Gomantak Times – Weekender, 25 July 2010

More often than not, the average person begins searching for a doctor only when illness strikes, which is not the best time to locate one, explains Orlene D’Souza

Sonia had just moved to Goa with her family, and like all people who change their residence, she took great pains in locating the best school for her children, getting house help, meeting the neighbours etc. However, she overlooked one important aspect, and that was to identify a family doctor.

One morning, Sonia woke up with high fever and a splitting headache. The stress of her new job and settling into a new place had made Sonia susceptible to viral infections. She needed to see a doctor, but unfortunately, she didn’t know any doctor.

Like most of us, she too didn’t bother to look for a doctor until she really needed one.

So, she picked up the yellow pages and looked out for doctors in her locality. She shortlisted a couple of names, but she needed more information, so she asked for references from her friends and colleagues. However, this didn’t help much. Her friends and colleagues gave her contradictory feedback, making her decision making process even more difficult.

Asking for recommendations from friends and coworkers is not always the best way to start; after all, we each have our own needs and expectations of our healthcare provider. Choosing a doctor who best fits our needs is a difficult task and is perhaps one of the most important decisions we make. After all, we put our life in the hands of this person.

Here are few factors you would like to consider while choosing your doctor:

DOCTOR DEMOGRAPHY

The age and gender of the doctor sometimes influences our choice. We all have our preference when it comes to age and gender of the doctors. Some women might be more comfortable discussing their health problem with a female doctor than a male doctor. The age of the doctor seems to be important too. An older person might prefer going to an older and more experienced doctor.

DOCTOR CHARACTERISTICS

All doctors have their unique styles of relating to their patients, and as patients we have different expectations of this doctor-patient relationship. Understanding the doctor’s style will help you find your right doctor. Some of us would need a doctor who is an attentive listener, while there would be others who might need some reassuring or others who need comprehensive treatment information.

HOSPITAL AFFILIATION

It is good to know which hospital the doctor is affiliated to. Find out if the hospital has the facilities you are looking. Is the location of the hospital convenient; is the support staff good, does the hospital pricing match your expectations?

DISTANCE FROM HOME

Another factor you would like to consider is how far you would need to travel every time you need to visit the doctor. This is especially true if you do not have proper transportation facility.

WAITING TIME

If time is a constraint for you, it is important to find out the average waiting time for an appointment. You need to find out whether you could get an appointment the same day you call.

CONSULTATION TIMINGS AND PUNCTUALITY

If you are a working family, consultation timings is something you would need to consider. Look out for a doctor who practices after your regular working hours and who is punctual in honouring appointments.

OTHER FACTORS TO KEEP IN MIND

The other relevant factors to keep in mind when choosing a good doctor should be proximity to chemists, pathology lab and the presence of courteous and helpful staff. Careful consideration of the above will ensure that your choice of a family doctor is better informed.

[The writer is a faculty at the Marian Institute of Healthcare Management, Panjim, and can be contacted at orlenedsouza@marianinstitute.in]

Gomantak Times – Weekender, 18 July 2010

Advances in the field of medicine have made the detection and treatment of illness so much simpler. Yet, one feature is sorely lacking — the human touch. Meena Parulekar examines the need for this human element

Kuldeep Mishra, aged 54 years was diagnosed with a block in his right coronary artery a few days back in Mumbai and is advised to go ahead for a beating heart surgery by his cardiac surgeon after considering the severity of the block. Beating heart surgery is a special kind of by-pass surgery in which the heart is fully functional, use of heart-lung machine is not resorted to. Having undergone an angiography and angioplasty a few months earlier in January 2010, he is not sure of what he is heading for this time and needs reassurance from his doctor. The doctor advises him to choose between by-pass surgery or radiation therapy as there is not much time to lose.

For Mishra, however, there are other concerns like his feeling of discomfort with the stent post angioplasty and the nature and risk of bypass surgery. Is it asking for too much to have his doctor brief him about the nature and technique of medical intervention? Can his fears be allayed in some ways to prepare him physically, mentally and emotionally for the operation ahead?

HUMAN SIDE OF MEDICINE

Science and technology together have created wonders for mankind. Drugs and treatments that were thought impossible have today been discovered, tried and successfully implemented. The future is bright for molecular diagnostics, pharmacogenomics, stem cell engineering and the like. Medicine in itself is considered to be a noble profession and requires a certain amount of human touch to make the patient feel better. What, then, is human touch in medicine?

According to Dr Shobha Patkar, a practicing psychiatrist from Mumbai, the practice of medicine is both an art and a science. In the field of medicine, this very art is exhibited from the medical team in the form of empathy which goes much beyond mere words of sympathy.

Eg, “I feel sorry for you” – Sympathy.

“I feel your sorrow” – Empathy

This is precisely known as human touch and is displayed through the behavior of the physician.

Eg: 1) Attentively listening to the patient.

2) Trying to understand his feelings and attitudes.

3) Explaining the plan of action.

4) Allowing him to make choices if rational.

5) Creating an atmosphere of comfort, confidence and involvement to the extent required.

In short, human touch is nothing but genuinely being with the patient throughout his journey of sickness.

Earlier, the practice of history taking and complete clinical examination allowed the physician to know the patient and not merely know the disease. These days, after a quick initial dialogue, the patient is made to run to multiple numbers of experts, investigations and treatment modalities. In the process, the patient loses the primary anchor — the physician with whom he would have preferred to discuss the issues, clear the doubts and make decisions together. No wonder then, he feels not only exhausted, but rejected and helpless, too.

Advanced technology has not spared the doctors who rightfully expect the ‘humane’ approach from patients and relatives.

The so-called aware patient community who acquires information through advanced e-technology tends to doubt, disagree, and distress the doctor — forgetting that the doctor is a qualified and experienced person who has to be discrete and precise. In fact, many a time, a physician has to face legal consequences for not directing the patient to all possible and available diagnostic tools and treatment procedures, though medically not indicated in the opinion of the treating physician.

So, the patient and the doctor, both, have to be cautious and guarded just because mechanical culture is increasingly losing the human touch.

Dr Kalpana Chodankar at the NIO dispensary, Dona Paula, opines that advances in technology do serve as a boon in aiding the diagnosis, but should not stop the clinical examination of the patient, at large. A number of recent advances like mammography, CT scan are useful in terms of early diagnosis and assist in deciding the line of treatment for the physician. This is a huge benefit when one considers the severity of symptoms as manifested during a clinical presentation when it is too late.

IS HUMAN TOUCH NECESSARY?

It can be argued whether human touch is really required in medicine. In any civilized human society, we create, develop and nurture relationships as part of our social identity. In a virtual world, like today, where smileys take over real people in text messages, how much does the warmth of a real smile, a nice hug or a handshake matter?

Today, thanks to telemedicine, it is possible for a diagnosis to be made by a doctor while sitting in his plush cabin without actually having to go out and meet his patient in a remote village or a town in the country. It is technology that has made it possible to have a blood sugar test done in the convenience of our homes, or for that matter, the cardiac activity can be monitored by a simple device worn on the wrist of a patient. These are advances in the realm of technology that have surpassed our expectations.

For a healthcare professional, who has to deal with the human touch in such interventions, some issues that hold prime importance are: Nature of treatment or surgical intervention; availability of resources in the public or private setting; severity of symptoms/illness; co-ordination in terms of healthcare delivery with other services/service providers.

At the end of the day, a patient-centric approach is most desired for all interventions; however every situation/case has its own set of demands and constraints faced by the hospital administrators/doctors who handle their patients in a hospital.

For Kuldeep Mishra, the decision to go in for the beating heart surgery may be tough, but it may actually be the only best possible way to save his life.

The writer is faculty at the Marian Institute of Health Care Management, Panjim, and can be contacted at meena.sahib@marianinstitute.in

Pratibha Kumar’s children returned home from school with a consent form (see below) for her to sign. A cover note from the school accompanied the form informing her that the Department of Health had issued the form and it had to be filled, signed, and returned immediately. No other details were given to her.

Pratibha had never heard of XYZ before, but had heard that some vaccinations were dangerous. Not knowing what to do she called up a few of her friends and asked them what they were doing.

• Some parents said the disease was very dangerous and affected the brain.
• Others said they would check with their paediatrician.
• Others said that there would be no follow up for the booster doses
• Some said the side effects of the vaccinations were dangerous.
• Others felt they were forced to give consent if the child did not have any of the conditions listed in the form.
• Some said they had heard children had fallen ill after the vaccination and had to be rushed to the hospital.

Pratibha was completely bewildered. She did not know whom to believe and was unable to contact her children’s paediatrician. She decided not to give consent and randomly ticked “yes” to item 1 and 6 on the form. However, a nagging doubt persisted about whether she had made the right decision or not. She felt better the next day knowing that others had made the same decision — an article in the local newspapers reported that the vaccination campaign was not a success since many parents had refused to give consent.

Pratibha might have felt better, but for society, failed preventive health initiatives such as vaccination campaigns are a sad but recurrent reality.

WHY DO VACCINATION CAMPAIGNS FAIL?

Why do people refuse to participate in preventive health programs even when the programs are free and conducted at convenient locations? Social scientists, in the 1950’s, developed a list of factors that helped explain preventive health related behaviour. This model known as the Health Belief Model (HBM) provides useful insights that can help us design better preventive health programs and increase the probability that people will participate in them.

People are ready to act if they:

• Believe they are susceptible to the condition (Perceived Susceptibility)
• Believe the condition has serious consequences (Perceived Severity)
• Believe taking action would reduce their susceptibility to the condition or its severity (Perceived Benefits)
• Believe costs of taking action (Perceived Barriers) are outweighed by the benefits
• Are exposed to factors that prompt action (eg, a television ad or a reminder from one’s physician to get a mammogram) (Cues To Action)
• Are confident in their ability to successfully perform an action (Self-Efficacy)

GOOD VACCINATION CAMPAIGNS

Campaigns must begin with the dissemination of information and discussions that engage decision makers like Pratibha, paediatricians, public health specialists, school representatives, and other key opinion leaders.

Pratibha needs to know:

1. How likely is it that her children will develop the disease if not vaccinated against it? Why and to what extent are her children at risk? Does age, where they live, the changing weather, a recent outbreak, etc make them more susceptible? (Perceived Susceptibility)
2. What is XYZ? How severe is it? Is it fatal? What treatments are available? Are the treatments effective? What are the symptoms? How is it spread? (Perceived Severity)
3. How will the vaccination help? How effective is the vaccination? Will the vaccination have side effects? How serious will these be? Is the school equipped to handle any emergency after the vaccination is administered? What precautions need to be taken?

Do the benefits of the vaccination outweigh the risks? What arrangements have been made for the administration of booster doses? (Perceived Barriers and Benefits)

Distribution of consent forms should be one of the last stages of a well-designed program and accompanied by media messages (Cues to Action) that provide Pratibha with the impetus to make a decision. Discussions and information provided beforehand will ensure that she is now confident and capable of making the right decision (Self-Efficacy).

Pratibha Kumar can actively seek out information, arrange discussions groups, ask for advice from experts, and request that she be given more time and information before being asked to make such a crucial decision. The HBM is a useful starting point for her to gauge how much she knows and what is preventing her from making a confident choice.

[Ayesha Gonsalves is a faculty at the Marian Institute of Healthcare Management and can be contacted at ayeshagonsalves@marianinstitute.in]

Gomantak Times – Weekender, 4 July 2010

When it comes to dealing with a health problem, several medical options are available. From acupuncture to ayurveda to homeopathy, the choice is endless. Giovanni D’Cunha puts his finger on the pulse of alternative medicine

A grandmother, an old aunt, a mother — these were the experts in health from the time we remember.

They prescribed remedies from common cold and fever to wounds that we thought would never heal. Medicine was not considered the exclusive domain of an expert — experience was the greatest physician. Fast-forward to the 21st century and not only do we have a plethora of medicines to choose from, but also a gamut of medical paths we can follow.

FROM RISHIS TO RETAIL

Two major systems of medicine exist in India, what could be called the conventional and the alternative.

The conventional is the modern system of medicine (allopathy) that is scientifically proven and widely used for treating ailments. It is aligned with the pharmaceutical industry that synthesizes chemicals to produce drugs.

This system of medicine is considered the best when it comes to surgery, emergency and trauma. Alternative medicine is a collective term used to describe any form of healing that does not utilize conventional medical practices or use of synthetic drugs and medications. There are several different forms of alternative medicine innovated during the ancient times and is still being practiced in the modern world. In fact, some of them are considered more effective than conventional medicines. It includes acupuncture, ayurveda, naturopathy, meditation, hypnosis, diet-based therapies, homeopathy, and yoga.

However, what started off with the age old practice of concoctions made by the rishis has now developed into a very popular science by itself. There is a strong belief that alternative medicine, which is more cost effective over the long term, works better for just about everything especially for diseases like cancer, heart disease, rheumatoid arthritis, asthma, gastrointestinal disorders, headaches, sinusitis etc. This system of medicine is believed to work by assisting your body to heal itself rather than exposing it to strong drugs. It incorporates a more holistic and empowering healing philosophy that is seen as a natural step in the growth of medicine.

While Goa displays a healthy trend towards increasing numbers of ayurvedic centres, yoga classes and health clubs, ironically it is also becoming the hub for an unhealthy upsurge of lifestyle diseases. Rapid economic growth coupled with a bad diet and sedentary lives has clearly put more food on our plate than we can healthily handle. Most people today opt for a short term home remedy or hop across to a spa for a massage or a yoga session. Some pop a pain-killer as a quick symptomatic cure. None realize the trouble lies much deeper.

WHICH CAP FITS YOU?

People look for the best option to treat illness and have their reasons for selecting one or both systems of medicine. The “conventionals” are people who have a strong faith in the allopathic system of medicine. They believe that medical doctors are the primary healing experts and authorities. The “unconventionals” on the other hand, are those who see illness and health through a different lens. They believe that health is one’s own responsibility.

Hence, they would prefer natural remedies and discipline going by the adage, ‘prevention is better than cure’. A doctor in homeopathy from Mapusa adds, “While ayurveda as a form of alternative medicine has progressed, it is still a niche market with only a few people being aware of it. Both systems of medicine ultimately need to amalgamate — while the alternative would act like a first line of defense, the conventional would be there for a final cure.”

A study recently conducted aimed to find out if there exists a preference for conventional or alternative systems of medicine to treat lifestyle diseases like heart disease, diabetes and obesity. A questionnaire was administered to a randomly selected population of 125 residents of Panjim (above 30 years) since they are more prone to lifestyle illnesses. The results are quite an eye-opener.

There is indeed a polarization between the conventional and alternative systems of medicine when it comes to lifestyle disorders. People favouring the conventional system affirm that it is scientifically proven, provides quick relief and is more effective, while those in the alternative medicine camp argue that it has less side effects, is a long-term cure and more economical. It would be interesting to note, that people with a stronger willpower tend to use the alternative system of medicine over the conventional, since the alternative calls for a greater amount of self-discipline with regard to lifestyle. However, people covered by health insurance would automatically be led to opt for conventional medicine.

THE WAY FORWARD

Why would such a study be of significance to a manager in a health care setup?

• Such correlations could help plan marketing strategies based on patient preference towards a particular treatment.
• Most health insurance providers currently cover only the conventional system of medicine. The time has come when insurance companies need to re-assess the market need and develop customized policies for insurers who may want to be covered for the alternative system as well.
• Government policy formation and implementation needs to consider such preferences of the population to boost the health status of the state.

Alternative medicine is step by step taking center stage where even allopathic practitioners are prescribing these for the intervention of several complaints. The healthcare profession is starting to become aware of the good contributions made to good health by herbs, yoga, acupuncture, massage therapy, and holistic living.

We need to change our attitudes toward the “practice” of medicine. It’s not about “medicine” or treating bad health. It’s about producing good health. Drugs won’t get you there and most of the times they will set you back by suppressing a symptom that is pointing to the real problem. Instead of treating the symptom, treat the cause. The symptom will then disappear. Only then will you experience a true cure. The choice is yours.

[Giovanni D’Cunha is a faculty at the Marian Institute of Healthcare Management and can be contacted at giovanni.dcunha@marianinstitute.in]

Meena Parulekar – Gomantak Times – Weekender, 20 June 2010

Self-medication is quick and convenient, making it an appealing alternative to consulting a doctor. Meena Parulekar finds out if there are any bitter pills to swallow when it comes to self-medication

Shreya has had a splitting headache for the past two days. Unable to concentrate on her work, she pops tablets of aspirin every two hours to make her feel better. The headache does subside mildly, but she now complains of acidity and stomach pain.

Shreya is among those many of us who, at some point or the other, have indulged in self-medication.

An ambiguous phenomenon, self-medication has attracted the attention of the medical fraternity worldwide. Heard synonymously with over-the-counter products, self-medication has been debated on both its benefits and risk fronts. Self-medication is possible with non-prescription or over-the-counter medicines simply because there is no medical intervention required. In certain ways, the customer – in this case, the patient — has a choice to be exercised like many other consumer products.

An effort to streamline the products that can be successfully self-medicated has been compiled in a WSMI (World Self-Medication Industry) forum that brings together self-medication guidelines for developed countries of the world.

WHY SELF-MEDICATE?

What, then, is self-medication? It is the treatment of common health problems with medicines especially designed and labelled for use without medical supervision and approved as safe and effective for such use.

The objective of self-medication is primarily to enable an individual to understand his/her own health requirements and work as a tool in providing responsible self-care. This becomes even more important in the current state of affairs where the focus has shifted towards prevention of disease rather than cure. Both the level of information available to a health-conscious consumer and the options to promote healthy living have increased manifold in the last decade.

RESPONSIBLE SELF-MEDICATION

Can self-medication really help? If so what is responsible self-medication?

Responsible self-medication: where a patient is able to correctly diagnose his minor ailment, and has sufficient information available about the medicine/s he needs to use so as to make a “responsible” decision whether to use a medicine, which, how much, when, etc and also knows when to stop self-treatment and go to a doctor. The benefits are many, since for every little ailment, one need not rush to a medical practitioner.

Also, considering the fact that these drugs have a well established safety profile and are being used in

low doses makes the patient feel comfortable using them.

However, there is a thin dividing line separating self–medication from abuse of drugs. In a country like ours, this has grown to become a problem of serious nature. From cough and cold remedies to antibiotics and CNS acting agents, a number of drugs have been misused. One of the most important issues highlighted is the ease of availability of these medicines at pharmacies.

According to Raj Vaidya, a Panjim-based community pharmacist, it is common knowledge across the country that, unfortunately, many times one can easily get almost any prescription medicine without producing a prescription – and this includes habit forming medicines and medicines of abuse. So in India, self-medication is not restricted to OTC medicines, it very largely extends to prescription medicine self-medication, which of course is dangerous.

Some of the associated variables with self medication that could be highlighted are:

• Availability of drugs over the counter
• Counselling by the pharmacist
• Level of literacy of the patient/customer
• Information availability of over-the-counter drugs
• Demographic profile of the patient/customer
• Nature of relationship/rapport with the retail pharmacist
• Urgency of need for the patient

BEFORE SELF-MEDICATING

The concept of responsible self-medication has a major deterrent in the form of insufficient information available along with products that can be successfully self-medicated in India. Neither the advertisements nor the labels of the medicine or package inserts provide complete information to the patient in an easy to understand language.

In developed countries, self-medication is more like a social phenomenon. Accepted and practiced by many, products that can be easily self-medicated come with a host of related information, packaging and other benefits. The patient thus, at any point in time is able to comprehend and understand the role of the non-prescription medicine in promoting his health.

As consumers of the medicine, before we choose to self-medicate, it is important that we are aware about simple, but important, facts like:

• Interactions among drugs used for treating different conditions
• Possibility of individual allergies/sensitivities
• Misuse of medication
• Incomplete dosage regimen and its effects
• Storage of the medicine

For Shreya, it implies either to go through some pain and opt for home remedies or take another antiacidity pill for fast relief. There are always options available, but the onus is on us to decide. Shreya could still choose to call her doctor before popping up the next pill!

[The writer is faculty at the Marian Institute of Healthcare Management and can be contacted at meena.sahib@marianinstitute.in]

Meena Parulekar and Sarita D’Souza - Gomantak Times – Weekender, 6 June 2010

As shocking as it may sound, blood test reports can sometimes be erroneous, the reasons for which are many.

Seeing his son with a high fever, Rahul took the boy to the doctor. On examining the boy, the doctor asked Rahul to get a blood test done to check for possible causes of the fever. Since it was late evening and he had to travel on work the next day, Rahul took his two-year-old son for a blood test to a laboratory attached to a hospital. The next day, his wife Gauri took the results to the doctor.

The doctor was shocked to see the blood test show the possibility of leukaemia. He waited till Rahul returned and asked him to take his son for another blood test — the results indicated an infection. One can only imagine the angst and turmoil that the parents would have experienced on seeing the initial test results.

As we can see from the above incident, a pathological laboratory plays a key role in diagnosing a health condition. Pathology is understood as the study and diagnosis of disease through examination of organs, tissues, body fluids. Decisions about diagnosis and treatment, hospital admission and discharge largely rest on these test results.

For a lab manager, a wrong blood report signals the need to review the lab’s working. He would do well to examine the process followed at the lab including:

• Entry of the patient and recording of his details
• Checking the tests to be conducted with the doctor’s written recommendation
• Conduct of the test and handling of the blood sample collected
• Labeling of the blood sample collected and storage conditions
• Processing of the blood sample
• Documentation of the blood report
• Handing over of the report to the patient and maintaining a copy for the record
• Timelines involved for all the above

INCORRECT REPORTS

A wrong report could be the result of the following reasons: insufficient blood for testing, wrong details on sample tube and form, wrong sample taken, no signatures, wrong type of tube, mismatch with information on lab records, tube compromised, clotting, ability of processing technician, lab equipment and so on. The lab manager could conduct a root cause analysis to find out the reason/s for the error in the report and then put in place processes to eliminate the cause of the error.

Dr P N Velingkar, who runs a lab in the heart of the city, cites quality of the reagent used, process followed and a possible error in test kit as possible reasons for errors. He suggests that labs examine standards of previous reagents used and track their performance, perform an EQAS (External Quality Assurance Services) regularly. He also opines that while sometimes a patient wants the results urgently, it is important that the lab ensures adequate time for confirmation of results.

This helps review decisions on which tests the lab can conduct, lab layout planning, quality and maintenance of equipment, putting in place proper standard operating procedure for consistent processes, proper storage facilities, training personnel and providing proper working conditions.

REDUCING ERRORS

Continuous improvement cannot rely on a single approach. An error could arise out of several individual causes working together with each other. In addition to putting in place barriers to reduce errors in test results, training initiatives create a sharp awareness of the impact and potential risk of errors in the entire process.

Pathological laboratories face issues like access to patients, availability of trained lab technicians, managing working capital and investment for equipment. Also, according to Dr J P Agarwal, director of a diagnostic centre in Hyderabad, “Some onus also rests on the doctor who does the initial diagnosis. Only when the initial diagnosis is in the right direction, the lab report will also be on the right path.” Thus, there are several operating constraints faced by path labs.

Despite having to deal with several constraints, laboratories would do well to review their working to enable consistent and accurate reports. This would form the basis for better diagnosis and effective treatment so that parents like Rahul and Gauri can rest assured about their son’s diagnosis and treatment.

Health Watch, Gomantak Times 30 May 2010

While a routine health check may seem frivolous and unnecessary, today’s lifestyle makes it more of a necessity. But is Goa ready for health check-up packages, asks Giovanni D’Cunha

[The writer is a faculty at the Marian Institute of Health Care Management, Panjim]

You walk into a restaurant and the first thing you ask for is the menu. The day is not far when you walk into a hospital and demand for the best deal on offer. Or if you are a health conscious executive on the fast track, but don’t have the time for a regular blood test, would this option appeal to you? Your blood sample is collected by personnel from the path lab in the comfort of your home and the reports are delivered to you the next day, or you collect them on your way home.

One way that an individual can monitor his health today is by going for a periodic health check-up which may include diagnostic tests. These tests help to identify specific problems that may crop up due to unhealthy food habits, lack of exercise or a sedentary life style. As a result of the lifestyle that we lead we can become victims of modern diseases-diabetes, cardiac problems, obesity and hypertension-to name a few. Corporate hospitals and diagnostic labs today try to meet the need to provide facilities to conduct diagnostic tests which will aid a doctor to make a conclusive diagnosis of the patient’s current health.

A common process is the following: the patient goes to the doctor, the doctor conducts a physical examination of the patient. Depending on the initial diagnosis, the doctor may prescribe certain diagnostic tests which the patient has to do. He may get these tests done in the hospital’s diagnostic lab or may go to any diagnostic lab in the vicinity that would do the tests for him. Armed with the results the patient goes back to the doctor. The doctor now makes his final diagnosis and prescribes the treatment.

Health packages take this scenario to a different level. Not only does it call for preparedness on the part of the patient but more efficient use of the doctors’ time. Doctors today are dealing with an informed patient. The internet has thrown open doors of medicine and technology to a lay person like never before. Looking at meeting such a need, a number of diagnostic labs have come up in Goa. Hospitals too have recognized a demand for self-prescribed pathological health check-up packages coupled with their revenue potential. Any person can avail of this independently without consultation from a doctor. Packages of this kind are available at many hospitals, but often come at a cost.

Would people in Goa be looking for such a high cost, yet high convenience benefit?

HEALTH CONCIOUS

An extensive study was conducted in Goa this year to understand the patient and doctor perception towards such health packages. The target population was the people in and around Panjim.

The study served to confirm the assumptions of the researchers that people in Goa, living a fast-paced

lifestyle, welcome the idea of health check-up packages. This was chiefly seen among office goers. It was also found that office goers in a higher income bracket preferred to go in for general tests and blood profiling and would also like to design and develop their own test package with the tests that they need. Ronald May, marketing manager at Manipal Hospital, affirms this fact when he says, “Goans are becoming increasingly ‘preventive-conscious’ today. There is a growing trend in people to invest in such packages and curb any illness, if any, in the initial stages itself.”

There are various categories of health packages one can avail of, be it cosmetic, dental, eye, pre-marital, or just a general body-watch. Besides general blood tests, a comprehensive health check-up consists of tests such as the lipid profile, liver, thyroid and kidney screening, stress screening, eye and ENT examination, pulmonary function tests, gynaecologist consultation and pap smear tests.

Today’s unhealthy lifestyle makes it mandatory for everyone to undergo a complete health check up, at least once in a year. The periodic check up helps in identifying the cause of diseases at a very early stage and provides the opportunity for the proverbial “stitch in time”.

The Navhind Times – Zest, 15 May 2010

The focus is shifting and healthcare delivery has moved from the domain of physician care to the domain of the healthcare delivery organization. While new insights continue to be gained from professional practice in the field of health care, one also needs to look at practical aspects of delivering healthcare.

[The author, Meena Parulekar, is faculty at the Marian Institute of Healthcare Management]

The health sector encompasses various services that aim primarily towards affordable care and preventive medicine. Availability of skilled medical personnel, access to healthcare and insurance for the poor, freedom from preventable diseases like malaria and pneumonia are a few issues that are faced in delivery of healthcare.

While these continue to be challenges for the public health system in India, the last decade has seen changes like growth of organized healthcare with players like the Apollo group, Ranbaxy, Max India, Wockhardt and Fortis entering the healthcare market and opening up of the insurance market to the private sector.

With competition setting in, the emphasis is on value and greater transparency about quality, services and prices. One of the most important reasons cited is the changing expectations of the patient who wants to be actively involved in the ‘care’ delivery process. A paradigm shift of hospitals towards service lines in this changing scenario would hence become inevitable. In a well established clinical service line, physicians and administrators can exchange views more easily and share best practices with colleagues elsewhere in the system. If we look at the existing systems of knowledge exchange in the healthcare domain , it appears to be a one way flow from research which is funded by external agencies to the delivery stage (doctors, nurses ) and then to the patient. This meant that the doctor is the main caregiver.

The focus is shifting and healthcare delivery has moved from the domain of physician care to the domain of the healthcare delivery organization. While new insights continue to be gained from professional practice in the field of healthcare, one also needs to look at practical aspects of delivering healthcare, e.g. In the materials management department of a large tertiary hospital, who will do what, when, where and how? How will they hand over tasks, decision rights and accountability to the next person? These are issues that require managerial intervention. In a hospital where patient handling is critical, focus on managing patient waiting times becomes important. Similarly, considering the work environment of health care workers like nurses in a hospital, understanding their social and job related needs becomes a critical issue.

The McKinsey report of December 2008 on healthcare spending in the US re-affirms the need for healthcare reform while highlighting the importance of its stakeholders-doctors, payers and hospitals- involvement. Despite having among the better facilities in terms of hospitals and innovations in technology, it has been found that the cost of spending on healthcare for the common man in the US is perhaps the highest.

Thus, there is a felt need to narrow the gap between clinical practice and management practice in healthcare delivery organizations in order to ensure effectiveness and efficiency of ‘care’ delivery.

Management is a science that is based on observation and facts. The role of a healthcare manager would be to plan, organize and manage care and management of institutions in which care takes place. Put simply a healthcare manager would be in a position to guide these centers of healthcare delivery in making effective decisions that benefit the patient while also serving the organization interest . Any new intervention of designing processes and operating systems for the organization would require an understanding of the nature of clinical processes and the relationship between the medical knowledge, care processes, organizations and practitioners. Thus, healthcare as a domain, is fast emerging to be an integrated discipline. There is a component of industry intervention (pharmaceuticals, biopharmaceuticals and insurance) and patient focus that guides the efforts of skilled professionals in this sector.

A healthcare management program can be objectively designed keeping the above requirements in consideration. What a student is able to achieve through a healthcare MBA program is this objective of (a) Understanding the working of the organizations in the health sector,

(b) Drawing on management knowledge and competencies to deal with the specific issues faced in managing healthcare, and

(c) Gathering an integrated view of the entire system of healthcare delivery

Given the emerging trends in scale and needs of healthcare in India, a focused management approach to the specific issues faced in healthcare would serve the needs of the sector and also help the individual to contribute to achievement of better standards and in turn enhance the quality of overall healthcare delivery.

ExpressPharma 31 March 2010

Sherin Moraes, a student at Marian Institute of Health Sector Management, Goa writes about the implications of liquidity and profitability in a pharmaceutical company

A firm is required to maintain a balance between liquidity and profitability while conducting its day to day operations. Investments in current assets are inevitable to ensure delivery of goods or services to the ultimate customers. A proper management of the same could result in the desired impact on either profitability or liquidity.

Liquidity is a precondition to ensure that firms are able to meet its short-term obligations. The ‘liquidity position’ in a company is measured based on the ‘current ratio’ and the ‘quick ratio’. The current ratio establishes the relationship between current assets and current liabilities. Normally, a high current ratio is considered to be an indicator of the firm’s ability to promptly meet its short term liabilities.  The quick ratio establishes a relationship between quick or liquid assets and current liabilities. An asset is liquid if it can be converted into cash immediately or reasonably soon without a loss of value.

Consequences of low liquidity

a) A company that cannot pay its creditors on time and continues not to honor its obligations to the suppliers of credit, services and goods could result in losses on account of non-availability of supplies and lead to possible sickness or insolvency. Also, the inability to meet the short term liabilities could affect the company’s operations and in many cases it may affect its reputation as well. Lack of cash or liquid assets on hand may force a company to miss the incentives given by the suppliers of credit, services, and goods as well. Loss of such incentives may result in higher cost of goods which in turn affects the profitability of the business.

b) Every stakeholder has interest in the liquidity position of a company. Suppliers of goods will check the liquidity of the company before selling goods on credit. Employees should also be concerned about the company’s liquidity to know whether the company can meet its employee related obligations–salary, pension, provident fund, etc. Thus, a company needs to maintain adequate liquidity.

Profitability is a measure of the amount by which a company’s revenues exceeds its relevant expenses.4 Profitability ratios are used to evaluate the management’s ability to create earnings from revenue-generating bases within the organization.

The ‘profitability position’ of a company is measured using the ‘gross profit margin’ and the ‘net profit margin’. The gross profit margin is an indicator of the profit a business makes on its cost of sales, or cost of goods sold. It is the profit earned before any administration costs; selling costs and so on are removed. The net profit margin is an indicator of the amount of net profit per rupee of turnover a business has earned. That is, after taking account of the cost of sales, the administration costs, the selling and distributions costs and all other costs, the net profit is the profit that is left, out of which the company will have to pay interest, tax, dividends and so on.

Consequences of low profitability

A profit ratio indicates how effectively management can wring profits from sales. It also indicates how much room a company has to withstand a downturn, fend off competition and make mistakes. Potential investors are interested in dividends and appreciation in market price of stock, so they focus on profitability ratios. Managers, on the other hand, are interested in measuring the operating performance in terms of profitability. Hence, a low profit margin would suggest ineffective management and investors would be hesitant to invest in the company.

Thus, a financial manager has to ensure on one hand that the firm has adequate cash to pay for its bills, has sufficient cash to make unexpected large purchases and cash reserve to meet emergencies, while on the other hand, he has to ensure that the funds of the firm are used so as to yield the highest return.

This poses a dilemma of maintaining liquidity or profitability as indicated in the figure below:

The liquidity and profitability goals conflict in most decisions which the finance manager makes. For example, if higher inventories are kept in anticipation of increase in prices of raw materials, profitability goal is approached, but the liquidity of the firm is endangered. Similarly, the firm by following a liberal credit policy, may be in a position to push up its sales, but its liquidity decreases.

Similarly, there is a direct relationship between higher risk and higher return. A company taking higher risk could endanger its liquidity position.8 However, if a company has a higher return it will increase its profitability.

The liquidity and profitability ratios of four pharmaceutical companies-Cipla, Divi’s Laboratories, Bafna Pharmaceuticals, and SMS Pharmaceuticals-over a four year period were analysed to understand the relationship between liquidity and profitability. (See Box)

The liquidity and profitability ratios of the above four pharma companies indicate that liquidity and profitability could go hand in hand. Except the year 2008, there is a positive correlation between the movement in the profitability ratios and the liquidity ratios. Despite the limited scope of this study, the observations would suggest that a company while planning working capital need not maintain a trade off between the two as is usually felt. In the light of the above, financial managers would need to reflect on the implications of each decision that usually involves a trade-off between liquidity and profitability. It would also be useful to assess the effect of one decision involving this trade-off vis-à-vis another, so that an overall view can be taken.

The present economic scenario has its implications on liquidity and profitability. ‘Recession means a general slowdown in economic activity over a period of time. Production, employment, investment spending, capacity utilization, household incomes, business profits and inflation fall during recessions; while bankruptcies and the unemployment rate rise. Because of this, companies are reverting inwards. In order to survive during these times, frugal measures need to be adopted. ‘Frugal basically means prudent, not wasteful, wise in expenditures, and inexpensive’. Being frugal would involve measures such as:

Decreasing the size of sales force and concentrating on highly trained sales reps that have already established relationships with physicians. This reduces the amount of liquid cash needed to be kept to pay salaries to sales reps; thereby increasing the liquidity position.

Focusing on already established relationships rather than trying to build new ones reduces the amount of money needed to be spent in order to acquire new customers.

Embracing technology,such as use of e-detailing programs, can reduce expenses incurred by the company, and hence enhance the liquidity position of the firm.

REFERENCES:

http://www.msrit.edu/dept/mba/iitpowai.pdf; Date accessed: 23rd August 2009

http://www.accounting-ebook.com/15/1.pdf; “Meaning and importance of liquidity”; Date accessed: 23rd August 20093. http://moneycentral.msn.com/investor/invsub/results/compare.asp?page=financialcondition&symbol=prx, Date accessed: 23rd August 2009

http://campus.murraystate.edu/academic/faculty/larry.guin/fin330/liquidity%20vs%20profitability.htm, “the liquidity vs. Profitability tradeoff”, date accessed: 23rd August 2009

http://www.bized.co.uk/compfact/ratios/profit3.htm, Date accessed: 22nd August 2009

http://www.investopedia.com/articles/fundamental/04/042804.asp – the bottom line on margins, Date accessed: 22nd August 2009

http://www.exinfm.com/board/profitability_ratios.htm, Date accessed: 15th August 2009

http://www.my-quickloans.com/LIQUIDITY-vs-PROFITABILITY.html, Date accessed: 15th August 2009

http://money.rediff.com/companies/, Date accessed: 15th August 2009

http://en.wikipedia.org/wiki/Recession, Dt acc: 20th feb 2010

http://social.eyeforpharma.com/story/recession-and-pharma-how-be-frugal-still-build-business, Dt acc: 20th feb 2010