs to measure two aspects at each point of
the patient/clinic interaction. The first question should
focus on how well the clinic met the patient's
expectation regarding the interaction. Thus one question
should be: "How well did the receptionist meet your
expectations?" The answer could be given on a scale of
1 to 5 (e.g., much better than expected, better than
expected, as expected, worse than expected, much worse
than expected, respectively). In addition, for each point
of patient contact, a second set of questions should be
asked: "How important is the receptionist to your

overall satisfaction with your clinic visit? The answer
could be given on a scale of 1 to 4 (e.g., very important,
somewhat important, somewhat unimportant, not
important at all, respectively). This information can
then be analysed , to help you :
1) identify which areas of your practise patients are not

satisfied with( and therefore which need to be
improved);
2) and will also allow you to prioritise the improvements
( starting with the areas which patients feel are most
important to them).
An easier way is to print a patient satisfaction survey

card , and request each patient to fill out and hand this
in at the time they leave. On the card, instruct the
patient to mark a response of 1 to 4 (1 is strongly agree
and 4 is strongly disagree) to statements such as the
following:
• It was easy to get an appointment.
• I was greeted in a friendly manner when I arrived.
• I waited a reasonable amount of time before I was
seen by the doctor.
• My doctor answered all my questions.
• I would recommend this practice to family and
friends.
Also include space on the card for the patient to jot
down comments and suggestions. Open ended
questions such as: 'What do you like best about our
practice?' and 'What can we do to improve?' are also
very helpful and will provide you insight into your
patient's viewpoint. While you don't have to act on
every suggestion that your patients give you, you
should take action on the key items that are causing

dissatisfaction. Remember that your goal is to improve
quality, not to place blame.
Most doctors in India still think that they are doing
their patients a favour by treating them. It's high time
we changed our perspective , and treated patients as
valuable customers. Adopting a customer-oriented
approach will help you to see things from your patient's
point of view , and become a better , more successful
doctor. As you learn to see your patients as interesting,
valuable people who are giving you the privilege to
serve them, your own life will be immensely enriched
by your patients.
Chapter 21
Improving Your Emotional

Intelligence: Honing Your
People-skills
People may not remember what you did for them, or even
what you said, but they will always remember how you made
them feel.
— Anonymous.
Most doctors have a high IQ, which is how they manage

to get into medical college in the first place, in the face
of very stiff competition. However, a high IQ is not
enough to ensure that you will do well in practice.
Numerous studies show there is little correlation
between IQ scores and success in medical practice . All
of us know classmates who were walking medical
encyclopedias , but who have never done well in
practice.
So if being well-informed and having a high IQ is
not enough to become a successful doctor , then what
is ? Research shows that the magic ingredient for success
in most fields , including medicine , has nothing to do
with cognitive intelligence. The key is a "soft" skill,
called emotional intelligence. Emotional intelligence was
defined in 1985 by U.S. psychologists Drs. Peter Salovey
and John Mayer as: "the ability to monitor one's own
and others' feelings and emotions, to discriminate
Improving Your Emotional Intelligence: Honing Your People-skills 1161
among them, and to use this information to guide

one's thinking and actions". Emotional Intelligence
teaches you how to deal with your own feelings and
those of others, and consists of five competencies.
Knowing your own emotions (self-awareness). This is
the ability to recognize your feelings, and is the
cornerstone of Emotional Intelligence, because it is
crucial to insight and self-understanding.
Managing your own emotions (self-regulation): This
is the ability to manage your emotions and impulses.
Motivating yourself; You need to be able to marshal
your emotions to reach your goals.
Recognising and understanding other people's emotions
(empathy) : Empathy is the fundamental ' people skill
that builds on emotional self-awareness and is the
ability to recognize and understand emotions in others.
5 (managing relationships or social skills) : The art
of building relationships depends upon your skill in
managing emotions in others, and these are the abilities
that determine popularity, leadership, and interpersonal
effectiveness. People who excel in these skills do well
at anything that relies on interacting smoothly with
others; they are social stars.
It is hardly surprising that most doctors have never
heard of emotional intelligence , or tried to improve
their emotional quotient ( EQ). After all, medical
colleges select doctors for their academic skills , and
teach them to become skilled diagnosticians and
technicians , which is why most doctors are technically
competent. Unfortunately, no one teaches medical
students or residents how to relate to their patients, or
to handle their own feelings. While some pick up these
skills from their teachers ( who serve as role models),
others never learn them.
Why is a high EQ so important for doctors ?

Medicine is the ultimate service profession, and without
understanding our emotions and those of our patients,
we are not going to be able to perform our job
competently. Not only does this hurt our patients , it
hurts us also - and many doctors can never figure out
why they have such a hard time keeping their patients
happy , even though their technical skills are superb.
EQ testing of physicians has yielded interesting
results. The EQ score of doctors was much lower than
expected, the average being only 90 in physicians, while
the EQ of the average citizen is 100. ( In comparison,
the average IQ of doctors graduating from medical
school today is 120 , much more than the norm of 100.
) Most physicians were weak in the intrapersonal area
(understanding one's own feelings) and the interpersonal
realm (ability to deal with others). This is hardly
surprising. Some doctors have become so used to being
put on a pedestal and giving orders, that they start
thinking of themselves as being infallible and are not
very considerate of their patient's feelings.
Unfortunately, medical training is often responsible
for actually dehumanizing doctors and causing
emotional impairment, so that while their IQ may
increase after medical college, their EQ definitely
declines. Not only do we see so much suffering that
we get inured to it, we are also taught to distance
ourselves from our patients. Doctors who get
emotionally involved with patients or display their
feelings are considered to be "unprofessional" since
being emotional is considered to be a sign of weakness.
In a profession that requires emotional sensitivity and
compassion, we are encouraged to numb ourselves in
order to cope with what we witness of the human
Improving Your Emotional Intelligence: Honing Your People-skills 1163
condition. What a shame ! We need to remember Dr

Peabody's immortal words, "The secret of the care of
the patient is in caring for the patient".
A major part of the problem is that medical training
desensitizes residents and teaches them to ignore their
own feelings. Training can often be brutal, and sleep
deprivation is the norm for most residents. Doctors are
expected to be self-reliant and independent and the
focus is on cramming and learning prodigious amounts
of information. There is little acknowledgement of the
tremendous stress residents find themselves under, and
practically no emotional support. If we do not nurture
them, how can we expect them to nurture their patients
when they start practice ? If they are not allowed to
have feelings or to discuss them, how can we expect
them to become compassionate when they go out in
the real world ?
Physicians who can empathize and respect their
patient's feelings are much more successful at getting
their patients to trust them; more productive; and less
likely to get sued. Patients do not care how much you
know, until they know how much you care. We are
now realizing the importance of emotional intelligence
in medical practice and the Veterans Administration
hospital system in the US has incorporated EQ self
assessments and training in its leadership institute
program for doctors.
Remember that a high EQ will not only help you
take better care of your patients, it will also help you
progress in your career. Doctors need to interact with
superiors, employees and colleagues. Those who know
how to persuade others because of their high EQ usually
manage to sail through life and achieve their goals.
Success is often dependent not upon know-how, but
know-who - and who you know (and who knows

you.) is vitally important for success. Many doctors
feel this is "unfair" and resent colleagues who may be
professionally incompetent , but still rise to positions
of power because of their ability to please "higher-
ups". Politics is an inescapable fact of life , and we
need to leiim that it exists, whether we like it or not.
" People competence" is as important as technical
competence, and smart people learn this early in life.
Social and emotional abilities have been shown to be
far more important than IQ in determining professional
success and prestige, and as the saying goes, IQ gets
you hired, but EQ gets you promoted. Rather than
complain about it, why not learn to improve your own
chances of success, by polishing your own EQ skills ?
Think of EQ as a different way of being smart - and
the good news is that you can raise your own EQ. A
high IQ is not incompatible with a high EQ. IQ and
EQ are complementary skills, and the first step is to
become aware of the importance of this skill, so that
you can concentrate on using your high IQ to improve
your EQ. Growing emotionally is a lifelong process.
No matter how old you are , you can always learn to
become aware of your feelings, to accept them, and to
use the information they offer to your patients'
advantage and your own. Some doctors develop these
skills intuitively, while others need to learn them
A number of books can help you improve your EQ,
and these include: The EQ Edge: Emotional Intelligence
and Tour Success by Howard E. Book, Steven J. Stein;
and Raising Your Emotional Intelligence : A Practical
Guide by Jeanne Segal. The best way to learn is to find
a role model with a high EQ (psychiatrists usually
have high EQs) and copy him. While a high IQ may
help you get higher marks on an exam, a high EQ will
help you become a happier person and more
productive physician.
Chapter 22
Keeping Up-to date:

Learning How to Learn
It is impossible for a man to learn what he thinks he already

knows.
— Epictetus
Most doctors take pride in their medical knowledge,

and the hallmark of a medical professional is his medical
expertise. Unfortunately it is a sad fact of life that most
practicing doctors are too busy to keep up to date with
the newest medical knowledge . Few read medical
journals ; some do attend medical conferences, but
primarily to meet friends and socialize , rather than to
learn; and most depend upon their "friendly " medical
representative to educate them. Many senior doctors
feel that their years of accumulated experience mean
that they do not need to learn anything new anymore.
However, as Michael O'Donnell points out in A Sceptic's
Medical Dictionary, clinical experience can be defined
as making the same mistakes with increasing confidence
over an impressive number of years.
This sorry state of affairs a poor reflection on the
medical profession today and can actually be dangerous
for you. Thus, if a patient has a poor medical outcome
because you are not up to date , you can be sued for
medical negligence. Keeping up to date is important
Succesful Medical Practice: Winning Strategies for Doctors
not only to protect yourself , but is also essential if you

wish to build a successful medical practice. Your
colleagues are much more likely to refer patients with
complex problems to you if you have a reputation for
being well-informed and well-read.
Unfortunately, most doctors have never been taught
how to learn. While we have all learnt how to cram,
burn the midnight oil and bluff our way in the viva,
so that we managed to pass all our exams during our
days as medical students and residents, most of us have
never learnt how to manage knowledge. We need to
remember that we are now adult learners , and have
different learning needs , as compared to the days when
we were medical students, and our only requirement
was to pass an examination.
One of the reasons many doctors find it difficult to
continue learning is that they are often not motivated
enough, and most carry on a successful practice based
on outdated information which they were taught
decades ago. Another problem is the sheer size of the
information which needs to be mastered. Not only does
the task appear overwhelming, the rate of acquisition
of new information is so rapid, that keeping up seems
to be a full-time job. As a famous medical professor
once told his students, "Half of what I am going to
teach you is wrong - and I don't know which half."
Not only does medical knowledge have a short half
life, we are also literally drowning in an information
overload.
So how can you cope ? Essential to information
mastery is understanding the relationship between data,
information, and knowledge: data are raw facts and
figures; information is data organized into a meaningful
context; and knowledge is organized data (i.e.,
information) that has been understood and applied. We
Keeping Up-to date: Learning How to Learn 1167
need to focus on knowledge, and hopefully transmute

that into clinical wisdom with the help of experience
and judgment.
While it is important to retain the information you
need on a day to day basis in your head, it's even more
important to know where to find reliable information
when you need it - for example , when you are
presented with a patient who has a difficult clinical
problem. Unfortunately, even in this day of
"information overload" where doctors are surrounded
by tons of information, studies show that approximately
two-thirds of questions that arise in a clinical practice
remain unanswered. It seems to be a case of : " Water,
water everywhere, but not a drop to drink." This is
because doctors need user friendly information, at the
"point of use" - at the patient's bedside , when it can
be applied clinically.
Most doctors are reluctant to "look up " information
in front of the patient , because they feel that this will
cause the patient to lose confidence in them, as it
suggests that the doctor does not know everything.
However, good doctors have learnt that looking up
information in front of the patient can actually impress
the patient that you have taken the time and the trouble
to confirm key facts - and this can be very reassuring
to the patient. Every doctor needs a personal medical
library, so that he has the information he needs at his
fingertips. However, medical books become outdated
and journal subscriptions are very expensive.
Fortunately, the advent of the internet has made
accessing knowledge much easier - and much less
expensive as well. MDConsult , a commercial service
at http://www.mdconsultindia.com , provides Indian
doctors access to the world's largest online medical
library, with over 40 full text respected medical text
books and 50 full text medical journals, for less than Rs

6000 per year.
US companies have gone one step further, and now
offer ingenious software solutions tailor-made for
doctors, which provide medical knowledge at the
bedside through PDAs (hand-held personal digital
assistants, which act as intelligent electronic aides or
"peripheral brains"). Even more exciting is the recent
use of computer technology to assist doctors in applying
their knowledge to solving clinical problems. Computer
support can be used to make the best possible medical
decisions , and expert systems and artificial intelligence
hold a lot of promise. Excellent examples are Medweaver
at www.diseaseref.com and PDXMD at www.pdxmd.com.
Doctors are lifelong adult learners , and the key to
knowledge management is self-management: knowing
what you need to know. You need to be your own
filter, so you can turn off unneeded data , and focus
only on what you need to know, so that your learning
is self-directed. You should also be aware of your
preferred learning style. Many doctors learn by reading,
while others prefer alternative options:
• visual (by watching, for example, as an observer);

• verbal (by listening, for example, by attending
lectures) ; or
• kinesthetic (by doing , for example , by assisting an
expert) .
The most efficient technique is that of modeling

(imitating). We learn most rapidly and effectively by
observing an expert correctly performing the desired
behavior, and then trying to model( copy) the desired
behavior . Whether it's surgery or tennis, seeing and
working with someone who performs the skill

proficiently is worth a thousand words. This is why
taking a "sabbatical" and spending time with an expert
is so useful.
All the learning in the world is of no use until you
integrate it into your clinical practice. An efficient way
of doing this is to develop clinical protocols or flow
charts for tackling the common problems you face on a
daily basis. You can then update and modify these
protocols, as you acquire new information. Not only
will these protocols allow you to learn more effectively,
they will also help you to practice medicine on a more
systematic basis.
To become effective learners, we need to make use
of insights from the field of adult learning, which teaches
that as we mature, our approach to learning changes.
In order to learn new information, we require that this
information be interactive; relevant; practical; and
connected to past experience. This is why most doctors
promptly forget over 90% of what they hear in a lecture
in a medical conference - because the information is of
little practical use to them, or has been poorly presented.
This is why newer teaching formats have been
developed, which use multimedia and computer
simulation, and since these actively involve the learner,
they are more effective in ensuring that the information
transmitted is retained.
Knowing how to learn is essential, and you need to
find out which of the following learning styles works
best for you.
Activists
Activists believe in doing things, and their philosophy
is: "I'll try anything once". They are happy to try out
the newest drugs, and thrive on the challenge of new
experiences but are bored with implementation and

longer term consolidation. They are happy to play with
new medical equipment and love devising new
instruments and operative techniques.
Reflectors
Reflectors like to stand back to ponder experiences

and observe them from many different perspectives.
They collect data, and prefer to think about it
thoroughly before coming to any conclusion. Their
philosophy is to be cautious, and they prefer sticking
to what has worked for them in the past and stood the
test of time.
Theorists
Theorists adapt and integrate observations into complex

and logical theories. They think problems through in
a vertical, step by step, logical way. They like to analyse
and synthesise. They are often the medical college
professors, who prefer looking at the "big picture".
Pragmatists
Pragmatists are keen on trying out new ideas and

techniques to see if they work in practice. They are
down to earth people and their forte is solving
problems, which they see 'as a challenge'. Their
philosophy is: "If it works it's good"; and they are
interested in getting results, rather than worrying about
why things work the way they do.
Each learning style has its own advantages and
disadvantages. It's helpful to experiment with different
styles; and you may also need to adapt your style,
depending upon the material you need to learn.
The most effective way to learn is to learn around

your patients. This is the secret behind most successful
doctors- they use their patients as their textbooks.
Patients present with clinical problems, and while most
patients have "garden-variety" routine problems which
are easy to tackle, some have complex problems for
which you need to hunt for information in order to
provide a solution. Finding out information about your
patient's problem is the best way to keep on learning.
Most of us remember our patients, and if we read about
their illness, this knowledge will "stick". You can find
this information formally by referring to text books and
journals - or informally, by talking to colleagues or
referring your patient to a consultant. This is why you
should treasure your rare patients - because you learn
the most from complicated cases.
The best doctors are those who learn the most from
their patients - after all, patients are the true experts on
their own illness . While they may not teach you about
the pathology of their disease, your patients can teach
you a lot about courage, coping skills , how to die and
even how to live - if only you will listen . As a doctor
you are privileged to be granted access to a human
being's innermost secrets - make the most of this
privilege.
Your mistakes can be very valuable teaching tools.
We all make mistakes in medicine - after all, this is an
imperfect science and we are all human beings.
However, rather than try to "bury "our mistakes , we
should actively try to learn from them A post-mortem
used to be the classic teaching tool in medicine for
exactly this reason. Of course, rather than make
mistakes, it's best to learn from others' mistakes. This is
why CPCs ( clinicopathologic conferences) are such a
useful learning tool. Unfortunately, most of us hide

our mistakes, rather than try to correct them , which
means that valuable learning opportunities are lost.
We all have areas of ignorance . Rather than be
ashamed of these , we need to actively identify these ,
and try to fill in the gaps in our knowledge. Remember
that nothing is so difficult that it cannot be learnt.
Learn other stuff as well - not just medicine. The
more you use your brain, the better it performs.
Learning is fun if you are motivated - and you can
have a ball learning new skills, such as tennis or golf.
Finally, remember that the best way of learning is to
teach. If you do not have medical students, you can
always teach your patients . This is not always easy to
do - after all, you have to understand a topic very
clearly before you can successfully explain it to someone
else.
Chapter 23
Time Management:
Working Smarter
I recommend you to take care of the minutes, for the hours

will take care of themselves.
— Lord Chesterfield
Most doctors are very busy people. In fact, many of us

take pride in the long hours we work and the large
number of patients we see everyday - and the ultimate
"status symbol" for a doctor is a packed waiting room,
with many patients (and their families) anxiously waiting
for a chance to talk to the doctor. However, the fact that
patients need to wait for hours to see you is actually a
symptom of a disease common to many doctors - poor
time management skills.
It is true that doctors do need to wear many hats -
not only do you have patients to look after, you have
many other responsibilities as well- for example,
managing your clinic, looking after your investments,
buying shares, attending meetings and taking care of
your family. As time goes by, you get busier and busier,
and you may find that your life is getting out of control
- instead of running your life, you may find that your
activities are running you. Time is the only resource in
a physician's practice that can't be exchanged for
money. You can't buy more time and you can't save it
up for future use. Once it's gone, it's gone.
As a highly skilled professional, time is your most
important resource and you need to use the science of
time management to regain control of your life. While
it may not necessarily enable you to see five more
patients a day ( which may not even be in your best
interests in the first place - more is not always better),
it will help you to juggle your professional and personal
activities with greater ease. And you'll also be able to
find time to catch up on your reading and keeping up
to date with the medical literature as well.
Step number one is the most important - and often the
most difficult as well. You need to start by identifying
your top priorities in your life. This prioritization helps
you avoid dissipating your precious hours and energy
on a legion of low-level activities. Once you know what
deserves a Yes, it's easier to say No to whatever else
comes along. Don't limit your prioritizing to the
professional realm. Defining your life's goals is not
easy - but it's helpful to list the five most important
things in your life in the space of one minute. To define
a goal, use the SMART rule:
S : Specific - Get it clear

M : Measurable - so you can define it
A : Achievable - so you can stretch yourself
R : Realistic - anchored in reality and attainable
T : Timed - a deadline is set and provides a
degree of urgency
Once you've identified your ideals, you then need to

compare them to reality. The diagnostic tool for this is
a diary of what you do every waking hour. You may
Time Management: Working Smarter 1175
get a rude shock when you find , for example, that

there is a big gap between your desire to be with your
family and the amount of time you actually spent with
them. However, don't get disheartened by this. In fact,
this simply means that you need to manage your time
much more effectively than you are doing at present -
and there are many techniques for doing so.
One reason most doctors are such poor managers of
their own time is that we get so used to being told
what to do and when to do it, as medical students and
residents. We are so accustomed to following orders,
we forget that as practicing doctors, we are masters of
our own time - and we need to organize our life and
clinic around our priorities and goals. Also, most of us
have never been exposed to the science of time
management, with the result that we often use our time
very wastefully. However, we need to remember that
our time is our most valuable resource - and we need
to utilize it efficiently. Any doctor who makes his patients
wait for more than 60 minutes on a routine basis is a
poor time manager. Not only is this very disrespectful
to your: patients, it can also cause you considerable
aggravation, because you get pressurized by the large
number of patients waiting to see you - and you no
longer enjoy seeing patients anymore. While a busy
clinic full of patients seems to be the hallmark of a
"good doctor" in India - and many doctors find such a
full clinic boosts their ego ( "see how busy I am ") - it's
actually likely to lead to poor clinical care, as complex
problems can get missed or overlooked.
A useful time management tool is a 2 X 2 matrix
developed by Stephen Covey that classifies activities as
important or unimportant, urgent or not urgent.
Dealing with junk mail, for example-something neither
important nor urgent-epitomizes Quadrant IV. Greeting

certain drop-in visitors may qualify for Quadrant Ill-
urgent, but not important. Quadrant I is familiar ground
to doctors. When a heart-attack patient comes to the
ER, say, the situation is both urgent and important.
Planning and relationship-building fall into the often
neglected but critical Quadrant II-not urgent, but
important. For purposeful productivity, you need to
spend more time in Quadrant II.
Basic planners marketed by many companies for busy
executives can help you to map out your day in detail.
(I am surprised that no pharmaceutical company has
recognized the need for planners designed especially
for doctors as yet - I am sure these would make very
useful and popular promotional giveaways) Planners
usually include: a task list, appointment schedule, daily
expense log, and space for diary entries, as well as
monthly calendars for upcoming events and an address
book/telephone directory, so that everything's in one
place.
For doctors who are computer-friendly, or are
addicted to their laptops, computerized planners such
as Lotus Organizer or Microsoft Outlook offer similar
facilities - and have the ability to remind you
automatically of tasks to be accomplished as well.
The following time-saving techniques can help you
find more time to do the important things in your life.
Control your paperwork. Most doctors dislike
paperwork, so that this often piles up. An office littered
with piles of papers can sap your energy. Three simple
rules govern how you handle a piece of paper .
1. Turn it into an action item on your to-do list;

2. File it-assuming that it's valuable,
3. Throw it away.
Follow this system, and you'll end up throwing away

lots of paper - and don't forget to buy a really large
wastepaper basket.
Delegate. Refusing to delegate jobs squanders your
time. An efficient nurse can double your productivity -
and this is why most senior doctors have at least one
staff member who has been working for them for many
years, who keeps the clinic ticking like clockwork.
Learn to say No. As a doctor, you are a respected
member of society, and will receive many requests to
serve on committees and clubs, and you may find that
you are spending endless hours doing so . However,
you have to learn to become Dr. No in order to protect
your time for what is valuable to you. The easiest way
to say no without hurting the other person's feelings is
to say - " I can't help you, but I know someone who
can. " You can even build goodwill this way.
Learn to focus. When you are seeing a patient,
concentrate only on the patient - refuse to take
telephone calls during this time. Not only will this help
you take better care of your patients, your patients will
appreciate this as well.
Learn to analyse what you do. If you have a task to
perform, instead of just doing it in the mechanical
fashion you routinely do, use the Rule of 3 Ds: Do you
really need to do it in the first place ? If not, then
Dump it ! Can someone else can do it ? If so, then
Delegate it ! Is there a quicker and easier way to do
it ? If so, then Discover it.
We all have only 24 hours in a day - but how well
we make use of this time is what separates the
successful doctors from the unsuccessful ones. If you
find that you are always rushing from place to place,
trying to catch up with your work which is constantly
piling up, and have no time either for yourself or your

family, you need to learn basic time management skills,
so that you regain control over your most precious
asset - your time.
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Chapter 24
Managing Mistakes
in Medicine
We are built to make mistakes, coded for error.

— Dr Lewis Thomas
While it is true all doctors make mistakes, it is equally

true that most of us refuse to discuss them. Medical
mistakes have always been shrouded in a conspiracy of
silence through the ages, and this was because it was
important to give patients the impression that doctors
were infallible . Such a strategy may have been
appropriate in the past, when doctors had few effective
tools in their therapeutic armamentarium, and trust in
the doctor was a vital element of the healing process.
This is why blind faith in the doctor was encouraged ,
and to keep the doctor on his pedestal, it was essential
that he have an aura of infallibility around him.
Given the prevalence of errors in our work, and that
one of our first principles is "first do no harm," it is
strange that we talk so little about this problem. Perhaps
it is because we view most errors as human errors and
attribute them to laziness, inattention, or incompetence
As a result, when we do talk about errors, we seek to
place blame, because deep down we believe that
individual diligence should prevent errors, and so the
Managing Mistakes in Medicine 1181
very existence of error damages our professional self

image.
We must realize that all of us pay a heavy price for
trying to cover up medical mistakes.
Since we often prefer ignoring, overlooking or
covering up our mistakes, we fail to acknowledge them,
so we never learn from them - and many experienced
doctors end up repeatedly making the same mistakes
through their lifetime. Also, since we don't discuss our
mistakes, we deprive other doctors of the chance to
learn from them We know that we can learn a lot from
mistakes - often knowing what not to do is more
valuable than knowing what to do.
The human cost of medical errors is high. Not only
do our patients pay the price of our mistakes
(complications, iatrogenic injury and even death), so
do we when we don't talk about our mistakes. Hiding
mistakes means we end up carrying a burden of guilt
and shame - which can become overpowering with
time, especially when compounded by the fact that we
often need to lie to hide and cover up our mistakes.
All of us know what it feels like to make a bad
mistake. You feel exposed - and scared in case anyone
else has noticed your goof-up. You agonise about what
to do, whether to tell anyone, and what to say. Later,
the event replays itself over and over in your mind.
You question your competence , but fear being
discovered. You know you should confess, but dread
the prospect of potential punishment and of the patient's
anger.
Making a mistake can be forgiven - but not taking
action to prevent it again is unforgivable, which is why
we need to be open about them. Part of the problem
lies with our medical training , which focuses only on
teaching residents how to fix problems successfully.

When medical students and junior doctors make
mistakes, they are often scolded, ridiculed or punished,
which means that we end up being terrified of making
mistakes, and often try to do our best to cover them up.
This attitude needs to change, and we need to realize
that mistakes are an integral part of every learning
experience. It is important to provide a structured
environment in which these mistakes can be safely
made, so patients are not harmed, and there are many
ways of doing so safely (for example, providing effective
supervision by countersigning a student's medical
orders; and using animal models to teach surgical skills).
Learning and mistakes go hand in hand, and since
all doctors need to be lifelong learners, we will all make
mistakes throughout our lives. All humans make
mistakes, and doctors are no exception. However,
medical errors are far more complex than those which
occur in other fields. As Hilfiker put it so eloquently"
The drastic human consequences of medical

mistakes, the repeated opportunities to make them,
the uncertainty about our own culpability when
results are poor, and the medical and societal denial
about mistakes results in an intolerable paradox for
the physician. We see the horror of our own
mistakes, yet we are given no permission to deal
with their enormous emotional impact.
This is why we often overreact to the mistakes we make.

Most doctors are perfectionists, who pride themselves
on their professional skills and competence - and they
feel uncomfortable when these are threatened. The fact
that our patients pay a heavy price for our mistakes

makes it difficult to live with the knowledge that a
patient who trusted you and placed his life in your
hands may end up losing it because of your fallibility.
After making a mistake, physicians' emotional reactions
include: panic, guilt, embarrassment, humiliation, and
feelings of inadequacy and isolation. The ability to
acknowledge an error is the first and most critical step
in the physician's healing process, but this is often hard
to do. Many physicians typically respond to their
mistakes defensively, by blaming the system, other
members of the health care team, or even the patient.
Other unhealthy coping mechanisms are denial of
responsibility ("it's a bad system"), discounting of
importance ("it had no significant clinical effect"), and
emotional distancing ("everyone makes mistakes").
Our profession is difficult enough without our having
to bear the yoke of perfection. The most effective way
for physicians to cope with their emotional reactions
after making an error is to discuss such feelings with
trusted friends, colleagues or a spouse. However, medical
culture (partly because of the fear of malpractice
litigation) encourages cover ups of mistakes, because
of which most physicians bear the burden of their
mistakes in isolation.
When an error occurs, most patients would like to
be informed about this error; and they naturally expect
the doctor to provide an explanation or an apology, and
to rectify the error—and this is what the doctor's ethical
obligation to the patient is. However, given the fear of a
malpractice lawsuit being slapped on them, most
doctors today still react to errors by trying to cover them
up and hiding them from the patient. This often makes
a bad situation worse. Most patients who finally end

up pursuing litigation usually have multiple complaints
including (1) professional failure in diagnosis or
treatment, (2) a lack of communication on the part of
the doctor, and (3) some form of insensitivity on the
part of the doctor that has emotionally upset them. This
sorry state of affairs implies that insult has been added
to injury. Such a development not only destroys the
relationship of trust between doctor and patient but it
also makes the patient more vengeful if he does find
out about the medical botch-up through another source.
In the final analysis, remember the golden rule - do
unto others as you would have them do unto you. Try
to look at things from the patient's point of view. All
said and done, honesty is still the best policy.
When colleagues or employees make mistakes, please
be charitable - it may be your turn to err tomorrow.
Don't lose your temper, or make fun of them. Instead,
try to help to correct the mistake; and teach them to
learn from their error, so they are more confident for
the future. When your junior or colleague makes an
error, encourage a description of what happened,
acknowledge the gravity of the mistake, and empathise
with the emotions it elicits before embarking on a more
objective analysis. A good response would be: " I am
glad you are willing to discuss this error openly. This
reflects your intellectual honesty and compassion, both
of which are attributes of a good doctor. I know you
feel terrible: this is normal. Let's sit down and review
the case. Now, if you had it to do over, what could be
done differently?" The right response to mistakes is to
use them as teaching tools, so we learn from them, and
don't repeat them.
To prevent mistakes, you need to be aware of the

settings where mistakes are more liable to occur - and
be even more careful during these high-risk times to
prevent problems . Circumstances which increase scope
for error include: times you are tired, lazy, or
overconfident; late at night, when you are sleepy; when
you are angry; when the patient is irritating ; or when
the patient has a complex medical problem .
It's important to take a proactive approach towards
preventing mistakes, and you need to work on
developing systems, policies and protocols to prevent
mishaps. For example, instead of relying on memory,
use preprinted forms. A good example is the use of
preprinted order forms for post-operative orders, which
simply need to be ticked and signed. Flowcharts and
algorithms can be helpful to prevent diagnostic errors;
and personal digital assistants can serve as peripheral
brains, since they can be equipped with extensive drug
and clinical databases.
The Institute of Medicine report, To Err Is Human:
Building a Safer Health System, which was released in
December 1999 in the US, focused the glare of public
attention on medical mistakes. Its most important insight
was that most errors result from faulty systems, not
from incompetent providers, and it is these systems that
need to be revamped to anticipate human error and
catch it before it harms the patient. Unfortunately, when
something goes wrong in a hospital, the press looks for
victims and villains , and ends up blaming doctors
unfairly.
Errors are not unique to healthcare. Other industries
already realize that it is faults in the system which permit
humans to err, and they have designed changes in the
system itself to minimize errors. The aviation industry

is renowned for designing a system to minimize the
chance of errors by relying heavily on research, on
reporting of errors and near-misses to identify potential
problem areas, and on designing redundancy into the
system so errors are caught before they become disasters.
When errors occur, we should learn and prevent,
rather than blame and hide. Reporting of errors is
essential - and it is important that we allow it to be
done voluntarily and anonymously, so doctors (and
other staff) do not feel threatened when they report
errors. After gathering data about adverse events or near
misses , we than need to analyse them. A structured
approach to analysing critical incidents allows us to
systematically examine systems and processes rather
than fall back on habitual blaming behaviors and biases.
This technique is called root cause analysis (RCA) and
is widely applied to investigating industrial accidents
today. Many studies have shown that errors are not the
result of a single incident. Rather, they occur as a result
of a chain of events (latent errors), which when
compounded together lead to the active error.
Allowing patients to become active partners in their
medical care is effective in reducing mistakes. Encourage
your patients to seek more information and to become
an expert on their own problem. Any one doctor or
nurse can make a mistake, but the well-informed patient
can prevent such errors by acting as his own last line
of defence. You may forget and make mistakes, but a
well-informed patient will not allow you to get away
with them.
Dealing with Mistakes
1. Accept responsibility for the mistake.

2. Discuss it with colleagues.
3. Disclose and apologise to the patient.
4. Conduct an error analysis.
5. Make changes in your practice to reduce similar
errors in the future.
The best way to put this advice into practice is to

think about the last mistake you made that harmed a
patient. Talk to a colleague about it. Notice his reactions,
and your own. What helps? What makes it harder?
Physicians will always make mistakes, but how we
handle them is up to us. The best way is by being
more honest about our mistakes to our patients our
colleagues and ourselves.
Chapter 25
Steering Clear of Malpractise

Threats: How to Avoid Legal
Battles
A lawyer with his briefcase can steal more than a hundred

men with guns.
— Don Corleone, in The Godfather.
A number of studies have shown that being sued is one

of the most stressful experiences a doctor can undergo.
Since most doctors think of themselves as being caring
and competent, being sued can be a blow to their ego
and self-esteem. It is not an experience that most doctors
are prepared for, not are they taught how to cope with
it. However, being sued is one of the professional
hazards of practising medicine in today's day and age,
and it is going to become an experience doctors are
going to have to increasingly face.
There are many reasons for this. Patients are getting
increasingly disenchanted with the medical profession
as a whole, and society now perceives most doctors as
being mercenary and uncaring. Patients often have
unrealistic expectations and they expect the magic of
modern technology to be able to cure all their ills. Also,
India is likely to follow the American route, where
medical malpractice means big bucks for lawyers, and

we are likely to see a new bread of ambulance chasers
spring up in India as the world continues to shrink.
Remember that often a lawsuit is triggered by a simple
misunderstanding, an unavoidable bad outcome or a
patient's anger, rather than actual malpractice; the mere
fact that you are being sued does not necessarily mean
that you have been negligent or that you are a bad
doctor. Many doctors resent that they are being
'penalized' for one single error, believing that fact that
they have taken good care of hundreds of patients for
years on end counts for nothing is unfair. Others are
concerned about the impact the suit can have on then-
practice if the media gets wind of it.
Doctors are usually independent individuals, who
are used to doing things for themselves. Many are
uncomfortable with the idea of having their actions
challenged and their motives questioned; especially
when this is done in public, by lawyers who they feel
do not understand and cannot appreciate the pressures
and intricacies of clinical problems and medical practice.
The first suggestion of trouble is a written complaint,
usually sent by the patient's lawyer. Remember that
this doesn't necessarily mean you're being sued; it simply
notifies you that a lawyer is reviewing a patient's case
and may ask you to provide copies of his records. The
first thing you should do is notify the insurance
company that provides you with professional indemnity
coverage. Most companies require you to do this within
a specified time as a condition of coverage. Then, send
your own lawyer a copy of the complaint.
Just because you are being sued for malpractice does
not mean you are a bad doctor ! Remember that the
vast majority of malpractice actions end in a victory for
Steering Clear of Malpractise Threats: How to Avoid Legal Battles 1191
the doctor. In order to get a damage award in a

malpractice action, the patient has to prove 4 elements.
1. Duty: The patient must prove that the clinician
owed the patient a duty of care.
2. Breach of standard of care: The patient must prove
the clinician failed to act as a reasonably prudent
clinician of similar type would have acted, under the
same circumstances.
3. Injury: The patient prove that he sustained an
injury.
4. Proximal cause: The patient must prove that the
clinician's breach of the standard of care caused the
patient's injury.
If you don't remember the patient or what he came
in for, study the complaint, then carefully examine your
medical records. If, even then, after racking your brains,
you still can't recall the encounter, don't worry: the
patient's lawyer will have to provide you with more
specifics if he decides to pursue the complaint further.
Do tell your spouse about it: a supportive spouse will
get you through the rough times ahead. However, tell
your spouse not to mention the complaint to anyone
else. Don't discuss the incident with your colleagues.
Getting confidential advise from a respected senior
colleague can be helpful; use this person as a sounding
board. If anyone, whether a nurse or a reporter, asks
you about it, say that your lawyer has told you not to
say anything.
Being sued can be a long drawn out and painful
process. Not only does it eat into your time, but also
saps your energy and monopolizes your attention, as
you try to defend yourself. It also extracts a huge
emotional toll, and many doctors when hit with a
lawsuit go through a process of five classic phases. The
first response is one of Denial: I am a good doctor; this
can't be happening to me! The next stage is one of

Anger: how dare the patient sue me when I have done
my best for him? Doctors will often vent their anger
on family-members, their staff, and even other patients.
The next stage is one of Bargaining, where the doctor
pleads with God to, 'let him off the hook this time,' and
promises never to err again! This is followed by
Depression. Many doctors start doubting their
competence and professional ability, and wonder if they
should just stop practicing medicine altogether. The
final stage is one of Acceptance, when the doctor comes
to terms with the fact that being sued is simply one of
the professional hazards of practising medicine in today's
day and age, that it is not a reflection on his personal
worth, and learns to get on with his life. Being prepared
for the emotional havoc this can play with your life can
help you to cope better: don't try to minimize the impact
the suit has on you and your feelings by pretending it's
of no consequence !
Dr Bernie Siegel once said to a group of doctors, "
There are three words that will keep you from ever
being sued for malpractise - Love your patients". This
is advise which will always stand you in good stead !
Chapter 26
Crisis Management: Coping

When the Chips are Down
If we had no winter, the spring would not be so pleasant; if we

did not sometimes taste of adversity, prosperity would not be
so welcome.
— Anne Bradstreet
Doctors are trained to treat medical emergencies such

as a cardiac arrest, intraoperative bleeding, or an
asthmatic in acute respiratory distress, which means they
are used to handling a crisis . These are life-or-death
crises, and doctors are expected to retain their cool and
remain unflappable, because their presence of mind can
spell the difference between life and death for their
patient.
However, these are crises which affect other people
- your patients. Handling a crisis in your personal life
is often a completely different cup of tea, and many
doctors go to pieces when faced by a personal crisis.
The truth is that all of us face crises in our lives - but
thankfully, not too often. A personal crisis is as old as
mankind, and divorce, financial loss, being sued for
malpractise, illness and bereavement are some of the
things in your life that can bring you to crisis point.
By the law of averages, it's simply a matter of time
till you are hit by your first crisis. The older you grow,
the greater the chances of facing a crisis - and the

sooner you learn to cope with them, the better. This is
why self-made individuals who have come up from
scratch often end up doing so much better than others
in life. They have faced many crises in their life before,
and have successful dealt with them. Each crisis you
handle makes you stronger, and more capable of
handling the next crisis as well. It's also much easier to
learn from other's problems , which is why it's such
a good idea to help others (juniors and colleagues) to
cope with their crises. Your objective advise can help
them deal with their problems- and will also teach
you what to do when you face similar problems in
your own life.
Adversity is the best teacher , and a crisis can teach
you a lot about life and how to live - the key question
is - how well can you learn ? Accept that the crisis will
change you - hopefully for the better. Living through
a crisis can be hell - but you need to learn to maintain
your equanimity . Don't take out your anger and rage
on your employees, patients, colleagues, friends or
children. Trust your inner strength - you have been
through worse, and you can weather this storm as
well. There are certain personal qualities will help you
cope better and these include: self-confidence;
optimism; a sense of humor; resilience; and faith in
God. Interestingly, playing games such as chess or
tennis will help you deal better with a real life crisis
when it hits. Being 0-5 down in a tennis match or
facing a check is a crisis of sorts, and dealing
successfully with this mini-crisis will help you deal
with the bigger real-life crises, when these arise.
Unfortunately, when faced with a crisis, many
doctors start feeling sorry for themselves; start blaming
Crisis Management: Coping When the Chips are Down 1195
others for their predicament; or waste energy looking

for a scapegoat. You need to move beyond self-blame
- don't react like a victim. When a marriage crumbles,
a job is lost, a loved one dies or a child suffers a
debilitating illness, people tend to blame themselves-
"If only I had worked harder," or "If only I had taken
better care of him." None of us gets through life without
some mistakes. You may share some of the responsibility
for the crisis, or, more likely, it would have happened
no matter what you did. Either way, the important
thing is what you do with the rest of your life. When
recovering from a life crisis, self-blame is a luxury you
can't afford. This is pointless and an exercise in futility
- it's better to deal with the crisis and move on.
You may believe it is impossible for you to recover
from this hard time; and sometimes a second crisis
comes and sets you back before you recover from the
first crisis. Everyone has their own level of being able
to cope before they reach their breaking point. High
adrenaline levels will help you manage the initial crisis;
but persistently elevated levels can be
counterproductive. You may find that the stress of
coping will start affecting other parts of your life such
as your concentration, sleep, appetite and sexual life.
You will find your feelings swinging wildly from hope
( that the crisis will blow over) to fear ( that the worst
will come to pass) , and this can affect your mental
and physical health. The crisis needs to be
acknowledged and dealt with - you need a chance to
adjust and start the healing. Please reach out for help
-you will soon find out who your real friends are in
your time of need.
Don't let what you are going through embitter you.
For example, one of the commonest crises a doctor will
face is being sued for malpractise. Many doctors become
cynical and disillusioned once they have been sued,

and start treating all patients as potential adversaries.
Don't let one isolated incident jaundice your view on
life - you need to bounce back and move on.
It's interesting that the Chinese expression for "crisis"
consists of two characters - one means "danger" and
the other "opportunity." Every crisis carries its own
blessing with it - but often only the passage of time
and a lot of maturity will allow you to find the good
side in this mess. People seldom tap into their deepest
strengths and abilities until forced to do so by a major
crisis. Living through a crisis will definitely make you
more empathetic towards other people who also find
themselves in a crisis - such as your patients. Many
doctors find they are much more sympathetic towards
their patients when they have faced a critical illness
themselves.
One of the best ways of learning how to cope with
a crisis is from our patients . Compared to most of our
personal crises, our patients go through much worse
situations, such as the loss of a child, life threatening
illnesses, and imminent death. Many will deal with such
a crisis with such grace and wisdom, that they are living
lessons for all of us. Their attitude can be a source of
inspiration and courage for you.
It's important to keep your perspective - be objective.
You will have to accept that life is not always fair, and
that "bad things do happen to good people" because "
we live in an imperfect world." A sense of humour can
be invaluable at this time. No personal crisis ever marks
the end of the world, even if it seems to do so at that
time. Don't magnify the problem or start imagining that
it is unmanageable. Also you need to learn to be
detached - don't take it personally. Many people have
been through worse, and have survived their baptism

by fire , and so can you. Keep your self-esteem intact
- this will help you to bounce back. Learn to accept
reality, no matter how bitter it may be, because the
sooner you do this, the easier it is to deal with it. As
Rudyard Kipling advises so wisely and eloquently in
his poem, If:
If you can meet with triumph and disaster,

And treat those two impostors just the same.
Research has shown that when faced with the same
crisis, some people will crumble; other will survive;
while others will thrive. These are the hallmarks of
the survivors .
Reason : Survivors focus on problem-solving their

crisis. They control their emotions; set aside panic and
think logically during a crisis, especially about the true
nature of the crisis and realistic options for solving it.
They always have a Plan B, in case things don't work
out as expected.
Focus : Survivors are 100 percent present in the
moment. Thinking too much about past experiences
or future possibilities distracts from survival.
Integration : Survivors must be emotionally healthy
enough to integrate their tragedy and its consequences
into being one part of their larger life story.
Positivity. After a crisis, you will never be the same
again. Making lemonade from lemons is crucial after a
crisis. The key challenge is, how can you make
something positive of this? How can you come out of
this a better person?
While some crises can blow over quickly, others can

be a long drawn out and painful process. Not only
does it eat into your time, it also saps your energy and
monopolizes your attention. It also extracts a huge
emotional toll, and many doctors when faced with a
crisis go through a process of five classic phases of
grieving, as first described by Elizabeth Kubler-Ross
when talking about dying patients. The first response
is one of denial: I am a fine doctor and a good human
being ; this can't be happening to me. The next stage
is one of Anger: Why should this be happening to me
when I am such a good person? Doctors will often
vent their anger on family-members, their staff, and
even other patients. The next stage is one of Bargaining,
where the doctor pleads with God to, 'let him off the
hook this time,' and promises never to err again. This
is followed by Depression. Many doctors start doubting
their competence and professional ability, and wonder
if they should just stop practicing medicine altogether.
The final stage is one of Acceptance, when the doctor
comes to terms with the fact that dealing with a crisis
is simply a fact of life everyone has to face up to; that
it is not a reflection on his personal worth, and learns
to get on with his life! Being prepared for the emotional
havoc which going through a crisis can play with your
life can help you to cope better: don't try to minimize
the impact it has on you and your feelings by pretending
it's of no consequence.
It's usually a good idea to continue working, if you
can do so. Your patients can be a source of strength ,
and if you find satisfaction in taking good care of them,
this will help to bolster your self-esteem and
confidence. Hiding and running away from the
problem will often compound it.
It's a good idea to prepare for those crises which you

can. Some are predictable, and you need to manage
these proactively. For most doctors today, it's simply a
matter of time till a patient sues you for alleged
malpractise. Taking out a professional indemnity
insurance policy and knowing what to do when you
are sued will help you retain control. Be prepared -
have a plan, and then follow it.
A key part of handling a crisis is damage control,
and there is often a lot you can do to prevent the matter
from becoming worse. It is natural to feel like a helpless
victim after a devastating crisis, but you can’t recover
from grief until you overcome these feelings. In the
midst of your sorrow, make a plan to take charge of
your life. While you may not be able to solve the whole
problem or wish it away, remember that no matter how
much of our life we think we cannot change, there is
always that part that is within our control, and that we
can work on - be it 2 percent, 5 percent, or whatever
- it is always more than we suppose.
Going through a crisis often serves as a wake-up
call, which forces you to look at the "big picture" and
where you are heading in life. Treat this crisis as an
educational lesson - it may prove to be an expensive
lesson, but you need to learn it. Many of us get so
desensitized by the daily monotony of life, that we often
lose our ideals and goals. A crisis will help you focus on
the purpose and meaning of your life; so that it can
actually serve as an opportunity for personal and
professional growth. Life is full of ups and downs, but
the sad reality is that we all learn much more from the
downs.
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Chapter 27
Risk Management:
Keeping Problems at Bay
Risk comes from not knowing what you’re doing.

— Warren Buffett
All doctors today are aware of the risk of being sued.

While lawsuits against doctors used to be rare in the
past, trends are changing rapidly and we are quite likely
to follow the American example where practically every
doctor has been sued at least once, and where being
sued is considered to be one of the occupational hazards
of practicing medicine. While this can be bitter medicine,
there is little point in waxing nostalgic about the good
old days; we need to come to terms with the new reality.
Learning how to minimise the incidence of adverse
events in medicine, and their impact, is called risk
management, and this has become a well-established
science today. The practice of risk management involves
identifying those aspects of problem behaviour on the
part of doctors, that cause patients to sue, and then
eliminating or controlling them to reduce the likelihood
that a malpractice claim will be filed. Unfortunately,
most doctors in India are still unaware of this field, and
most of us learn about it the hard way.
2021 Succcsftil Medical Practice: Winning Strategies for Doctors
Risk management is tied to the concept of quality

control. The ideal solution to quality control would be
to prevent all risks, but unfortunately this is impossible
because provision of much needed medical care is
unavoidably accompanied by the occurrence of injuries.
What can you do to minimize your risks? Risk
management focuses on preventing problems, and the
most important issues are discussed in what follows.
Clinical Competence
Medical knowledge requires maintenance. Keep

yourself up-to-date. Do your homework. Good doctors
can prevent the most serious errors by being primed
to recognise and treat them. The sequence of events
leading to poor patient outcomes and eventually to
malpractice suits can usually be clearly visualised.
Failure to perform an adequate clinical assessment of
the patient, omission of necessary tests, an improper
diagnosis and failure to treat the patient's condition
can lead the physician and his patient towards disaster.
Fortunately, proper attention to the details of the clinical
encounter and an awareness of the most common
problem diagnoses can help you to avoid these pitfalls.
Remember, however, that being competent as an
individual is not enough. You are in charge of the
entire medical team caring for the patient, and you need
to ensure that your staff too is competent. They will
learn from you, and it is your responsibility to teach
them.
It is important to realise your own limitations, and
to ask for consultations and referrals to seniors when
necessary. Also, do not criticize other doctors and
their care; after all, what goes around, comes around,
and your criticism may backfire in the long run.
Risk Management: Keeping Problems at Bay 1203
Communication
This means being able to manage high-risk situations,

where the patient is likely to sue. Thus, the patient
who has had a poor outcome (for example, the birth
of a baby with birth asphyxia: the obstetrician's
nightmare) is like a time bomb which may explode if
not handled with care and tact. The most important
skill is that of patient communication, of being able to
talk and explain to the patient what went wrong, and
why. This is the skill of having a good bedside manner,
of treating patients as human beings worthy of your
time and attention. For many physicians that goes
without saying, but for some it bears repeating.
Unfortunately, arrogance seems to be second nature
for some doctors in India and, as Tuthill puts it, "If you
act like God you'll be expected to perform like God,"
and that's a sure invitation to a lawsuit. Remember,
patients who like their doctors and medical office staff,
and feel a strong sense of loyalty and friendship towards
them are much more inclined to resist the notion of
suing even if things do go wrong. For example, if a
complication does occur, do not try to hide it. It is best
to explain it as some form of biological variation in the
patient responsible for an unusual clinical presentation
or therapeutic response, for in most cases this is the
best tactical explanation.
Fortunately for most doctors, the majority of patients
who experience an adverse event or poor clinical
outcome because of an error do not sue their doctors.
Nonetheless, an adverse event or unexpected bad result
can serve as a red flag, warning the doctor that he
may be slapped with an allegation of malpractice. The
severity of the injury and the degree of patient or
family dissatisfaction may be additional 'early warning'

signs that a lawsuit may be on the way. So what should
you do to prevent problems if an adverse event does
occur?
First, remember what not to do - don’t lie; don’t
hide; don’t pretend; and don’t push off the unpleasant
duty of talking to the patient or his relatives to someone
else. It is your responsibility and only you can do it
properly. Don’t make a bad situation worse by running
away from it! Unfortunately, the first response is often
to bury the error and hide it, but this often makes
matters worse.
Junior staff members should report all incidents to
their seniors, who can take appropriate steps. After all,
with seniority comes experience, and often your seniors
will have encountered similar problems in the past,
and will know exactly what to do. Their advice and
guidance can be invaluable.
The first priority should be to attend to the patient's
medical needs. Take responsibility for dealing with the
problem, ask for consultation and make arrangements
for follow-up. Discuss with all staff members the factual
details and sequence of what occurred , and attempt
to reconcile any opposing perceptions. Coordinate your
response to ensure that everyone is going to tell the
same story.
When a serious adverse event occurs, expressing
sincere sympathy and compassion to the patient and/
or family is often the most important response to help
diffuse a potentially volatile situation. As soon as
possible after the event, factually record the incident
and medical response and document plans for further
follow-up if indicated. It's a good idea to ask the most
involved and knowledgeable staff member(s) to record
factual statements of the event in the patient's record
Risk Management: Keeping Problems at Bap 1205
and any follow-up needed or done as a result of the

incident. However, do not ever alter (or allow anyone
else to alter) any prior documentation, or insert
backdated information. Ill-advised record alterations can
render otherwise defensible cases almost impossible to
defend. Do not use the medical record to speculate or
air grievances about other care-givers, equipment or
administrative processes.
Be accessible for questions from the family and the
patient. Repeated requests for an explanation of the
event is a common reaction of upset patients and family
members. Be empathetic and don't get irritated. Be
honest with the patient and family. If you try to wriggle
your way out by lying, you may find yourself trapped
in a quagmire from which it may be very difficult to
extricate yourself later.
Organise a family meeting if several relatives are
involved in the patient's care or if treatment decisions
are complicated. Empathise with the family and offer
emotional support. Your goal should be to show
compassion for the patient's distress, without admitting
liability - and this can be tricky, but you need to find
the right balance. Accept responsibility for follow-up
of serious complaints, but do not accept or assign
blame, or criticise the care or response of other
providers.
Should you apologise to the patient if there has
been a goofup ? The best approach is a rational one -
describe the incident and medical response in brief,
factual terms and if additional follow-up is indicated,
discuss those plans with the patient. Show concern for
the patient's condition, but don't criticise yourself or
other care-givers for a poor outcome or engage in
'thinking out loud' about what happened or why.
If the event involved a medical device or piece of
equipment, preserve these materials for investigation.
2061 Succesftil Medical Practice: Winning Strategies for Doctors
Do not return defective devices to a manufacturer

who may be a possible party to a claim. Electronic fetal
monitoring strips, X-rays, and pathology slides are
examples of other important data to preserve following
an adverse event.
Today patients have higher expectations of the
medical care they receive, and they expect their doctor
to have excellent technical skills and to apply his medical
knowledge expertly to their problems. They expect
value for the money they spend on medical services,
and they also demand to be treated with respect,
courtesy, and caring. When they find their expectations
belied they turn into critics, and even plaintiffs.
Insurance
Ensure that you are covered and have adequate

professional liability insurance. Indeed, it would be
foolhardly for any doctor today to practice without
taking out comprehensive coverage for malpractice
insurance, and fortunately insurance premiums in India
are still reasonable. While coverage will not prevent
you from being sued, it will help to mitigate the possible
financial impact on your resources.
Documentation
It has been said that the medical record is a defendant

physician's only friend, or foe. In every malpractice
case, attorneys for both sides scrutinise medical records
carefully, looking for specific types of evidence that will
bolster their respective cases. Every medical record has
a potential for legal scrutiny, and it serves as a legal
record of the care provided to the patient. The rule is
simple: if it is not documented it did not happen.
Absent data, poorly integrated information, or
diagnostic conclusions that are not logical or are not

properly recorded leave an impression of sloppy
practice and poor physician judgment. In fact, keeping
accurate medical records is so important, that we have
devoted a complete chapter to this.
If you want to reduce your risk of getting sued for
malpractise, follow these simple suggestions.
1. Be a nice person. Be pleasant to be around. Be
agreeable. Be friendly. While being nice is no guarantee
that a patient or family is not going to sue , they are
far more likely to sue you if you are unpleasant,
obnoxious and rude. So be nice.
2. Be honest. Don't make promises you can't keep.
And when you make a mistake, admit it. Promptly. The
reason for this is that when we lie, we send off signals
that something is not right. And most people can spot
that a mile away. If you are honest and forthcoming
with patients and family, they are more inclined to like
you, and far less inclined to sue.
3. Be open. Make it a point of being available and
easy to reach, both in a physical sense, and in a
psychological sense. If something doesn't make sense,
say so. If you don't understand something, tell the
patient. And if you don't have all the answers, tell the
patient that, and say that you will find someone who
does have the answers. And do it.
4. Be accessible. Don't hide from your patients. Don't
avoid them. Again, I'm not suggesting that you be there
for them 24 hours a day. But when you are there, be
there. And if you have other patients to care for, tell
your patient honestly that you have other patients at
the moment, but you will be back with them as soon
as you can.
5. Keep up to date professionally, and not do things that

you are not competent to do. This is just a part of being
honest with yourself. Know what you can do, and do
it. Know what you can't do, and don't do it.
Life is full of the unexpected, and this is especially
true in an inexact science like medicine. No matter how
competent and careful you are, problems are bound to
occur. If you are prepared for these, and have a plan of
action to deal with them, you will be able to cope much
better when they do crop up.
Chapter 28
Health v/s Wealth: The Danger

of (Mis)managed Care
Managed care is not the problem; profit is the problem.

— Christine K. Cassel.
The delivery of medical care in India today leaves a lot

to be desired. The government has failed dismally in
its goal of providing healthcare for all, and while some
hospitals are international centers of excellence, the
majority of patients do not have access to quality
medical care. While private medical care can be
excellent, it is often very expensive, and since there are
no standards, the quality can be very uneven. This sad
state of affairs results in many patients being dissatisfied
with their medical care, and doctors no longer
command the high prestige they used to.
Since the healthcare industry today is so poorly
organised, it seems very tempting to treat medicine as
a business , in order to manage medical care more
efficiently . The word managed itself is very enticing -
after all, anything which is well-managed is good -
and why can't medical care be managed too ? The
hope is that managing medical care can not only help
to control costs, it can also help to provide better
medical care by standardising it to maintain quality
Health v/s Wealth: The Danger of (Mis)managed Care 1211
control - after all, the reasoning is if healthcare is a

service industry , why not manage it as one ?
In its broadest sense, managed care can be defined
as any attempt to influence the access, delivery, or
financing of health care It can also be considered to
simply be the application of business principles to health
care.In current everyday use, the term managed care
often refers specifically to managed care organizations
(MCOs), such as health maintenance organizations
(HMDs).
The concept of managed care is a US model, which
also explains why it is so attractive for Indians - after
all, anything made in the US must be good. Managed
care has become a buzz word in medical journals, which
are now full of guidelines, protocols, and pathways,
created to help doctors to provide standardised high
quality medical care. So much for the promise, which is
such a seductive idea, that it is greeted with an initial
wave of euphoria. It seems to be the perfect marriage
, in which business managers concentrate on minimizing
costs and running hospitals efficiently, allowing doctors
to concentrate on being doctors and providing medical
care to their patients .
This is why when managed care companies send
out their executives with their sales pitch to doctors,
most are happy to sign up. Isn't this is win-win situation
? The doctor now becomes a "preferred provider" , and
gets more patients through the managed care referral
network. After all, isn't this simply a better method of
paying for medical treatment.? The doctor does not
have to worry about collecting payment from the
patient, since the managed care organisation pays . Most
doctors in India are quite happy with the concept of
"third party payment" - after all, isn't this exactly what
2121 Siicccsful Medical Practice: Winning Strategies for Doctors
MediClaim does ? If the insurance company is paying,

this reduces the financial burden on the patient - and
the doctor is free to charge more, since it's not coming
out of the patient's pocket , and in fact, in the heyday
of "third party payment" in the US 30 years ago, many
doctors did ,become very rich very soon. So, why not
make hay while the sun shines ?
The key difference, of course, is that with regular
mediclaim insurance , it is the doctor who decides the
medical treatment - the insurance company pays the
treatment money (fee for service) according to their
published guidelines. Thus, the financial risk of falling
ill is underwritten by the insurance company, leaving
the doctor as the medical authority, with no one to
second guess to cross-question his medical decisions.
However, managed care organisations ( usually called
HMOs , or health maintenance organisations), play an
active role in managing how money is spent. They set
guidelines for medical care, choice of medications, and
can limit access to specialists in order to improve cost
effectiveness. Treatment decisions by physicians often
require the blessings, or "authorisations", of utilization
reviewers and HMOs can refuse to pay for care if they
do not think it is appropriate - and this can hurt both
patient and doctor.
We need to learn from the US, before we find
ourselves in the same mess they are in now - at least
we have the wisdom of hindsight to help us. Let us
not forget that the managed care model was introduced
in the US for only one reason - to control the runaway
skyhigh costs of medical care there. The intent was never
to improve the standard of medical care - which should
be a doctor's only goal. However, the sad fact is that
physicians are very naive as businesspersons , and even
Health v/s Wealth: The Danger of (Mis)managed Care I 213
though they think they are very clever , they are easily
manipulated by businessmen and HMOs, so that they
often end up fighting against each other because of ego
hassles , medical politics and professional rivalry.
The list of problems which has plagued HMOs is a
long one - and affects everyone concerned adversely -
doctors, nurses, hospitals, other medical staff - and
patients. In fact, the only people happy with HMOs
today are the HMO executives, who are laughing all
the way to the bank.
Let us start with the problems patients face. The
biggest one is of access, and it's very difficult for patients
to get an appointment to see their physician - waits of
upto 3-4 weeks are the norm. For complex problems,
the difficulty is far greater. It can be very difficult for
the "primary care physician" to refer the patient to an
expert - because the doctor needs authorisation from
the HMO before he can refer the patient for an expert
opinion - and HMOs are understandably reluctant to
refer patients to specialists - after all, specialists are
expensive. Also, it's not possible for your doctor to
even choose whom to refer you to. He is forced to send
you to a doctor on the HMO's panel - who may not be
the best for the patient's particular problem.
However, the effects of HMOs on doctors are much
worse. Most HMO doctors no longer look forward to
seeing patients, because they are compelled by the HMO
efficiency experts to see "x" number of patients per day.
They are treated as mindless automatons on a factory
assembly line, who have to process one patient in 10
minutes, no matter how complex the problem. Doctors
who spend too much time on a patient actually get
pulled up because the bottom line is no longer the
quality of care, but rather its cost.
Doctors working for HMOs are often under

considerable stress, and many burnout quickly. For one,
their actions are always being scrutinized and analysed.
"Big brother" watches the HMO doctors closely, by a
mechanism called utilization review (UR), in which
clerks scan medical records to ensure HMO guidelines
are being obeyed to keep costs down. Since HMOs are
run by bureaucrats, they believe medical care can be
applied by following "cookbook" rules, and any
deviation from these guidelines leads to punishment.
The ability of the doctor to make medical decisions
individualized for the particular patient is taken away,
making medical care very impersonal and uncaring.
Since the focus is on maximising profits, doctors spend
more time on the paperwork, rather than with the
patient ! Everything needs to be documented, never
mind caring about the patient ! Also, because doctors
need authorization for everything, they spend half their
life on the phone, talking to clerks , explaining why
their patient needs a particular medical procedure, or
why hospitalisation needs to be extended in a given
case. The exasperation factor is tremendous, and the
waste of time and energy is huge! Doctors are also
hamstrung in making decisions. Thus, only drugs which
are in the HMD's formulary can be prescribed -if the
patient needs an alternative which may be superior,
but more expensive, the HMO will simply not pay for
it !
Payment is another sore issue. Since the HMO has
so much financial muscle, it is the HMO who decides
payment terms - when and how much to pay. Often,
payments are too little and too late, with the result that
doctors get squeezed - and in fact, doctors in the US
today often end up losing money by seeing patients
since the reimbursement from the HMO does not cover
Health v/s Wealth: The Danger of (Mis)managed Care I 215
their overheads. Many are now finding that they need

to work harder and harder for less and less, so that like
the Red Queen in Alice in Wonderland, they need to
run in order to remain in the same place. With the
introduction of HMO commercialisation, doctors are
forced to become businessmen - and learn all about
new terms such as cost containment, authorisation,
capitation, and gatekeeper (which you won't find in
any medical text book).
One of the most harmful effects of HMOs has been
the poisoning of the physician-patient relationship. The
doctor has simply become a healthcare provider , and
his professional status and reputation has been
destroyed. Doctors are given financial incentives for
reducing costs - and this is obviously going to affect
the quality of care the doctor provides, as he tries to
skimp on expensive treatment. In fact, patients have
become very distrusting of doctors in an HMO system,
because they feel that doctors are denying them the
medical care they need. Thus, in a few short years, the
trust patients used to have in their doctors has been
wiped out, and a doctor v/s patient relationship has
been created.
To add insult to injury, the HMO applies constraints
as to what the doctor can do and cannot do, but if
something goes wrong, then it is the doctor who has to
bear the full brunt of the patient's wrath. After all,
how can an HMO clerk be held responsible for medical
decisions ? This means that doctors are now sandwiched
between the HMO management and their patients -
and receive flak from both sides. In fact, some experts
even wonder if it is possible for doctors to practise
medicine ethically in an HMO setting, when they are
answerable to two different masters - the HMO
management (to keep costs down), and to their patients
(to provide high quality medical care). Physicians now

have to play a fine balancing act between their duty to
their employer (the managed care organisation) , the
health interest of their patients, and their personal
livelihood. What a far cry from the "good old days"
when all the doctor had to worry about was looking
after the patient's best interests. Responsibility without
power leads to burnout.
Patients and doctors have already started rebelling
against the excesses of the HMOs in the US. Laws for
patient rights, to protect them against HMOs are being
passed; and doctors are now joining unions, and offering
creative alternatives to HMO models, such as private
practice physician networks.
Managed care will be introduced in India - it's simply
a matter of time, because we are talking big bucks. As
Dr Arnold Reiman, the past Editor of the New England
Journal of Medicine noted, "Health care is being
converted from a social service to an economic
commodity, sold in the marketplace and distributed on
the basis of who can afford to pay for it." However, if
we import the US model, the only ones who will benefit
will be HMO managers and execs. Doctors in India need
to band together to withstand this danger, for the sake
of their patients - and for their own sake. The only
time to do it is now - tomorrow may be too late. Let's
not forget that it's not possible to provide medical care
without doctors - and if we are united , we can act as
our patient's advocates , and support a model that’s
patient-centered, as opposed to one that just cuts costs.
Doctors have traditionally always been leaders - and
we will have only ourselves to blame if we do not act
now.
Chapter 29
Making Your Marriage Work:

Keeping Your Better Half Happy
The family you come from isn't as important as the family

you're going to have.
— Ring Lardner
It's true that being a physician is hard - but often being

married to a physician is even harder. Many doctors
acquire personality traits such as perfectionism,
compulsiveness and workaholism which help them
provide better care to their patients, but end up making
them problematic spouses. They expect to be in "control"
all the time; and since they are so used to their patients
putting them on a pedestal, they expect their spouses
to do the same too - which means they can be quite
impossible to live with. Many take pride in being
married to the profession, as a result of which they
spend little time and energy in nurturing their spouse
or cultivating intimacy. Most of their friends are other
doctors , and usually they end up talking shop when
they "socialise", as a result of which the wife is often
left out in the cold. Unreasonable hours and being on
call at all times are part of the doctor's job description
- and the spouse has to put up with these. To add
insult to injury, rather than being admired and
appreciated for having to put up with such a difficult

husband, she is considered to be lucky because she is
married to a doctor. Society expects her to be a martyr
and to sacrifice her personal happiness in order to
keep her husband happy. Playing second fiddle is not
so bad in the honeymoon years, when some of the
glamour of being a respected doctor rubs off on to the
spouse. However, when the novelty wears off, many
spouses chafe as being treated as second class citizens.
They never have an opportunity to develop their own
independent identity, and many remain just " Dr X's
wife" . While some play this role successfully by
becoming the manager of their husband's practice,
others end up feeling stifled and suffocated.
Many spouses cannot understand why their
husbands who are so understanding, caring , and
thoughtful towards their patients in the clinic become
so thoughtless when they reach home . Many doctors
literally enact the story of Dr Jekyll and Mr Hyde when
they move from their clinic to their house daily.
Often it's upto the non-medical spouse to shoulder
the burden of keeping the marriage together, and
because she is often the junior partner, doing so can be
hard for her - she bears the responsibility, without
having the authority to make the needed changes. The
medical spouse will often retreat into his work, and to
keep the faqade of a happy marriage intact, the wife
will often have to sacrifice her own interests and desires.
In order for your spouse to be happy spouse, she first
needs to be happy herself as an individual - people
who are unhappy can never create a happy marriage.
www.medicalspouse.org has a lot of information which
can help you help your spouse cope better with being
married to a doctor.
Making Your Marriage Work: Keeping Your Better Half Happy I 219
Just like an unhappy marriage can create an

enormous amount of stress which can poison every
part of your life, a happy marriage can add a
phenomenal amount of bliss to everything you do. Is
there a prescription to keeping your marriage healthy
and happy ? The truth is that most of what you need
to do to keep your spouse happy is based on simple
common sense - spend time together, respect each
other, have fun together. Even simple things like just
phoning to say you are thinking of her can go a long
way. However, even though most of us know all this
(and in fact, dispense this advise to our patients on a
daily basis), we are not very good at putting this into
practice in our own lives.
Men are often responsible for not providing their
fair share of input towards making a marriage work. It
is true that men are from Mars, and women are from
Venus; and you need to learn to see things from each
other's point of view. Remember that a marriage is a
dance - you are both equal partners, but your partner
can dance only as well as you let her. If you have an
understanding spouse, count your blessings - but you
can't keep on taking advantage of her . Women will
often spend a lot of energy on cementing the
relationship so you can grow together, but you need to
reciprocate for this to work well. While it can be hard
to juggle career, work, marriage, and family, it's helpful
to remember that your marriage should be your first
priority. If you don't go to work, someone else will fill
in for you - but if you don't look after your wife, there
is no one else who can do so. A happy marriage is
vitally important for your children because it provides
them with happy memories for the future and lays the
foundation for an emotionally secure adulthood. A
bad marriage can ruin not only your career, but your
happiness - and your children's happiness as well.
Incidentally, by making your marriage your first
priority, you will not be sacrificing your career. Ironically,
you will end up doing even better at work. A good
marriage cap help you become a better doctor - a happy
personal life will help you perform far better in your
professional life. Both of these are closely linked together,
and it's stupid to try to compartmentalise them. Few
things feel as good as marital harmony, and people who
live in a supportive and loving marriage thrive.
Increasing intimacy in your life may be the best way of
ensuring your health, productivity and happiness.
Making your marriage work can be the best thing you
ever do - the rewards will far outweigh the effort. Being
a doctor can be demanding , and the positive energy of
a committed marital relationship can help you perform
even better.
A marriage needs to grow as you grow, and as you
mature, you need to nurture it. Most marriages move
through the following stages.
Stage 1: Romance—"You're perfect"

Stage 2: Fault Finding—"You're flawed"
Stage 3: Blaming—"You do it to me"
Stage 4: Acceptance—"You just do it"
Stage 5: Transformation—"We grow together"
Many couples get stuck in stages 2 and 3, and so

much hurt and damage can occur in these stages that
many married couples decide to divorce, while others
either withdraw from one another and live in a politely
superficial way, leading lives of quiet desperation; or
they continue to fault-find and blame and may verbally
attack each other for decades.
Making Your Marriage Work: Keeping Your Better Half Happy 1221
Some couples naively believe that if they have

managed to stay married for 10 years, their marriage is
stable. This is not true. You still need to continue
working at it, otherwise you may grow away from each
other . The second half of marriage can be a time of
renewal - a time to renew your teamwork, your
friendship and your romance, so you become one of
those "wise couples" whom younger people secretly
aspire to emulate. If you know such couples, observe
them and learn from them - they have much to teach.
All marriages have their ups and downs, and conflict
is a given in every marriage, however, divorce is often
the worst solution. Not only doesn't it solve anything,
it often makes matters worse , leaving behind a lot of
bitterness, for both the partners, as well as the children.
Learning how to deal with conflict as in integral part of
your marriage . Work to create an "us versus the
problem" attitude rather than a "me versus you"
mentality. Remember that healthy negotiation can solve
most problems - after all, you are both on the same
side ! The rules are simple: listen; validate your spouse's
perception, show that you care, focus on the problem,
don't rake up the past; emphasise where you agree;
and learn how to say "sorry". Nothing feels worse than
not getting along with your spouse - all the money in
the world is not worth having an unhappy mate.
Use your resources to save your time and energy,
so that this can be used to spend time with each other
and your family. Remember, you are intelligent people
- create a support system to simplify your life so you
can beat stress together.
There are some common issues which often threaten
to break up a marriage. These include: money and
financial arguments, infidelity and affairs (doctors have

many opportunities to succumb to temptation);
boredom and staleness; career crises, children -
especially when they grow up and leave home ( empty
nest syndrome), and retirement, because doctors often
have no clue what to do with themselves when they
are not working. It's helpful to be aware of these
stressors, so you can take appropriate action at these
times to bolster your marriage.
Medical marriages in India are often exposed to more
stress than those elsewhere. For one, many marriages
are "arranged" and a doctor is considered to be a prized
catch , which means the spouse is forced to look upto
him right from the night of the suhaag raat. Not only
can this be a pain in the neck, a marriage between
unequals is doomed right from the start. Moreover, since
the joint family system is still common, this often leads
to increased pressures on the non-medical spouse,
because she is supposed to adjust to her husband's
demands. Also, since divorce is still not considered to
be a socially acceptable alternative, many marriages
continue to be quietly and desperately unhappy.
Making a marriage work well can be an uphill task
for all couples - but it can be especially hard when both
are doctors. At first glance, a doctor-doctor match sounds
ideal because both understand the long hours and the
stresses of medical practice; they speak each other's
language and the spouse is a respected colleague who's
always on hand for consultation. However, doctor
doctor marriages are not a bed of roses. Tightly packed
schedules allow little time to deal with family
commitments; and because both are so busy fulfilling
work pressures, there's little time for husband and wife
Making Your Marriage Work: Keeping Your Better Half Happy I 223
to be alone together, and they may end up growing

apart.
Marriage, just like a medical career, requires a serious
commitment to succeed. If you fail to invest the
necessary time, problems are bound to arise.
Unfortunately, time is one thing physicians don't have
a lot of, which explains why conflict in medical marriages
is so common. The simplest advise is to treat your spouse
as your most important VIP patient. Do this for purely
selfish reasons - a loved spouse is also a loving spouse,
and will take much better care of you . It will be the
best investment of time and energy you can ever make!
The wise words of Kahlil Gibran are worth
remembering.
You were born together, and together you shall be

forevermore.
But let there be spaces in your togetherness,
And let the winds of the heavens dance between
you.
Chapter 30
Parenting - Bringing up
the Next Generation
There are only two lasting bequests we can hope to give our
children. One of these is roots, the other, wings.
— Hodding Carter
Being a parent is the world's toughest job, and being a

doctor can be very challenging as well, which means
that trying to combine both can be overwhelming for
most of us. One would expect doctors to be good
parents, because they are intelligent, educated, and
know enough about pediatrics and psychology, to be
able to bring up children well. The sad reality, however,
is that the children of most doctors are quite unhappy
with their parents, and their commonest complaint is
that their doctor-parents have very little time for them.
Why is it so hard for doctors to be good parents ?
Aren't they smart enough to know that their children
are their most important investment ? The fact is that
the pressures of trying to balance both family
commitments and work pressures are enormous. While
many doctors do a bad job at parenting, the difficulties
are even greater when both parents are doctors.
The personality traits that make for good physicians—
self-discipline, sacrifice, ambition, and a certain amount
of obsessiveness—can’t help but influence a doctor's
Parenting: Bringing up the Next Generation 1225
parenting style. Doctors are rugged individualists

who are used to toughing it out, and they don't usually
ask for help, which means they often don't deal very
well with the perplexities of family life. They are used
to knowing what to do, and to even advising their
patients as to how to bring up their own children; but
they are completely flummoxed when it comes to the
real-life problems presented by their own children. They
don't know how to ask for help - or what to do with
it, when it is given. This often ends up making a bad
situation worse, as the rift between parent and child
widens.
Doctors are usually high-achievers; and because
they have accomplished so much in their own life, they
expect their kids to accomplish a lot too. Doctors feel
that because they are giving their children lots of money
and the best education, their children have to perform
well. To whom much is given, much is expected', is often
the doctor-parents' motto, and they will often pressurise
their children to over-perform. Many feel their children
don't work hard enough, or that they under achieve.
Many children retaliate , and when they start feeling
that they don't measure up to their parents' unrealistic
expectations, they become underachievers, to get their
own back. IMany children of doctors resent the amount
of time and energy their parents spend on their patients,
and wish they could get some of this. However, medicine
is a jealous mistress, and they often fail in their efforts.
They start feeling that their parent is not as interested
in them as they are in their patients, and they stop trying
to keep them happy, because they feel the effort is futile.
This gap keeps on increasing as time goes by, so that by
the time the child has become a teenager, the combined
effects of the generation gap and this daily inattention

have exacted a heavy toll on the parent-child
relationship.
Because medicine is a caretaking field, doctors would
be expected to make caring, concerned parents.
However, many are so obsessed with being the best is
their field, that even though they want the best for
their children, work and home frequently pull them in
opposite directions. Women doctors have a much worse
time of it. While men can delegate parenting to their
spouse, mothering is still a full-time job, whether or not
you are a doctor. Women doctors have to be super-
women to try to juggle the pressures of both parenting
and their profession - and they often end up messing
up both. Since they are usually perfectionists, they
find that striking the right balance between work and
home is not always easy. In fact, many compromise
and take a specialty such as dermatology, psychiatry
or pathology, because this is less time-intensive and
allows them more time to accommodate to their family
priorities.
Not having enough time to spend with their kids is
by far the commonest complaint of most doctors.
Medicine idealises being busy, which means that if
you want to spend time with your kids, you have to
limit how much you work, which undermines your
professional stature. Many doctors will sensibly decide
that while there are other doctors who do what they
do, they will never get another chance at raising children
- after all, you are the only mother your children have.
After time constraints, the second biggest problem
physicians cite about raising children is discipline. The
two, not surprisingly, are related. If you cannot spend
enough time with your children, they are not likely to
Parenting: Bringing up the Next Generation 1227
listen to what you tell them to do. You cannot dictate

to children the way one dictates to patients, because
the process of negotiating with children is extremely
time-consuming.
Sadly, it's not only the children who are hurt by this
lack of togetherness . Doctors are very conscious about
the important role parents play in their children's lives,
and when they find they cannot devote the time and
energy their children need, they often end up bearing
a huge burden of guilt, which complicates matters even
more. They try to expiate this by giving their children
all the toys and luxury and pocket money they want -
which makes matters even worse because their kids then
exploit this guilt, by asking for more and more . As one
doctor put it, the problem is "affluenza—my children
expecting too much."
Some perfectionist physicians give themselves failing
grades as parents: "I don't feel I'm very good at it," or
"I wasn't brave enough," or "Whatever you do is not
enough." However, there is no doubt that being a parent
can be one of the most rewarding achievements of your
life. Some of the joys of parenthood as described by
physicians are: "Being able to love someone more than
I could have imagined." "Seeing life through their eyes,
and learning from their innocence." "Having
grandchildren." Children also gratify egos - they love
you unconditionally, like no one else ever will.
So what can you do to become a better parent ?
Make every effort to attend all your child's special events.
Sending a substitute, like a spouse, doesn't work - you
cannot outsource this job. You are important to your
child, and when you are physically with your child, be
there emotionally as well (remember to switch off the
mobile). Take up a game together with your children,
such as tennis . This will allow you to spend time

together, and both of you can look forward to this
"quality" time - especially if he starts beating you as he
grows older. This will allow the family to keep physically
fit as well; and allow emotional bonding too. Make
sure you spend at least one holiday every year together.
Don't forget the extended family. Make sure your
children meet their grandparents, cousins, uncles and
aunts ; and participate in family events, such as
marriages and get-togethers. This can give them strong
roots, which will help them for the future. Help them
to honour family traditions after explaining to them
why they are important. A simple thing you can do on
a daily basis is to eat a meal together every day, and
make a weekly appointment for having fun (dinner and
a movie if you want to keep things simple) with the
whole family. A common mistake many doctors make is
to over emphasise the importance of academic
achievements. The important thing is to find the area
in which your child shines, and give him as many
opportunities as possible to excel in this.
Just like you can help your child, don't forget there
is a lot your children can contribute to your growth
and well-being too. Your children can broaden your
horizons and teach you new stuff, keeping you young
and alert ! Take pride in their achievements, and set
up rituals such as bedtime stories , which help to create
family bonds. While bringing up a second child is a lot
easier because of all the experience you've gained from
bringing up the first one, sibling rivalry can add a new
layer of complexity to family building.
Should your child become a doctor too ? The decision
whether to become a doctor like Mom or Dad can be a
soul-searching experience for both generations. Many
Parenting - Bringing up the Next Generation 1229
children need to rebel when they become teenagers, to

demonstrate their own independence, which is why
many will deliberately choose not to follow in their
Parent's footsteps. Others see the toll which being a
doctor can take on an individual's lifestyle. They feel
sorry that their father has such little spare time for
himself and for his family, and do not want to repeat
the same mistake and fall into the same rut when they
start their own family. On the other hand, many
doctor's children are pushed into becoming doctors.
Physicians often want their children to become doctors,
because they have an established practice, which they
can hand over to them. They also feel they can provide
useful career guidance, and their contacts would help
give their children a flying start in the medical
profession. However, many of these children often end
up as unhappy misfits, disappointing themselves and
their parents as well, and making a mess of their lives.
Others are propelled into medicine because they find
the work their father does is fascinating, and would
love to follow in his footsteps. Many children are
profoundly influenced by their father's love of medicine
and his empathy for patients. When a parent is a proud
physician, the pressure to carry on the family tradition
can be intense; and some doctors will take their
children on hospital rounds, and even into the
operation theater, where they hold retractors during
surgery. The important thing is to let your children
make up their own minds. Any doctor's child who
wants to become a doctor just because he cannot think
of alternatives displays a complete lack of imagination.
Medicine is a career which is worth pursuing only if
your children want to. They should go into it for their
own reasons, because there's a lot they'd have to give
up. The best advise is to tell your children - do what

excites you, whatever that may be. Given the pressures
and stresses of modern medicine, many doctors are now
actually discouraging their children from entering
medicine. But many doctor's children do pursue
medicine , despite managed care woes, government
regulatory hassles, and malpractice threats. Their
inspiration is often their physician-parents, who serve
as such strong role models that their kids yearn to be
just like them - after all, there will always be room for
a good doctor. As a doctor's child, who is a doctor
herself says.
Growing up with two parents who are doctors, and

seeing how much joy they derived from their work,
I eventually came to realise that in no other
profession could I reap so much happiness, because
of the positive impact I could have on other people's
lives.
Society needs to realise the important role parenting

has in doctors' lives. We can start providing newer
options, such as tele-medicine, part-time jobs, or job
sharing, which will allow doctors to both do a good
job professionally, without taking them away from their
children. A happy doctor at home is a happy doctor at
work, and we should stop looking down at doctors
who wish to work part-time so that they can spend
more time with their children as being unprofessional
or unmotivated. Our children are our most valuable
investment, and our most important contribution to the
future.
The sad truth is that children do not remain children
for very long. They grow up and grow away too soon;
so make the most of them while you can. Savor these
Parenting - Bringing up the Next Generation 1231
years - they won't come back again. Take good care of

your children now and they will take good care of
you as you grow older.
Kahlil Gibran put it best when he said:
Your children are not your children, they are the

sons and daughters of life's longing for itself. You
may give them your love but not your thoughts, for
they have their own thoughts. You may house then-
bodies but not their souls, for their souls dwell in the
house of tomorrow, which you cannot visit, not even
in your dreams.
232| Succesful Medical Practice: Winning Strategies for Doctors
Chapter 31
Retiring:
From Medicine, Not from Life
It is not by muscle, speed or physical dexterity that great

things are achieved, but by reflection, force of character, and
judgment; in these qualities old age is usually not only not
poorer, but is even richer.
— Cicero.
Traditionally, practising physicians saw no need to

retire. Many feel that they are indispensable to their
patients and the exalted role that physicians enjoy both
professionally and socially is difficult to abandon. At
most, aging physicians simply reduced their workload,
and most retired only when forced to do so because of
ill-health.
However, trends are now changing, and many
doctors are choosing to retire. Some are being "pushed"
to retire because they are fed up of having to deal with
the increasing hassles of providing patient care in the
new millennium, and have burn tout, while others are
"pulled" to retire because they would like to spend part
of their life enjoying themselves; they feel economically
secure and want more time to enjoy other things in life,
such as their grandchildren.
Remember that just like you can start your career
when you feel the time is right - at the age of 25 or 30;
you can also retire when you feel the time is right.
There is no magic number at which you should retire,
and many physicians have continued to lead productive
lives practicing excellent medicine to the ripe old age of
90 too. Most doctors never retire officially - after all,
why waste all those years of accumulated experience ?
As you become more senior, it is also likely that more
and more patients will start to seek you out, and if
patients need your services, why should you refuse to
give them the benefit of your many years of knowledge?
What can physicians do to make the last one or two
decades of their lives enjoyable? Retirement is your final
career and requires every bit as much thinking and
planning as your other career decisions. Ask yourself:
What would you do if you did not have to work for a
living ? What you would like to leave behind for
posterity ? Where do you want to live? How will you
use your time so you feel productive and inspired? What
are your interests? What role will your family play? Do
you want to be closer to your children—or farther away?
You also need to prepare for a possible decline in
health—your own and that of your family and loved
ones. It's also important that you have a plan in place
as regards your clinic . If you want to sell it, the best
time to do so is when you are still in active practice, so
that you can capitalise on your professional goodwill.
Many doctors find that taking in a junior partner, who
will then buy you out in a few years when you are
ready to retire, makes the transition as smoothly as
possible. Don't retire until you have enough financial
security to lead a life of comfort, and enough financial
reserves to cope with emergencies. Otherwise you may
find that you are financially dependent upon your
children, and this can be very uncomfortable, especially
if you have been used to being the breadwinner all
your life.
Retiring: From Medicine, Not from Life 1235
Planning for retirement and being ready for it

emotionally are often two different things, particularly
for physicians. Many doctors resist retirement but
lingering in the profession too long can be tragic. Don't
wait till colleagues and patients start talking of you as
a doddering old fool. Doctors who find the idea of
retirement uncomfortable have become so used to
seeing patients day in and day out, that they really
don't have much of a life outside their clinic. They are
much happier being Dr Desai, rather than being the
old man who lives up the street. And their self-esteem
is so closely tied to their "being a doctor", that they
are not happy to let this go. This is why while many
physicians look forward to retiring, others dread the
prospect. Upon retirement, they mourn the loss of
their position - not just among their colleagues , but in
society as a whole. No one seeks you out for your
medical skills anymore - and you soon learn the hard
way who your real friends are. You may feel diminished
because all you have is your money - and your
memories. For most people, it is normal to feel a loss
of identity upon retirement, but physicians may feel
this most strongly. From the time we enter medicine,
we are told that the most important thing in our lives
is our patients - before wife, children and family. No
wonder we have such difficulty when we leave our
patients behind. For many doctors, the clinic provides
a daily place to go. If you suddenly have no place else
to be, it can be a loss.
While many physicians worry about what the
quality of their lives will be after retirement, the good
news is that studies show that retirement has a
predominately positive impact on the emotional state
of physicians. Many are happy to be relieved of the
demands of practice, and also enjoy indulging in
pleasurable activities such as travel, leisure, sports,

dabbling in the stock market and playing with their
grandchildren. Retirement allows more time for physical
exercise and health may actually improve during
retirement. However, about one-quarter of physicians
will experience some depression after retirement,
because of their sense of loss of self-esteem, poor health,
diminishing cognitive skills, or unhappy marital
relationship.
Retirement is easiest if work isn't the only thing that
gives you satisfaction in life. If all you have done is just
work at your job your whole life and then you suddenly
retire, that's an acute loss. However, if you're involved
with your family, have hobbies and multiple interests
and participate in your community, when you retire
you lose only part of your emotional investment. The
best preparation may be simply to expect some stress
from the transition to retirement. For many doctors,
that first year is a difficult period, but after that, most of
them happily integrate themselves into their new life.
Once you retire, your most important relationship
will be with your spouse , and this will be a reflection
of your lives together. A non-supportive spouse will
never find a friend waiting for him in retirement. Make
sure you do your homework well in the thirty or forty
years prior to retirement. Don't suddenly expect to find
a good mate waiting for you in retirement - especially
if you weren't a good mate. Interestingly, the marriage
often becomes stronger after retirement, because the
couple spends more time together, and become more
dependent on that relationship as a source of support,
as they grow old together. In fact, a third of physicians
felt that their retirement years were the best years of
the life, and were as good as they years they spent
courting, gaining professional status, and attaining
financial security.
A successful retirement may depend on identifying

what really matters to you, and then keeping those
aspects alive. This is the one time in your life when
you can do things purely for yourself. You can enjoy
yourself and goof off, without feeling guilty about it.
It's most important to remain intellectually active .
Without this, the human organism withers and dies.
The good news is that you no longer need to focus
exclusively on medicine. You can now pursue whatever
interests you - whether it is a hobby or a completely
different profession . Learn for the sake of learning,
because it is enjoyable ; and it's a good goal to try to
learn something new every day. Don't use your age as
an excuse to stop learning - the brain remains as young
as you choose to keep it.
Consider your body, mind, and spirit and take
reasonably vigorous exercise in each area. What's true
for your brain is even truer for your body, because if
you don't use it, you will lose it. Physical activity is
another necessity , and having a sport you enjoy can be
a huge blessing. Along with your mind and body,
remember also that we all have a creative side to us,
and we need to exercise this to maintain full health.
There are many creative activities on offer if we don't
already have some, or are seeking something new, and
plenty of available information. A balanced portfolio
would include two inside pursuits for inclement weather,
two outside for fresh air and exercise, two solo for peace,
and two in company for stimulation.
You can now be financially relaxed , because you are
no longer under any pressure to earn more money or
keep up with the Joneses. The good news is that you
can shed the administrative aspects of medicine, but
keep on helping patients. Since you are a doctor, and
there will never be a shortage of patients, the good

news is that there are many opportunities for volunteer
work and charity work for doctors, no matter what
your age. You can be true to yourself, and as eccentric
as you please, because you don't have to put on a
show for anyone else anymore.
Growing old can be difficult to cope with; and most
of us have been so used to giving orders and taking
care of our patients that we can find it hard to let
anyone else take care of us. You may also find you are
socially isolated, because you may have distanced
yourself from friends and family in your professional
pursuits. It may be difficult to pick up these threads,
but the good news is that there is a whole new
generation of grandchildren you can become friends
with.
Hinduism very wisely described the four stages of
life - the four dharmas. Once you retire, you have
reached the vanaprastha stage. However, you don't need
to retire to the forest and live as a hermit. Instead, you
can use this stage to serve as a mentor to your juniors,
and give back to your community what it has given to
you. You need to start preparing for the end of your
life, and you will find that serving others unselfishly is
the one thing in life which can give you the most
happiness. You have now become an elder, and can
provide guidance and advice to the Youngsters. You
have now become wise, after years of hard knocks and
weathering life's ups and downs and have a chance to
share your wisdom with the world, since you are no
longer in the rat race. Your motto should be to grow
from ageing to sageing so you are a respected elder in
the community. It's nice to be respected, but remember
you have to earn that respect to deserve it. Not having
to do things with a vested interest or for purely selfish
reasons can be very exhilarating - you can now finally

learn what freedom really means.
This is also an excellent chance to get ready to make
peace with yourself, and prepare for the final stage of
life - dying and death. You can explore your spirituality,
and do things just for yourself, so that you can make
this stage of your life the most important and the most
satisfying.
Chapter 32
Medical Ethics:
How to Do What is Right
Reading about ethics is about as likely to improve one's

behavior as reading about sports is to make one into an
athlete.
— Mason Cooley
The medical profession in India is in crisis and society

no longer holds the medical profession in the high
esteem it used to in the past. Most honest doctors would
agree that ethical standards in the profession are
deteriorating, and this seems to be a downward spiral.
When, where and why does the rot start - and what
can we do about it ?
Most people still believe that when youngsters join
medical college in order to become doctors, they usually
do it because they have idealistic goals and want to
serve and help others. Of course, it doesn't hurt that
doctors have a good income, but that's like icing on the
cake . You would expect that by the time they become
doctors, after going through five-and-a-half years of
medical college and three years of residency , they will
have thoroughly imbibed these ideals and goals from
their seniors so that they can serve society as caring
and selfless doctors. However, in real life, the situation
seems to be completely the opposite, and idealistic
Medical Ethics: How to Do What is Right 1241
students seem to become hardened and cynical by the

time they graduate.
We have learnt - rather painfully and rather
sorrowfully - that we've already lost the battle before
they even join medical college . By the time they are in
the eighth standard, they seem to have only one priority
in life - to get as close to 100% marks as possible, by any
means, fair or foul. This is why school classes seem to
have been replaced by coaching classes . This means
that by the time this child has finished his Xllth
Standard and is about to join medical college, a mind
set has already been established. Most students are
fiercely competitive - and seem to feel that the end
justifies the means. In medical college , things get worse
- the eventual goal, of course , is to get as close to the
top as possible in the final MBBS exams because all
subsequent registrations and post-graduate seats
depend on that. Medical students are no longer really
looking at medicine as a profession which is meant to
serve humanity - that has now become incidental. In
olden days, students needed to have a have a vocational
aptitude before they considered going in for medicine.
Today, of course, this is not considered at all. Not by the
parent, certainly not the child himself because the child
is relatively immature, not the teacher in school, and
certainly not the people who select who is going to
enter medical college. In the past, factors like whether
you were interested in human beings and how you
behaved with others was an important criterion in
selecting medical students. It still is, in medical colleges
in UK and USA today, where students are interviewed
before the final selection. With our system, we select
any Tom , Dick and Harry whose only criterion is that
he has obtained more than 99 marks. The second

major problem which has set in is the advent of the
private medical colleges . Here, you end up paying
through your nose for that seat. So, you have already
made a big capital investment - and the family than
expects a return on that investment. The other factor
which worsens the situation in medical colleges is a
rapidly reducing numbers of role models because most
medical college professors today are "full-timers" who
treat teaching as just a job they are paid to do. What
is also happening is that there are now a large number
of youngsters who earn huge incomes very fast;
everyone wants to become rich quick. Medical college
students are no exceptions - they also want what then-
friends have; a flat, a car, posh consulting rooms . All
these factors combine together, so that the chief goal
of a medical student now is to become successful in
practice, rather than provide good care to patients.
Many patients today feel that medicine has become
a business, and that doctors are just out to make money,
by indulging in unethical practices such as unnecessary
surgery, ordering expensive lab tests, and asking for
excessive consultations amongst one another. They sense
that doctors have become corrupt, and that unethical
practices flourish. Doctors justify this by saying that
all of society has become corrupt today, and it's not
fair to judge them by different standards - the same
benchmarks should apply to all professions. If we are
willing to accept corrupt politicians, then why should
we single out corrupt doctors ? A lot of junior doctors
also justify their unethical practices by saying - my
seniors are doing it as well - why shouldn't I ? Many
doctors feel that they are overworked and underpaid;
and that society owes them money because they work
so hard, so patients should not grudge them their fees.
Just like there are lots of corrupt doctors, fortunately

there are also umpteen examples in the medical
profession today of individuals who have done well
for themselves and have risen to the top without being
unethical. Names which come to mind include: Dr
Noshir Wadia, Dr Dastur, Dr Udwadia, and Dr Chaubal.
None of these people have stooped to any kind of
malpractise; they are absolutely straight, and they are
at the top of the profession . They are doing reasonably
well, and have an unmatched reputation to boot, and
are excellent role models we can try to emulate. Of
course, if you set your aspirations at an unrealistic level
- if you want the latest model Mercedes , a bungalow,
and a holiday abroad every 3 months, then you will
have to indulge in underhand practices. However, if
you have rational goals—shelter, food, education for
the children and care for my family—these can be
acquired by any doctor who is honest and straight
forward .
When most doctors start practice , they don't start
it with the intention of being crooked. However, when
they hang out their shingle, they find that the reality is
that patients will not come to them unless they grease
the palm of the local GPs. That's what everyone else is
doing, so you better do it as well - the competition is
intense ! And when they start, they do it for financial
reasons . Most justify this by saying, "I need to do it
now to survive - but after four or five years, when I
am well settled, I'll stop." The sad reality, of course is,
that once you start, you cannot stop - it's a downward
slippery slide. There are two or three methods by which
juniors could be helped to stay straight. The first would
be for his senior to down load work to him. In the
past, senior consultants would act as mentors to their
post graduate students and say, 'Come , set up your

clinic in this locality. I get lots of patient coming from
your area and I will direct them to you. Dr Sanzgiri,
Dr R N Cooper and Dr Joshi are some famous names
who come to mind, and many of their students are
now leading doctors. The second method would be to
encourage junior doctors to start practice in the right
town. Unfortunately, every one wants to settle down
in Bombay, Hyderabad, Bangalore, Delhi - and this is
neither sensible or practical. If the same individual
was to relocate in a relatively small place , he would
not encounter these teething problems. The interesting
thing is that in no time at all, they have a roaring
practice, with their own bungalows and cars - because
there is no competition - and they are the only act in
town. More importantly, they also have immense social
prestige, and they often leave their contemporaries in
larger towns far behind. The final method is perhaps
the best - we need to develop some means of identifying
honest and upright doctors who are competent and
skilled, and then publicise these names, so that they
are available to all patients. Retired senior doctors who
have an unblemished reputation could offer this
service. They would sit down very transparently, very
openly and evaluate other doctors . You could then
publish this list of reputed and ethical doctors, and
this list would help patients to identify honest doctors
of proven competence. You may not be able to evaluate
the crookedness of a doctor, but identifying honest
doctors will be a first step in the right direction. The
list need not be comprehensive in the beginning, but
once it becomes an established practice, doctors will
start clamouring to be evaluated, so that they can get
on to the list. This is not likely to be a very popular
Medical Ethics: How to Do What is Right | 245
suggestion, because doctors are usually egoistic

individuals who do not like being judged by others,
but if we do not establish a mechanism of doing so,
good doctors will start getting tarred with the same
brush, and all doctors will suffer as a consequence,
While most doctors are aware of unethical practises
and corruption in the medical profession, most prefer
keeping quiet about this . Society generally perceives
that doctors engage in a conspiracy of silence and secrecy
- and most doctors refuse to stick their necks out by
identifying "bad" doctors. This is a major reason why
patients have not been able to lodge complaints against
doctors in the consumer courts. The consumer court
requires two doctors to verify that the case has merit,
before accepting a complaint against a doctor. In reality,
since doctors refuse to opine against another doctor,
most of these complaints never see the light of day.
While most doctors are worried about the skeletons in
their own cupboards, if any doctor wants to improve
the system, he needs to have the guts to stick his neck
out. He may get ostracized by his colleagues in the
process, but there is really no other option if we need
to set our own house in order. Unfortunately, most
doctors are completely apathetic and couldn't care less,
and this is indicative of the malaise affecting our whole
society at large. This is why we get what we deserve ,
including our politicians.
Unfortunately, the entire medical system has become
morally bankrupt. Large corporate hospitals too indulge
in malpractice by pressuring their staff doctors to admit
a minimum number of patients, as well as to generate
a certain amount of revenue. It is a sad reality that these
hospitals are profit-making bodies, and their primary
concern is going to be their bottom-line. However, they
cannot function without doctors on their staff and

doctors could get together to resist these pressure tactics.
Unfortunately, doctors are often so embroiled in petty
politics that they cannot band together to look after
their own interests.
The pharmaceutical industry is also guilty of shoddy
ethical behaviour. They aggressively push their
products, and entice doctors to prescribe the latest
and most expensive "me-too" pill - irrespective of
whether or not it is in the patient's best interests . This
is true of the medical equipment industry as well,
which wants doctors to buy the latest and newest (
and most expensive) scanner. This means that doctors
then get pressurised into scanning large numbers of
patients daily, whether or not their patients need these
scans, in order to make their investment cost-effective.
These companies are commercial organisations - and
their goal is to maximise their profits , by any means.
If doctors are willing to be bribed, it just shows how
morally bankrupt they are. In fact, a major
responsibility of a good doctor is to act as a gatekeeper
of medical resources, so that he uses them wisely and
efficiently for his patients. Unfortunately this misuse
of medical resources is a worldwide phenomenon - as
documented by the many Medicaid scams in USA.
The Indian system is even sicker than others, and the
real tragedy is that the sufferers are the poor
defenceless masses, who cannot fight back.
Being ethical in your daily medical practice is
straightforward if you remember the three basic
principles of medical ethics: autonomy, beneficence and
non-maleficence. Being ethical simply means respecting
your patient's ability to make his own decisions for
themselves making sure that what you do helps your
patients, and does not harm them. Finally, it all boils

down to the golden rule - treat your patients the way
you would like to be treated yourself.
Our education teaches us what is right and what is
wrong - and even if the rest of the world does what is
wrong we should choose to ignore that and concentrate
on what is right and do it. You have to use your own
conscience as a guide. Remember that we are all human
beings first and last, and that the best doctor is one
who follows his heart and takes an active interest in
helping other human beings . Society gradually does
recognize doctors who are good and ethical. It does
take a long time to build up a good and honourable
reputation but then this lasts for a lifetime. And the
best thing is you also get a good night's sleep.
2481 Succeed Medical Practice: Winning Strategies for Doctors
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Chapter 33
Preventing Burnout:
Manage Stress
If you had to define stress, it would not be far off if you said
it was the process of living. The process of living is the
process of having stress imposed on you and reacting to it.
— Stanley J. Sarnoff
Doctors are used to stress. Wounds get infected,

complications occur and patients die. Medicine has
always been a stressful profession, and doctors have
always had to deal with making life and death decisions
, delivering bad news, working long hours, managing
with little pay , and coping with heavy work loads and
bad working conditions. However, in the past, the
doctor's social status, prestige and income compensated
for their stress. Today, the struggle to attract patients,
the rampant prevalence of unethical malpractises in our
profession; shrinking incomes, declining social status
and the threat of malpractise suits and legal action
have brought many physicians to the brink of burnout.
In the US, physician suicide rates are three times that of
the general population; "burnout" is becoming
increasingly common, and ten percent of physicians
will develop a drug addiction during their lifetimes.
The figures in India may be even worse, but since we
continue to take an ostrich in the sand attitude, we are

blissfully unaware of what the facts are.
Some of the most obvious stressors are the demands
associated with practising medicine today. Everyone
wants to practise in the cities, where the prestige
and glamour is, with the result that competition for
patients is intense, and most doctors in private practice
have to struggle to survive. The unbiquitous cell phone
ensures that doctors are "on call " all the time - they
have no time for themselves. With the introduction of
managed care, patient empowerment and the inclusion
of doctors under the Consumer Protection Act, this
situation is likely to become even worse. Doctors are
finding that they have to answer to many masters -
hospital trustees, patients, courts, third-party payors -
and it's hard to keep so many people happy. Also,
doctors, like everyone else in today's society which is
powered by advertising and marketing pressures to
consume more, want to earn more , buy more, and
spend more - and keeping up with the Patels and Shahs
is hard work.
Fulfilling family and personal responsibilities can
create another set of stressors . Doctors' children often
resent the amount of time the parent has to spend away
from them - and missing school plays or turning up
late for family functions is the norm for most doctors.
Spouses try to be understanding, but it can be hard for
them to deal with an "absentee husband" or midnight
calls and unscheduled emergencies.
Professional boredom can be an additional source of
stress. After a few years of practice, when they start
getting very busy, many doctors find themselves getting
fed up of seeing patients with the same problems day
in and day out. They find they are in a rut, and long for
Preventing Burnout: Manage Stress 1251
new challenges. Ironically, they find that as they become

more established in practice, they have a long line of
patients who are waiting to see them - and they cannot
cope with this demand, because they only have 24 hours
in a day. They try to work harder and harder to try to
keep up, but often find that they can never catch up.
Finally, an extremely important source of stress is
internal. Most doctors have personality traits which
make them much more prone to burnout. They are
often perfectionists, who because of their self-image and
training, need to do everything themselves, and find it
difficult to ask for help or support. Also, in order to live
up to the superhuman image which patients demand
of them, they often act as if they are infallible - an
impossible task which soon takes its toll.
Unfortunately, doctors are better at taking care of
their patients than of themselves, and while doctors are
quick to advise their busy executive patients to "take
life easy", they have not been good at dealing with the
stress in their own lives. While stress is a fact of life,
remember that there are two types of stress: eustress
and distress. Eustress, or positive stress, occurs when
you control your stress. Distress, or negative stress,
occurs when your stress controls you.
Doctors who find themselves experiencing
continuous job-related stress could be headed for
"burnout," the popular term used to characterise loss
of physical, emotional and mental energy. If ignored
or denied, the consequences can be serious - not only
for the doctor, but also for his family, patients and
colleagues. The symptoms of burnout are as varied as
the sufferers. Some doctors become angry, blowing up
at anyone who crosses their path - including nurses,
patients family members and other physicians. Some
become quiet, introverted and isolated, which can

indicate the start of a serious depression. Others manifest
burnout by under- or overeating , abusing alcohol or
other drugs and using mood-altering substances. Some
doctors work more because it's the only thing they know
how to do - they feel that doing more for their patients
helps their patients, so they think it will help them, too.
Others become chronically late or psychologically
absent. Burntout physicians become impaired
physicians. Doctors who drink too much, work too hard,
take illicit drugs, become depressed, get ill (the list of
"impairments" because of burnout goes on and on) and
do not do anything about it , are not only harmful to
themselves, but also harmful to others. Missing a
diagnosis or mismanaging a patient because a physician
is too stressed adds to the physician's sense of
incompetence and lack of control - and a stressed-out
physician is a lawsuit waiting to happen.
Unfortunately, doctors are not very good at
recognising the symptoms of burnout in themselves
and the problems are multiplied when they are so
impaired that they refuse to acknowledge they have a
problem. It is sad but true that while it is easy to
recognise problems in other people it is much harder
to recognise them in ourselves - and hardest of all to
do something about them. While family and friends
are often the first to notice the warning signals , most
are not sure how to help - after all, doctors are the
ones who help others, aren't they ? How can they
need help themselves ? Colleagues , because of
professional pride, enter the conspiracy of silence and
try to "help" their impaired friend by covering up for
him - but end up just making the problem even worse.
The burnt out physician can find it difficult to ask for
help - and is often trapped and isolated. If you feel

your colleague is getting burnt out, make sure he seeks
help. Getting help does not mean he is a a 'bad' doctor-
it will just make him a better one.
The Best Defense
Since prevention is better than cure, how can you avoid

burnout ? Stress is inevitable , but the good news is that
you can learn to manage it. Most of these stress
reduction tips are applied common sense , but you need
to have a plan of action in order to implement them.
Learn to take care of yourself. Doctors are good at
taking care of everybody but themselves. Doing
something good for oneself is a difficult concept for
doctors to accept, and many feel that somehow they're
failing as doctors if they want to take time out and be
good to themselves. The medical profession is up on a
pedestal - and the work ethic is so strong, that many
doctors feel they are expected to sacrifice their life ( and
their whole family's life ) for their profession . Many
perversely take pride in the time they devote to their
patients to the exclusion of all else.
So what should you do? For starters, practice what
you preach - eat right, get sufficient rest and exercise
routinely. Pay more attention to your body's signals of
stress. Learn to pinpoint the sources of stress and
practice stress-reducing strategies, such as yoga,
progressive relaxation techniques, breathing exercises
and meditation.
Balance your life on a priority basis. One of the best
ways to arm yourself against burnout is to have a rich,
fulfilling life outside the clinic. Don't let medicine become
both your wife and mistress - look for satisfaction away
from work. Achieving balance can be a process that
takes considerable time and effort. Just like you cannot

get fit by going on a diet and frantically exercising for
a month, you have to make life-long decisions about
how you will spend your time. You need to learn what
to say "No" to - and feel good about your answers.
Since it is difficult to strike such a balance alone, many
physicians benefit from having a mentor or coach to
provide insight and inspiration. A wise and
understanding spouse can be a bedrock of support in
this endeavour.
Learn to cut back on the routine work. If you find you
are getting bored of doing the same procedures day in
and day out, re-think your professional goals. After all,
taking out the 500th appendix can get to be very
monotonous (unless it belongs to the Chief Minister's)
You can choose to reduce your work load, or accept
only patients who have complex problems which
challenge you. While many doctors are reluctant to turn
patients away, because they are scared that a reduced
work-load will translate into a reduced income, the fact
is that if you refuse to do work you don't like, you will
find yourself attracting the work you do like - and this
will actually improve your efficiency - and your
bottomline as well.
Develop a strong support system. Doctors have a hard
time reaching out for help because they do not like to
feel they cannot cope with their own problems. Support
from other doctors ( who have "been there, done that"
and can empathise with what you are going through)
is extremely helpful. Physician peer support groups,
where a group of colleagues meet on a regular basis
and develop the security to share feelings and concerns
(about patients, work, family problems, or anything
else) can greatly reduce a sense of isolation and enhance
a sense of well-being.
There are many do's and don'ts, and most are easier
said than done. However, you can change your work
habits if you resolve to do so.
DO's:
Doctors who enjoy their work and find meaning in
it, have high self-esteem - one of the best buffers against
burnout. When you work, work hard. But also learn
to work smart, delegate and manage your time well, so
you find time to play as well. Remember, all work and
no play makes Dr Jack a dull man.
Learn to rest. Keep your evenings and weekends
free to recharge your batteries. Allow yourself to take
time for your own personal self care. After all, how can
we help others if we can't help ourselves?
Get regular exercise. Spend money by joining a gym
or hiring a personal trainer; this will ensure that you
actually do work out. Even if you go twice a week,
you'll feel mellower and more energetic. Hike, play
tennis, or engage in other physical activities that give
you pleasure.
Learn to practise voluntary simplicity. The secret of
contentment is in wanting what you have, not in having
what you want.
Release yourself from unrealistic expectations. It's not
true that the harder you work, the better your work.
Remember that if you are good to yourself, you will
end up being better to your patients.
Develop your hobbies and interests. Painting,
collecting, or anything you always wanted to do but
never got around to are all good starts.
DONTs:
Don't let petty annoyances sap your energy, don't
sweat the small stuff.
Don't try to do "everything." Understand your limits

and don't try to perform all procedures. Don't try to
treat medical problems which are beyond your
competence; learn to refer or call for a consultant.
Don't run around from clinic to clinic, hospital to
hospital and spend half your life commuting - this is a
waste of your energy and productivity. It's far better to
find a niche and focus on this, and then allow your
patients to come to you rather than go hunting for
them.
Life is short and the practice of medicine is getting
more stressful. You can only do yourself and your
patients a favor if you balance your life and prevent the
scars of "battle" from wounding you permanently.
However, even burnout can be a gift, and as Hemingway
said, "We get stronger in all the broken places." If we
learn to take time to enhance our relationship with
ourselves, family and friends, even burnt out physicians
can renew themselves, making themselves better doctors
- and better human beings.
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Chapter 34
The Impaired Physician:

Healing the Wounded Doctor
A gem cannot be polished without friction, nor a man

perfected without trials.
— Chinese Proverb
A doctor's life is extremely stressful, and doctors have

one of the highest suicide rates amongst professionals.
Some doctors start abusing drugs or become alcoholics
when they cannot cope with the stress they are under.
However, the medical profession tries to hide these
impaired physicians, and they usually remain medicine's
dirty little secret. This is because most doctors would
rather pretend that such problem doctors do not exist.
However, pretending that there are no problem doctors
just makes the problem even worse for everyone: for
the doctors who are having problems since they have
nowhere to turn to for help; for their patients , because
impaired doctors provide inadequate medical care and
can cause harm; for the profession's public image when
these problem doctors come to light; and for society at
large which loses faith and confidence in the medical
profession.
An impaired physician is defined as one who is
"unable to practise medicine with reasonable skill and
safety to patients because of physical or mental illness,
The Impaired Physician: Healing the Wounded Doctor 1259
including deterioration through the aging process or

loss of motor skill, or excessive use or abuse of drugs,
including alcohol." Impaired doctors are not uncommon,
and studies show that ten to fifteen percent of
physicians will have a problem affecting their ability to
practise medicine at some point in their careers. In
fact, such a high incidence should hardly be surprising
because many of the personality traits which cause
doctors to choose medicine as a profession also
predispose them to abuse drugs. These include:
compulsiveness, conscientiousness, and the need to
retain control over their feelings. Easy access to drugs
of abuse just compounds the problem.
What is really remarkable about the problem is not
that it exists, but rather that we refuse to discuss it
publicly. The major difficulty in solving the problem
of impaired doctors is the conspiracy of silence which
surrounds them- and most colleagues of a problem
doctor often refuse to acknowledge that something is
wrong, even when faced with evidence that should
arouse suspicion: alcohol on the doctor's breath,
dishevelled appearance, an explosive temper, repeated
failure to return patient calls, or consistent tardiness.
Why is it so hard to report a problem doctor?
Doctors are groomed to think of themselves as a
breed apart, and this notion can lead to a dangerous
arrogance. Doctors have always been expected (and
many treat themselves) to be infallible - only one step
below God. This is why many doctors adopt denial as
a defense mechanism when they feel one of their
colleagues is malfunctioning. Denial isn't lying - it's an
unconscious defense mechanism used to avoid facing a
fearful truth. For a doctor to acknowledge that a
colleague has a problem means the entire profession is
vulnerable to that problem - and it also emphasizes

your own vulnerability.
Also , the professional bond is so strong, that doctors
do not want to report problems in their colleagues -
they do not want to be considered to be whistleblowers,
because they then run the risk of being ostracized by
colleagues and the medical community.
What are the clues which should lead you to suspect
a colleague may have a problem ? These are usually
fairly obvious - once you stop taking an "ostrich in the
sand " attitude. A physician who is impaired will go
through subtle personality changes as the disease
progresses. Mood swings will occur, ranging from
irritability, outbursts of anger, and paranoia to sudden
euphoria and hyperactivity. He may be frequently
absent; behave badly with staff and patients; give
inappropriate orders; and his handwriting may
deteriorate. Physical symptoms of chemical dependence
include declining personal hygiene, multiple physical
complaints, frequent hospitalization or visits to
physicians, and accidents. The physician may withdraw
from involvement in community activities and display
embarrassing behavior at parties.
Unfortunately, many of us compound the problem
by inadvertently enabling it. Many hospital doctors
employ a strategy of protective support towards their
impaired colleague, and quietly shift work away from
him and do it themselves. This strategy may protect
his patients, but it's of no help to the physician, who
should be regarded as a patient himself—especially if
he has a chemical dependency. Ignoring an addiction
problem is a death sentence.
So what can you do if you suspect a friend has a
problem ? Please don't ignore it or blame him for it -
he may be crying for help, and may not know where

to turn. You can have an off-the-record session to let
him know that there are concerns about him, and that
you are concerned for him. Such a chat allows you to
gather more information, assess whether the doctor
realises he has a problem, and, if appropriate, urge
him to seek help.
In order to cope with this ever-increasing problem,
many developed countries have Physician Health
Programs which diagnose impaired physicians, treat
them or refer them to treatment programs and monitor
them. The purpose of these programs is rehabilitation,
not witch-hunting. When they receive a report on a
potentially impaired doctor, they begin a discreet inquiry.
They assess the reliability of the reporting sources, gather
corroborating data and wait till they reach a critical
mass of information before they take action.
The best PHPs have been remarkably successful in
helping impaired physicians. The secret of most effective
PHPs is a careful monitoring program which includes
1) random urine or blood screens for drug testing , 2)
written reports from counselors, 3) self-reports written
by the physician in recovery, and 4) written verification
of attendance at self-help and support group meetings.
Doctors who relapse either are retreated, subject to
intensive monitoring, or reported to their medical
councils for disciplinary action in order to protect
patients.
Indian doctors need PHPs too, and I hope that the
Indian Medical Association will take the lead and set
these up. Till then, you can take the initiative, and set
up a peer assistance committee in your own hospital or
medical society. Peer assistance committees consist of
senior respected doctors (retired doctors can be excellent

members because they often have the required time,
perspective and experience) who are interested in
helping their colleagues. However, serving on such a
committee can be very demanding, because working
with problem physicians can be an extraordinarily
convoluted and difficult process. Psychiatrists who have
a special interest in treating addiction problems can
provide the needed technical expertise. Since
impairment coincides with an increased risk of
professional liability lawsuits, hospitals should have a
vested interest in setting up these committees, since
they are an integral part of risk management and
preventing malpractice problems. (It is a sad
commentary on the state of the Indian medical
profession today , that no Indian hospital has such a
service for its doctors.) These committees also should
be proactive in fostering public confidence in the
organised practice of medicine, because they assure
society that professional standards are being seriously
adhered to and public well-being is sincerely served.
Peer assistance committees, when working effectively
and efficiently, provide education and preventative
programs, and may identify disorders before impairment
develops - after all, early identification, treatment, and
rehabilitation of physicians is in everyone's best interests
. Intervention should be a well-planned, structured
process in which the impairment of the physician is
dealt with in a caring, objective, non-judgmental manner
so that the physician receives a professional evaluation .
The key to a successful committee is the authority to
effectively act on received information, verify its
accuracy, and seek additional information as necessary
to help determine a proper course of action. The mission
of a Peer Assistance Committee is to help the doctor,

and the primary role is physician advocacy. These
committees have to be completely confidential, so that
doctors feel safe reporting their colleagues - and
impaired doctors themselves should be comfortable
asking for help , when they feel they need it for
themselves. You can find more information on how to
help impaired doctors by going through the valuable
guidelines provided by the Texas Medical Association at
its website, http://wzow.texmed.org/cme/phn/ifp/default.asp .
The plight of the impaired physician has been
described very eloquently by Abraham Verghese, in his
moving book, The Tennis Partner. We need to learn to
take care of wounded doctors- they are our friends ,
colleagues, mentors, and classmates. Timely assistance
can help to save their careers, patients, family - and
even their lives - and who knows which of us will need
help in the future ourselves ? If we don't take care of
each other, who will ?
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Chapter 35
Professionalism in Medicine:
Striving for Excellence
Is it not also true that no physician, in so far as he is a

physician, considers or enjoins what is for the physician's
interest, but that all seek the good of their patients? For we
have agreed that a physician strictly so called, is a ruler of
bodies, and not a maker of money, have we not?
— Plato
Doctors are proud that they are members of the most

highly respected profession. They have traditionally
always been held in high regard, but this status is now
under siege. There are many reasons for this
" deprofessionalisation" of medicine, and doctors finds
they are threatened today by many forces: technology,
corporatization, specialisation, failure, and greed.
Technology: While modern technology is very
glamorous and allows physicians to bask in success
stories which are highlighted in the media, the same
technology also reduces the physician's role to that of
a mere provider of healthcare services, so that the
physician is perceived as more of a technician than a
professional. Technology can depersonalise medicine
and "deprofessionalise" a physician.
Corporatisation of medicine: The advent of profit making
corporate hospitals in India is transforming medical care
, so that it is now becoming part of what Arnold Reiman

called "the new medical-industrial complex" where
patents and profits are more important than patient
care, the doctor-patient relationship or bedside manner.
Patients now choose medical care like they select their
hotels - by brand name, rather than the competence of
the doctor.'
Specialisation: Superspecialisation and subspeciali
sation have become the norm in medicine today.
Specialists often have no personal relationship with the
patient, so that most specialists now identify patients
by their disease , rather than as human beings who
happen to have a disease. Patients in corporate hospitals
are often shuttled from specialist to specialist without
any coordination or continuity of care, so they often
end up feeling like cattle - and this breeds discontent
and unhappiness.
Limitations of modern medicine: Patients are now
becoming aware that doctors don't have cures or magic
bullets for most illnesses. The doctor is no longer seen
to be omnipotent and, with the realisation that there
are limits to what medical science can do, there is now
increasing interest in alternative systems of medicine,
further threatening the exalted status of the doctor.
Greed: When patients are bombarded with accounts
of gross negligence, incompetence, greed, and fraud on
the part of doctors in the media, they lose trust in their
physicians. Each newspaper article which describes
babies being sold, racketeering in kidneys or scams in
MDBS examinations digs a deeper grave for all doctors'
reputations. " Ask not form whom the bell tolls - it tolls
for thee".
Physicians the world over are now realising that
their professional status is under threat, as a result of
Professionalism in Medicine: Striving for Excellence 1267
which many are now organising to restore the

professionalism of physicians. The Medical Council of
India has also issued an updated version of its Code of
Medical Ethics to help restore the lost luster of the
profession.
We need to remember that medical professionalism
rests on three pillars : expertise, ethics, and autonomy.
Expertise derives from a body of specialised knowledge
and skills whose utility is constantly invigorated by the
results of research; ethical behaviour flows from a unique
combination of values and standards, where doctors
are expected to put their patient's interests ahead of
their own; and autonomy means that society is willing
to allow the profession to function independently
because it expects the profession to police itself. Our
autonomy also rests on three claims: firstly, that there
is such an unusual degree of knowledge and skill
involved in medical work that it can only be regulated
by doctors; secondly, that doctors are responsible and
may be trusted to work conscientiously, without
supervision; and, thirdly, that the profession will
regulate itself by taking appropriate action when
individual doctors do not perform competently or
ethically.
Autonomy is given on the understanding that
professionals will put the welfare of both the patient
and society above their own, and that they will be
governed by a code of ethics. This is why professional
self regulation is key to the concept of an "independent
profession." However, for self regulation and
professional independence to continue, patients must
feel able to trust their doctors , and society must feel
able to trust the medical profession. We must become
more transparently accountable for our performance and
show, in ways that the public can understand and

relate to, that self-regulation really works.
Today, however, society feels that the profession has
done a very bad job in regulating itself. The Medical
Council of India, the medical profession's apex body,
has itself become a hotbed of corruption. Many
laypeople feel that doctors are bound in a conspiracy of
silence in which they refuse to testify against the
negligent actions of other bad doctors. This is one of
the reasons why the government brought doctors under
the purview of the Consumer Protection Act so that
they could become more answerable for their actions to
their patients.
Shamefully, matters today have come to such a sad
pass that doctors are being compelled by law to declare
that they will not perform illegal acts. Gynecologists
are being asked by the government to prominently
display boards which say that fetal sex determination (
an act which has been illegal in India since 1997 after
the passage of the PNDT Act) is not performed in
their clinics. We all are to blame for this sad state of
affairs, because we have done such a poor job of
policing ourselves . A few bad sheep give the entire
profession a bad name, and because we turn a blind
eye , we make a bad situation even worse. As the
cancer of kickbacks and "under the table " payments
spreads, the practise is pardoned, condoned, and
tolerated , until it finally becomes the norm - so that
doctors who are not corrupt are considered to be
abnormal.
Remember that each individual doctor-patient
interaction allows you the opportunity to shine as a
professional - make the most of it. Being a professional
does not mean being cold and impersonal . In fact, a
doctor who is a good professional has a very close

personal relationship with his patients, because he
knows that he is in the service industry, where
everything is based on personal relationships.
The best way of being a good professional is to follow
the golden rule - do unto others as you would have
them do unto you. If you put yourself in your patient's
shoes, you will always know how to behave. It's helpful
to remember what you go through when you need to
hire a professional, such as a lawyer or an accountant.
Retaining a professional requires you to put your affairs
in someone else's hands. You are forced into an act of
faith, and while you can research their background and
check their technical skills, when the final decision on
whom to hire comes, you must ultimately decide to
trust someone, which is never a comfortable thing to
do. What you want is someone who you can trust will
do the right thing- and so do your patients.
So how do you get your patients to trust you ? By
proving that you deserve their trust - and you need to
earn this, by being generous with your knowledge,
showing your patients that you care; respecting their
time and fulfilling your promises. The hallmark of
doctors who have been elevated to the status of being
treated as trusted advisors by their patients is that the
doctor places a higher value on maintaining and
preserving the doctor-patient relationship itself , rather
than on the outcome of the current consultation.
Establishing a history of reliability is one way to build
trust. For example, if you tell the patient you're going
to call with lab results, make certain that you do just
that. Doing this the first time will show your patients
that they can count on you. Doing it again and again
will build trust. To win your patient's trust, you have to
behave as a professional - someone who will place the

patient's interests before his own - so that both of you
benefit in the long run. This is why senior doctors
valued their reputation so much - it was built on the
foundation of a lifetime of hard work - and even
though it is intangible, it represents the fact that
patients have trust in you.
The trust equation , as defined by David Maister, is
simple.
T = C + R + l/ S, where
T = Trustworthiness
C= Credibility
R= Reliability
I - Intimacy
S= Self-orientation
Credibility = Can your patient trust what you

say ?
Reliability = Can he trust your actions, confident
that you will act honorably ?
Intimacy = Is he comfortable discussing his
feelings and emotions with you ?
Self-orientation = Can he trust your motives,
knowing that you care about him, and will act in
his best interests ?
If you want to be respected as a professional, it is

also important that you look like one. Personal grooming
is vitally important, as is your bedside manner.
Remember that patients examine you in great detail,
and the way you carry yourself is very important.
You must look successful to convince your patients
that you are - and the packaging can be as important
as the product. Many patients say they feel better just

after seeing the doctor , which is you need to take time
and trouble over the way you look. Not only should
you be fit and not smoke, you should also be well-
dressed and well-groomed. A sloppily dressed doctor
can be invisibly signaling to his patients that he may be
sloppy in his operative technique as well. For example,
wearing a smart suit can help to enhance your image -
and if it helps your patients to get better sooner, surely
this is a worthwhile investment.
Remember that professional status is not a doctor's
inherent right, but rather a right which is granted by
doctors to society. Its maintenance depends on the
public's belief that physicians are trustworthy, and to
remain trustworthy, doctors must meet the obligations
expected by society. Professionalism should be taught
at all levels of medical education , so future generations
of doctors will still be proud to be a part of this ancient
and respected profession. Remember that if you are a
good professional, you will become a trusted advisor to
your patients, so that not only will you be their doctor,
you will also become their friend, philosopher and
guide - enriching both their life as well as yours.
Chapter 36
Physicians as Leaders
I start with the premise that the function of leadership is to

produce more leaders, not more followers.
— Ralph Nader.
Doctors have always been highly regarded, and are

considered to be the elite of society. The community
looks upto them, and they are expected to be role models
which others can emulate. Thus, while one would expect
many doctors to be leaders, unfortunately, very few
are. Names like Dr Albert Schweitzer, Dr Jivraj Mehta,
and Dr Bernard Lown ( who founded International
Physicians for the Prevention of Nuclear War, which
was awarded the Nobel Peace Prize in 1985) spring to
mind, but most of us would be very hard-pressed to
think of even a single contemporary Indian doctor
who could legitimately be considered to be a leader.
Why is this so ? Is it because Indian doctors are too
busy taking such good care of their patients, that they
cannot spend any time or energy in providing leadership
to the society they live in ? This is too charitable an
explanation. The sad truth is that the entire Indian
medical profession today is headless. Our medical
societies and associations are renowned for being
corrupt - and it is a matter of lasting shame for all
Indian doctors that the chief of the Medical Council of
Physicians as Leaders | 273
India has been locked up on charges of corruption by

the Supreme Court. What is even worse is that the
Court has chosen to appoint a non-physician to head
India's premier medical council.
Why have things come to such a sad pass ?
Unfortunately, most leading doctors are engrossed in
petty medical politics and pulling each other down, like
the legendary Indian crab who will ensure that none of
the others crabs in the basket will ever be able to crawl
to their freedom because he will pull them back to
captivity.
The entire profession now has a tarnished image.
Doctors are seen to be greedy, corrupt and unethical ,
and few doctors are proud to be doctors anymore -
which is reflected in the fact that so few want their
children to follow in their footsteps. After all, if leading
doctors take cuts and kickbacks, what is the image of
doctors in society going to be ?
We need to get our act together, and we can play a
leadership role if we want to. Not only is this our right,
it is also our responsibility. After all , we occupy a
privileged position in society, which has given us a
highly subsidised education, prestige , and a
comfortable income and we need to make the most of
these privileges to fulfill our role as responsible citizens.
After all, if doctors will not become leaders, who will
? We are educated, articulate , affluential , respected ,
and deal with humans and their problems daily - I am
sure the average doctor, would become a better leader
than the likes of our present leaders, such as Laloo
Prasad Yadav. We wield considerable personal influence
because of our one on one intimate relationship with
our patients - and doctors who have powerful patients
can have a powerful impact on society. Unfortunately,
many of us use this influence to further our own petty

ends rather than thinking of societal good. We need to
leverage this ability to provide leadership to society.
Unfortunately we have abdicated this responsibility
even in our daily professional life. In private hospitals,
doctors kow-tow to the trustees, and in government
hospitals, they scrape and beg before the babus and
politicians, to get the best postings . Far from being
leaders, we are so disunited and fragmented that even
illiterate workers have more powerful unions than
doctors do.
How does one go about becoming a leader ? How
do leaders become leaders ? Is it in the genes, charisma,
education, wealth, luck, training, experience ? It's
actually a little bit of all of these - leaders have
leadership skills , which all of us can learn ! There are
basically 4 groups of skills - personal skills; interpersonal
skills; team skills and organisational skills.
The Leadership Diamond created by Dr
Koestenbaum provides a useful model of how to think
like a leader. The Diamond describes four
interdependent leadership abilities-ethics, vision,
Courage and Reality, which are a leader's inner
resources. Their inter-relationship determines the shape
and size of the space within the Leadership Diamond,
which in turn describes an individual's leadership
capacity, called "Greatness."
In the Leadership Diamond, ethics refers to the
importance of people and integrity. It means caring
about people; being sensitive and of service to them;
and behaving in accordance with moral principles.
Vision means being creative , applying analytical skills,
thinking big; looking at situations in new ways; and
being inspirational. Courage is defined as taking charge,
using power wisely, acting with sustained initiative;
Physicians as Leaders I275
ETHICS
Be Service
REALITY
Have No Illusions
managing anxiety, and being free and responsible.

REALITY refers to a no-nonsense approach to facing
life without illusions; relying on data that is factual
rather than emotional; and being tough, task-oriented
and results-focused.
All of us are already leaders in some way - either in
our clinic, family, hospital, or medical association (some
are good leaders, most are indifferent and some are
terrible.) We just need to enlarge our perspective and
think big, so we can strive towards achieving
greatness - accomplishing a big goal which is worth
aiming for.
In order to become a leader, you first need to take
control of your own life. Start by working backwards .
Think about your epitaph - what do you want to be
remembered for , after you are dead and gone ?
Everyone has areas of special interest, which they are
enthusiastic and excited about - something which "turns
you on" . Treat this as your niche and then focus on
it. The trick is to start small, and then grow. Visualize
this as a T-shaped model of your life and spend the

first few years in developing depth in a specialised
area - the vertical stem of the T. Once you are
acknowledged to be a leader in this focused field, you
can then expand your horizons and start to broaden
your area of influence - start working on the horizontal
stem of the T. The depth of knowledge which you
have picked up in a specific area will prove to be
immensely valuable when you apply it to other fields,
since leadership principles remain the same in all areas.
Just like executives are taught to plan their career ,
doctors too need to plan their life, if they wish to become
leaders. If you do not have a goal you will never be
able to achieve it. The commonest mistake many doctors
make is that they focus all their energies on building
their practice so that all they accomplish in their life is
treating more and more patients. They become busier
and busier doing the same thing they have been doing
all their life. While patient care will always be your core
competence, after some time this is likely to lead to
boredom, and repetitiveness stifles personal growth.
Life has stages, and you need to progress from one
stage to the next . While most of us make the transition
from being a medical student and then a resident
(education) to becoming a doctor (professional work)
with ease, because this is performed automatically and
is expected of us, few of us are able to think of moving
on the next step, with the result that we often remain
stuck as competent doctors all our lives. This is why so
many middle-aged doctors burn out when they are 40
or 50. They have reached the peak of their plateau and
do not know where to go next, so that they never
achieve the leadership positions they are so capable of.
Traditionally, doctors have continued doctoring till they
Physicians as Leaders 1277
reached their graves, but this is no longer true, and

fortunately, there are many more leadership options
available today. While it is true that making the
transition involves a certain element of risk, the ability
to take risks is a key skill every leader needs. In fact,
not taking the risk is sometimes the biggest mistake
doctors make - and then regret for the rest of their
lives.
The final leadership platform is the arena of politics
where you can play a leadership role on a much larger
scale. However, for most doctors, politics remains a dirty
word, and a popular joke says politics is derived from
poly, meaning many, and from ticks, signifying blood
sucking parasites. While many of us enjoy complaining
about the poor quality of our leaders, and talking about
how corrupt and inefficient they are is a popular topic
of party conversation in India today, we cannot afford
to take such an ostrich-in-the-sand attitude anymore.
The government is now passing new rules and laws
which curtail medical autonomy and this bodes ill for
the future of our profession. We have no choice but to
become politically active if we want to regain control
over our professional independence.
An excellent example of the increasingly intrusive
government policies in healthcare is the recent
amendment to the PNDT (Prenatal Diagnosis and
Treatment) Act. This amendment is a major slap in the
face of all medical professionals, because it treats all
doctors as potential criminals, who need to be constantly
policed. Thus, the Act mandates that all clinics which
perform ultrasound scans should prominently display
a sign saying, " Fetal sex determination not performed
here". This is highly demeaning and is an insult to all
doctors. Why should doctors have to put up a sign
which says they do not perform an illegal act ? Using
the same analogy, all police stations should also have

a sign
saying , "Bribes not taken here “ ! To compound the
insult, the Act has created an avalanche of non
productive paperwork, because all ultrasound scans
performed during pregnancy need to be reported. Even
worse, this Act demands that we compromise our
patient's confidentiality, because the name and address
of every pregnant woman undergoing an ultrasound
scan (which today has become a routine procedure)
should be reported to the government.
The fact that such a poor piece of legislation was
passed in the first place makes for an interesting story,
and underlines how powerless doctors have become in
the face of vested interests. After the Census 2001 figures
were released, an NGO moved a public interest litigation
in the Supreme Court claiming that the decline in the
sex ratio was a result of fetal gender determination
because the government was not implementing the
PNDT Act properly. In response to the Supreme Court
directive, the Health Dept secretaries were hauled up,
and they promptly bent over backwards to comply.
Unfortunately, bureaucrats only understand paperwork,
and the Act was passed uncritically because it appears
to be designed to protect the girl child. In reality, this
amendment encroaches on our patient's reproductive
rights because it prevents them from using technology
to plan their family. Unfortunately, no one has spoken
out against it, and sadly, future generations will pay
the price. What is to stop the government from further
restricting reproductive freedom by implementing an
even more coercive population policy which enforces a
one-child or two-child norm, as suggested by former
Union Health and Family Welfare secretary, A.R. Nanda?
Doctors are obliged to protect their patients' best

interests and we need to stand up for our patients. We
do not function in a vacuum, and we need to take a
leadership role in shaping medical policies which affect
public health and private medical care for the sake of
our patients - and for our sakes as well. This is an
opportunity we need to seize, and while individually
there is little we can do, together we can command
respect and clout. An excellent example of our collective
power is the fact that a surgeon kidnapped recently in
Bihar by goons was released only after the members of
the Indian Medical Association of Bihar jointly
threatened to strike.
We need to learn from doctors in the U.S. Predatory
insurance contracts, HMO cost pressures, burdensome
government regulations, and the threat of unjust
malpractice suits have galvanised them into organised
political action. They can no longer afford apathy since
their survival is now at stake, which is why they are
playing an increasingly active role politically. They have
realised that if they wish to continue to practice quality
medicine , they have to get legislators to pass doctor
friendly and patient-considerate reforms. Doctors have
started to lobby for their rights, and many medical
societies are active and alert in this area. There are
none so blind as those who will not see, and if Indian
doctors continue to turn a blind eye, we will soon find
ourselves in the dire predicament the medical
profession in the U.S. does today. American doctors
are so buried in paperwork today in order to meet
legal guidelines that many are choosing to retire at the
age of 40, because they cannot put up with the irksome
burdens any more. The malpractise crisis has taken
the joy of medicine away, and if we don't watch out,
the three devils of modern medicine in the U.S. today

- stifling insurance contracts, HMO cost squeezing
techniques, and an avalanche of governmental
regulations and paperwork-are all likely to become a
reality in India in the next few years in response to
market pressures which shape the Indian economy as
we become part of the global economy.
Healthcare has become an important issue in India
today. The government is finally seeking to play an
active role in ensuring our population is healthy because
it realises that our people are our most important
resource, but because of poor health care, they cannot
reach their potential. Unfortunately, though this is such
a vital area in which doctors have so much expertise,
they have provided precious little input and this is
sad. We need to take a leadership role, and by becoming
politically active, we can influence issues beyond medical
practice, such as prescription-drug costs and universal
medical coverage. We must be involved in the process
that governs the way we practice. Isn't it better to be a
player than a victim? We need to play an active role in
ensuring that we take only the good from the West,
and leave out the bad, so we can capitalise on our
strengths. Government policies that threaten the quality
of health care are often developed by officials who aren't
knowledgeable about medicine. Doctors who hold
public office can defend our profession and protect the
patient-doctor relationship.
Doctors are well-educated, and because they are in
constant touch with their patients, they are aware of
ground reality. They are highly respected members of
society, and are likely to become much better leaders
than the present tribe of politicians, many of whom are
corrupt and semi-literate. But can doctors become good
politicians ? Isn't this role better left to others ?

Interestingly, there is a strong tradition of doctors
entering politics. Our past history provides many role
models of doctors who have become excellent leaders,
and a shining example is Dr Jivraj Mehta, the Dean of
Seth G S Medical College, who later became the Health
Minister of Bombay state.
It's also worth recollecting that the very first article
in the very first issue of the largest selling medical
journal in the USA, Medical Economics (October 1923)
was titled The Place of the Physician in Politics." The
author was Dr Royal S. Copeland of New York, one of
two physicians in the US Senate. Copeland argued
that doctors, thanks to their experiences in caring for
patients in the cities and countrysides of America, had
the broad vision required of a public servant. Copeland
acknowledged that a doctor would be reluctant to leave
his profession for a different calling. However, when
he does venture into this field, his education, his
experiences, his human contacts, his broadened
sympathies and intimate knowledge of the endless needs
of the human family must make him a useful and
active agent for the good of the nation. He knows the
heart of humanity.
Organizing doctors, the saying goes, is like herding
cats, and because of their fiercely independent spirit,
Indian doctors have failed to play an active role in
healthcare policies, because they are not organized or
united. The tragedy is that we often waste our time and
energy fighting each other. While many doctors are
politically active , they are usually active only in medical
politics , where they squabble over promotions, medical
society chairmanships, and grants. What a waste !
Many doctors are now sitting for the IAS

examination to become IAS officers, because they want
to take a more active role in running the country.
Doctors often top these examinations, and they do
become good bureaucrats, because they are trained to
think scientifically, search for the truth, and to fight
for their patients and to serve them. As an aside, it's
interesting to note that politicians want to stop doctors
and other professionals from applying for IAS jobs,
because they are worried that it will be difficult for
them to coerce educated public servants into doing
their bidding.
The best way is to start small - apply for a
corporator's seat, for example. Unfortunately, many
doctors have huge egos , and expect to get elected just
because they are doctors. Ground reality can be
unflattering and you'll have to learn humility - don't
expect to become health minister just because you are
a doctor. Fortunately, you may not have to indulge in
corrupt practices to get elected, because good doctors
have lots of good will in the community. If nothing
else, trying to get elected will teach you the art of
negotiation and compromise. Don't expect other
doctors to be supportive - and even your family
members may feel you are crazy to leave the security
and comfort of your medical work. While it is true
that becoming politically active may cut down your
medical practice , you may find that your patients
may be your most loyal supporters.
We all need to evolve with the passage of time , as
Shakespeare so eloquently described when talking about
the seven stages of man, and joining politics allows a
doctor to do so. Your sphere of influence grows, so
that your "stage" is then no longer your clinic or your
hospital, but the city or the state - and your patients

are then no longer just the ones who come to your
clinic, but rather the entire population. You start to
think on a much larger scale so that your potential for
doing good also becomes much larger. In India, poverty
remains the leading cause of ill-health, and as Rudolf
Virchow , the father of pathology (and a member of
the German Parliament ) wisely said many years ago:
Medicine is a social science and politics is nothing

else but medicine on a large scale. If medicine is to
fulfill her great task, then she must enter the political
and social life. Since disease so often results from
poverty, the physicians are the natural attorneys of
the poor, and the social problems should largely be
solved by them.
Doctors will make far better leaders than the corrupt

politicians we have today. Because they are educated,
financially well off and able to think scientifically, they
will be able to make decisions which are in the best
interests of society, rather than only looking out after
their personal selfish interests. Unfortunately, most able
doctors are so devoted to their profession , that they
hesitate to take on the larger work of helping to heal
the ills of our nation. However, we owe this to our
colleagues, to future doctors and to our patients.
You need to aim for a goal which inspires you. Be
proactive and learn to "think out of the box " - or get
ready to be left behind . Trust yourself - you are well
educated, resourceful, creative and capable . However,
you might need help to plan your next step, because it
is still not the traditionally accepted thing to do in India.
Fortunately, today there are professional coaches
available, who will help you plan your life. A number of

excellent websites (http://www.physiciancareerventures.com)
and books (Learning to Lead: A Workbook on Becoming a
Leader by Joan Goldsmith) are available to guide you as
well.
Be willing to go off the beaten track . Follow your
own heart - and others will follow you, so you can
become a leader, with the ability to influence far more
people than you could as a doctor.
Chapter 37
Spirituality in Patient Care:

Looking at the Bigger Picture
The possession of knowledge does not kill the sense of wonder

and mystery. There is always more mystery.
— Anais Nin.
While doctors are usually very good at taking care of a

patient's physical needs , we usually neglect to minister
to our patient's desire for spiritual comfort. This is a
deficiency we urgently need to rectify, because a
patient's spiritual health can have a significant impact
on how they cope with their illness. The idea that
spirituality can help to heal is very old, and traditional
cultures have always relied on medicine men, witch
doctors and shamans to use spiritual interventions in
order to cure illnesses, often with remarkable results.
After all, it is through both the channels of medicine
and religion that humans have grappled with the
common issues of suffering, despair, and death , when
confronted with an illness.
Since the topic is so unfamiliar for most doctors ,
let's first start with some definitions. Unfortunately, even
defining spirituality is difficult, because it is such a
nebulous and intangible topic, and has a different
meaning for everyone. While all of us are spiritual
Spirituality in Patient Care: Looking at the Bigger Picture I 287
beings, many doctors are uncomfortable talking about

spirituality because they consider it to be too unscientific,
and often confuse it with religion. The word spirituality
comes from the Latin root spiritus, which means
"breath"—referring to the breath of life. Since a "hard"
definition is impossible, let's settle for a "soft" one-
spirituality is the way you find meaning, hope, comfort
and inner peace in your life. Spirituality involves
opening our hearts, connecting with others, and
cultivating our capacity to experience awe, reverence
and gratitude. Many people experience spirituality
through religion and each religion attempts to help
ask and answer mankind's spiritual questions. Each
religion has developed a specific set of beliefs, teachings
and practices, but in contrast to religion that is
organised and communal, spirituality is highly
individual and intensely personal, and it is possible to
be spiritual with out being religious or even believing
in God . Spiritual distress occurs when individuals are
unable to find sources of meaning, hope, love, peace
and comfort in life; and illness can often trigger spiritual
distress in patients and family members. Spiritual care
consists of relieving this distress, and involves
compassion, listening and the encouragement of realistic
hope; and need not involve any discussion of God or
religion.
Addressing the patient's spirituality should be a
routine part of health care for many reasons: (1)
Religious beliefs and spiritual needs are common among
patients, and many patients would like their doctors to
address these issues; (2) Religious beliefs influence
medical decision-making; (3) There is a relationship
between spirituality and health; and (4) Supporting a
patient's spirituality can enrich the patient-physician

relationship.
However, there are a number of barriers doctors
encounter when talking about spirituality. Clinicians
practice in the bio-medical model and pride themselves
on being h^rd-headed rational scientists, so that many
feel that nebulous concepts such as spirituality are
unimportant and irrelevant. After all, you can palpate
an enlarged liver and auscultate the heart, but how do
you examine the soul ? Second, few physicians are
religious or spiritual themselves, which is why they often
fail to realise the importance of spiritual matters to
their patients. Since the effect of spirituality on health
is often not taught during medical training, many never
consider this area at all. Other doctors feel that the
spiritual concerns of patients are private and that
physicians should not inquire about them; and they are
worried that they may offend patients who have
differing religious beliefs. The simplest solution is to
avoid discussing religious or spiritual matters, which is
what most doctors end up doing, but this is often not
desirable.
It is difficult for physicians to ignore or avoid patient
spirituality , especially in India . Rather than shy away
from such discussions, you need to develop a technique
to become comfortable dealing with these issues. This
is why the American Psychiatric Association
recommends that physicians inquire about the religious
and spiritual orientation of patients "so that they may
properly attend to them in the course of treatment."
This is simple common sense - after all, patient care is
much more than disease management; and involves
addressing the needs of the whole person. Spiritual care
Spirituality in Patient Care: Looking at the Bigger Picture | 289
can play a complementary role to medical care,

especially in dealing with critically ill patients or the
dying.
Physicians can easily incorporate spirituality into then-
practice by assessing the patient's spirituality in order
to diagnose spiritual distress, and by providing
therapeutic interventions to alleviate this distress. For
assessment and diagnosis, the key is to learn to take a
spiritual history, to help you define the spiritual needs
of your patients. In fact, taking a spiritual history can
actually provide basic spiritual care for many patients,
in that it allows patients to voice their spiritual doubts,
needs and concerns, and allows physicians to comfort
them, if they need this. More advanced spiritual
treatment can be provided by referring patients to
sources of spiritual care such as priests; temples,
churches and mosques; family and friends; and
community resources (eg, satsangs and similar support
groups). Thus, many hospitals have chapels, temples
and prayer rooms today, and patients should be
encouraged to use these services.
Since the concept of taking a spiritual history is so
new for most doctors , the HOPE questions designed
by Gowri Anandarajah can prove to be very helpful,
because they allow for an open-ended exploration of
an individual's spiritual resources and concerns . A
useful way to introduce these questions is by asking:
"For some people, their spiritual beliefs act as a source
of comfort and strength in dealing with life's ups and
downs. Is this true for you?"
2901 Succesful Medical Practice: Winning Strategics for Doctors
H: Hope: What are their sources of hope, strength,

comfort and peace ? This helps to define their
basic spiritual resources.
O: Organized religion: Are they a member of a
religious group ? How active are they ?
P: Personal spirituality and practices: What specific
aspects do they find most helpful in their own
life ? Prayer ? Meditation ? Music ?
E: Effects on medical care issues : (for example,
dietary restrictions for Jains). This can help focus
the discussion back onto clinical management
Following the spiritual assessment, you have many

management options.
1. Take no further action. Spiritual concerns often have
no clear solutions, and experienced physicians know
that in many cases there is little they can offer to their
patients in the way of medical solutions. Often the best
therapeutic intervention you can provide is your
presence, understanding, and compassion, which is in
itself a spiritual response.
2. Include spirituality in adjuvant care. You can help
patients identify spiritual measures that can be useful
to them in conjunction with standard medical treatment.
For example, a patient may choose to have a picture of
their guru in their room, or listen to the Gita during
dialysis , or read the Bible before surgery.
3. Modify the treatment plan. Modifications can be made
based on a better understanding of your patient's
spiritual needs. This can include measures such as
stopping chemotherapy in a patient with terminal
cancer, referring a patient in spiritual crisis to a priest,
using community cultural resources, and teaching
Spirituality in Patient Care: Looking at the Bigger Picture I 291
meditation techniques to patients with chronic pain or

insomnia.
Before you can begin to address your patient's
spiritual needs, you first need to understand your own
spiritual beliefs . One way to promote self
understanding is to perform a formal spiritual self
assessment by taking a spiritual history on yourself.
Spiritual self-care is integral to serving your patients
and self-care can take the form of reconnecting with
family and friends, time alone (for meditation, playing
a sport, recreational reading, nature watching, etc.),
community service, or religious practice, such as praying.
Learning about spirituality will help you become a
better physician. It will help you find meaning in your
daily work as you appreciate the importance of your
primary role - to serve your patients. It will also help
you become more compassionate, and teach you the
importance of hope , and why you need to support
your patient's spiritual needs . Finally, it will help to
keep you humble, because it will teach you to realise
there is so much about the human body we do not
understand and cannot control - and that the human
spirit can perform miracles modern medicine still cannot
comprehend.
Finally, you should pay more attention to spirituality
for purely selfish reasons. Spirituality is key to self
growth, and allows us to continually be amazed at the
miracle of human life. By virtue of being doctors , we
are privileged to have a ring-side view of life's most
exciting battles , right from birth to death , but many of
us get jaded with time. Spiritual awareness allows us to
appreciate the wonders of life, so we can continually
rejuvenate ourselves and look on each day as a brand
new adventure, and lead a more meaningful life.
Spirituality allows you to get in touch with your own
humanity - the ultimate reward.
Chapter 38
The Joy of Practising Medicine:

How to be a Happy doctor
Focus on the journey, not the destination. Joy is found not

in finishing an activity but in doing it.
— Greg Anderson
Even though medicine has traditionally been regarded

as a profession which provides tremendous job
satisfaction, many of us are finding ourselves
increasingly dissatisfied with the practice of medicine.
In the past, when doctors met, they used to talk about
the interesting patients they helped to treat. These days
they usually talk about financial stresses, job pressures,
bureaucratic hassles and red tape. Doctors are
increasingly toying with the idea of changing careers ,
while others are burning out in their mid-forties. Where
has the joy of practicing medicine gone ?
In order to find joy in medicine, we need to find
meaning in our profession. Work is an essential part of
being alive and physicians are fortunate to work in a
job which can provide so much satisfaction . They are
presented with new challenges daily ; they can apply
their mental abilities and their physical dexterity to
successfully solve many of these problems; they are
accorded respect and status; and they have control and
The Joy of Practising Medicine: How to be a Happy doctor 1293
autonomy . Unfortunately, many doctors no longer

work for the sake of working - they're working for a
car, a new house, or a vacation. It's no longer the work
itself that's important to them, and this is a shame
because there is such joy in doing work well.
We are privileged to help take care of patients. We
need to respect our role so we can learn to respect
ourselves. If you do what you love , and love what you
do , you will find a higher purpose in life - and if you
are passionate about your work , your life will be full
of meaning. Getting paid for this should be seen to be
the ultimate bonus.
We are fortunate to be doctors because we can learn
so much from our patients. They bare their heart to us,
and make us privy to their innermost confidences, so
that daily we get a ringside view of human drama,
suffering, courage, life and death - the stuff of which
life is made. Doctors have a chance to plumb the depths
of the human soul, as they accompany their patients
through their suffering. Our work lends itself to
contemplation and introspection - allowing us insights
which few other people are privileged to have. Our
patients can teach us how to live and how to die - and
we need to keep our hearts open to their lessons. While
it is true that daily exposure to misery and suffering
can drain some doctors, causing compassion fatigue,
and leave others hardened and unfeeling, these same
experiences can also invigorate and rejuvenate you.
Watching patients die should remind you of your
own mortality , so that you remember to learn to live
each day well. Seeing very ill patients recover can renew
your sense of amazement at the marvels of the human
body, so that you appreciate the perfection of your own
body everyday. Observing friends and loved ones
provide comfort and courage to the ill can awaken

your own feelings of compassion so that you remember
to touch all your near and dear ones with love every
day. To live life to the fullest, we need to recapture
our sense of wonder at life daily, and being a doctor
allows you the privilege of doing that at close quarters.
It is true that physician morale is declining today,
and doctors are hard pressed to find job satisfaction.
However, instead of focusing our efforts on trying to
identify what is wrong with medicine today, we should
identify happy doctors and delve into their secrets, so
that we can copy them. I am sure we all know doctors
who still look forward to each day as an opportunity
to do good, and to become more skilled physicians. We
should try to learn from their successes. Many of these
happy physicians may never become the president of
the medical association, or grab media headlines , but
they are the true stars of our profession, because they
have found meaning in their lives. My personal role
model is my father, who is one of the most satisfied
people I know. His primary source of happiness is his
patients , and they have provided him a major source
of personal sustenance. He enjoys talking to them, they
enjoy talking to him, and his links with them are deep
and personal. He loves tham and they love him. Even
more importantly, I have learned that professional
satisfaction does not come from acquiring money, but
instead from gaining "social capital" through community
ties. He has numerous extracurricular activities , and is
very well connected with his family, friends and
neighbors, and these social bonds contribute enormously
to his satisfaction.
The first rule for being a happy doctor is very simple
- it simply means caring for your patients. Treat all
The Joy of Practising Medicine: How to he a Happy doctor 1295
your patients like VIPs - whether they come from

Dharavi or from London . Remember that the
relationship with our patients is at the heart of our
professional role - and a healthy doctor-patient
relationship nurtures both patient and doctor.
Medicine is really about service, not science, and the
true meaning of medicine is found in the relationships
we have with our patients. Savor your patients. When
a patient thanks you for your work, or says that you've
become like a family member, stop and relish that
moment. Those moments are the real reward for being
a doctor, if you can slow down to let them in. When
it comes to getting positive feedback, no profession in
the world comes close to medicine. The joy of medicine
is in doing good , which is why patients still confer a
special status on us - we need to prove ourselves
worthy of it.
Find an area of special interest in your field which
you enjoy, and acquire a depth of knowledge in this
focused area. Once you've mastered an area, then master
its intricacies. Not only is it personally rewarding, it'll
be professionally rewarding, as well. Your colleagues
will refer problem patients in this area to you ( allowing
you to become even more expert in the topic), and you
will also acquire a reputation amongst patients as being
very good in this area.
If you find your practice has become boring, tedious
and monotonous, you need to recharge your batteries.
Be willing to do something new, even if it involves a
risk - after all, if you continue doing the things which
bore you, the situation will get even worse. You can
consider hiring an assistant, to take care of the parts of
medicine you find boring, so you can concentrate on
what interests you. Other doctors have rediscovered
joy not by narrowing their scope but broadening it to

encompass a new area of expertise - for example, by
exploring alternative medicine, such as acupuncture,
homeopathy and chiropractic.
Try to publish and present your clinical experiences.
This will force you to read the medical literature and
provide intellectual discipline as well , as you have to
carefully document your experiences and answer your
colleague's queries. Advances in medicine depend upon
clinical acumen, and if we apply scientific rigor to our
clinical experience , we can all contribute to improving
medical practice. Treasure your rare patients and your
difficult cases - they can teach you the most.
Develop humility. Often you will find that the reason
you are unhappy in your professional life is that you
have let your ego get out of control. Practicing medicine
can make us feel that we are indispensable, and self
importance is a serious malady that stands in the way
of professional satisfaction.
Develop interests and friends outside medicine. While
it is true that medicine can be a demanding mistress,
don't let her take over your life. Good doctors are well-
rounded individuals , who have an open mind and are
curious about everything. Having outside interests will
not only make you a better person , it will also help
make you a better doctor, as you apply what you learn
from other fields to your medical practice. For example,
I enjoy playing tennis, and have found that learning
how to serve has helped improve my surgical skills by
honing my hand-eye coordination.
Do some charitable work - for example, offer a free
clinic once a week. One of the best ways of feeling
good about yourself is by doing good for others , with
no strings attached. The gratitude of the patients you
The Joy of Practising Medicine: How to be a Happy doctor 1297
see free of charge is worth much more than any amount

of money . As a doctor you have many opportunities
for being altruistic - make the most of them !
Don't make the mistake of equating wealth with
happiness - the pursuit of wealth only complicates our
search for happiness. . As physicians, we should be
grateful that we get the opportunity to make a positive
difference in the lives of others everyday - a goal most
humans aspire to. Be thankful daily that you can help
others - expressing gratitude is a powerful tool in the
search for contentment and self-worth.
Most of us become doctors in order to help others.
All of us get this opportunity to do so on a daily basis,
whether we work in Mayo Clinic or in the heart of
rural India. We should remember how lucky we are to
belong to such a privileged profession. Even in ancient
India, vaidyas were considered to be very fortunate
because their lives offered them the opportunity of
fulfilling all the three aims of a good life - dharma
(religious gain, by relieving the suffering of patients),
artha (material gain, by building up a rich practice);
and kama (personal satisfaction, by curing those whom
he loves and respects, and by acquiring fame for his
expertise). This is as true today as it has been through
the centuries. Medicine is a wonderful way to make a
living - be glad you are a doctor and make the most
of your profession - for your sake, and for the sake of
your patients.
Appendix
Can We Help You?
Do you have a practice management problem ? Are you confused

as to what to do with your life ? Your career ? Do you need to
explore alternative options ?
Please feel free to email us at info@drmalpani.com
Please send in as much detail as possible, so we can provide useful

advise. Basic information we would need would include:
Name:....................................................................................................
Email address:......................................................................................
Address:.................................................................................................
Specialty:...............................................................................................
Practising since:............ .......................................................................
Details of the problem you are facing: ............................................
What help you'd like:.........................................................................
We look forward to helping you to make your life more productive

and satisfying !
Dr Aniruddha Malpani, MD
Dr Anjali Malpani, MD
Medical Director
Vital Signs, Medical Practise Management Consultants
Jamuna Sagar
SBS Road
Colaba ,
Bombay 400 005.
India.
PTN Communications is a specialist
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Successful M edical P ractice
Running a successful medical practice can be hard work. Do you find that there
-
is too much work, too much hassle, too much competition, too much despair and
w in n in g s tra te g ie s fo r d o cto rs
too little reimbursement ?
Are you fed up of:

♦ Long energy-exhausting hours and crushing workloads leaving little
or no free time for yourself or your family ?
♦ Demanding and dissatisfied patients ?
♦ Inadequate payment for all your hard work ?
The purpose of this book is to help you find a truly satisfying way of practicing
medicine which would :
(a) Give you control of your time,
(b) Allow you to do work which you feel is worthwhile for patients that
you enjoy seeing, and
(b) Pay you well for your effort so that you enjoy going to work every day.
What you need to learn is to work smarter, more efficiently and more productively
and with less hassle and more satisfaction. The secret is to learn how to manage
yourself. The problem is that certain skills, especially time management, knowledge
management and relationship management, are not taught in medical schools
and most doctors have to learn them the hard way. This book will teach you these
skills, so that you can apply them to your life and become a more productive,
happier and successful doctor.
Dr An ia l' Malpani, MD
Dr Aniruddha Malpani, MD and Dr Anjali Malpani, MD are leading infertility
specialists practicing in Mumbai. They have over 24 years of experience in running
a successful private practice. This is their fourth book, and they hope it will help
doctors to manage their lives more efficiently. Dr Aniruddha Malpani, MD
For Copies contact:

PTN Communications
3-3-62/A, New Gokhale Nagar, Ramanthapur, Hyderabad - 500 013

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Successful

- winning strategies tor doctors

Dr. Aniruddha Malpani, MD

Dr. Aniruddha Malpani, MD

The education of the doctor which goes on after he has

Running a successful private practice can be hard work.

Like the White Queen in Alice in Wonderland, they find

Like them, do you find that you are fed up of:

The purpose of this book is to help you find a truly

Many doctors feel they are very productive because

is the difference between inputs, which is how busy

• Clinician , who has polished medical skills, a

While this may seem to be an intimidating list, there

them clearly, so you can apply them to your own life.

13. The Telephone: Your Clinic's Lifeline 107

30. Parenting - Bringing up the Next Generation 224

Planning Your Career:

If you don't know where you are going, you'll probably

Many doctors naively believe that once they start earning

• Entry, when you are starting out;

Whether you are 25 or 55, you always need to think

• In what way are you personally more valuable to

Traditionally, doctors have adapted themselves to

patients, you need to learn a wide variety of

The secret for planning your career is to pick a clear

• Values: What motivates you? What would make you

Thus, if you are an orthopedic surgeon and find you

serve as consultants to the pharmaceutical industry. In

things that they ordinarily wouldn't have tried left on

Visualize your own funeral. There will be four

This might seem a morbid thought to some, but it's

The starting point of all achievement is desire. Keep this

Starting practice can be difficult, because so many things

When should you cut the umbilical cord of training

specialization. Thus, while a family physician may be

Deciding where to practise is one of the most important

a spouse - you want a long, healthy, prosperous and

• The community's need for a doctor.

• Tour needs and those of your family

• The local medical facilities

Since this may be one of the most important decisions

and don't just accept the first opportunity which comes

Types of Private Practice

When you commence private practice , you will need

Which method you choose will depend on your own

This is by far the most popular type, and allows you to

where much of the support structure is provided and

If you want shared responsibility, a partnership with

partners if they are unable to meet their own debts.

is a social contract, and as in marriage, divorce can be

Group practise is becoming increasingly popular in India

There are additional options too. Many doctors now

Many doctors find practicing in a government hospital

generation of doctors, and this interaction with medical

Key Advisors You Need

When practicing medicine, you will need advisors to

relationship requires a high level of trust and

The accountant will be responsible for the following:

1. Setting up and monitoring financial record keeping,

A lawyer is another necessary advisor. You must ask his

The Bank Manager

A sympathetic and helpful bank manager is essential

until the practice begins to generate some income. It is