C H Unnikrishnan and Sumit Ghoshal
One of the serious concerns in the Indian healthcare scenario at present is the absence of a compulsory continued medical education (CME) system for doctors to update themselves with the fast-evolving changes in medical science. It is high time the government put in place a strong law that restricts the practice of doctors who do not undergo a certain period/number of well-designed and recognised CME programmes every year. The Medical Council, or any other competent health authority, should have the powers to make doctors comply with this law, says Dr Azad Moopen, Chairman, Aster DM Healthcare Group, who built one of the largest hospital networks in India and the Middle East countries. Moopen, a successful doctor-entrepreneur who strongly believes that a fully updated medical education system and a medical fraternity abreast with the latest knowledge is an essential part of quality healthcare, engages
in Straight Talk with
C H Unnikrishnan and
Sumit Ghoshal, Edited excerpts.
India is seeing an increasing trend of individual doctors taking up multiple roles as clinician, researcher and entrepreneur as they chase bigger growth trajectories in life. You have been a very successful doctor-entrepreneur. What is the key advice that you can give to the aspiring entrepreneurs who want to set up hospital chains or corporate hospitals?
Entrepreneurship needs a completely different skill-set. The professional skills of a doctor may not always help one to be successful as an entrepreneur. One very important thing that these aspiring doctor-entrepreneurs must do is a preparation, preferably for at least five years, by taking a sabbatical to learn the different aspects of the business before jumping into their own venture. This includes a deep study on market opportunities in multiple geographies, as it could be a multi- or single-speciality hospital, or even creating a completely different model to cater to a need that exists. Another important requirement is to get trained in management. Would-be entrepreneurs should do a 2- to 3-year internship at a large hospital or a course in a reputed institute on the management of finance, HR, technology and so on. This will help them avoid many mistakes that a maiden entrepreneur could potentially make. They may think that it can be managed, but the fact remains that a professional approach is required in all these aspects. Frankly speaking, I haven’t done this . I learnt it by committing mistakes, and from my experience, I can say that they can avoid most of those mistakes with this preparation. The third important thing is the access to funding, where you have to have good people or institutions who are on the same wavelength of thoughts to support you. It is also important that, at the same time, one should also look at access to capital from a bank or an institution. But, one thing that they should make sure is that the leveraging of loans should be at a respectable level, because the debt:equity position for the hospital business cannot be compared with that of other businesses. A hospital will take at least 5 to 10 years to establish its brand and gain patient trust, and it is easy for one to get into a debt-trap if they can’t hold on until that time.
You mentioned that updating the skill-set and knowledge are the most important elements in a quality healthcare system. But, what needs to be done to ensure this in a country like India, where the medical curriculum is not quite updated and the CME is poor?
It is an important question from the professional point of view. For this, there should be strict measures from the regulatory side to ensure quality of education and regular updating of doctors’ skill-set. The government should bring in a requirement that doctors have to fulfill a certain number of well-designed and recognised CME hours in a year. Some doctors who completes their graduation or post graduation 20 or 30 years ago may not have done much to update their skills as the regulation does not make it mandatory over here. In the West, and even the GCC, it is compulsory that doctors must earn their specified CME credits in their respective fields for getting their licenses renewed. In India, another serious concern is the dated medical curriculum. Sad to say that most of what is in Indian medical curriculum is still the same that I studied 40 years ago, despite the fast changes that happened in the field of medicine. And once you graduate, you are free to practice lifelong with that degree, unless you voluntarily take an initiative to study and update further. There should be a thorough revision in the medical curriculum in India. For instance, there are many things that is essential in the profession today — such as medical ethics, dealing with patients‘ relatives, taking the consent of the patients for even touching them — that are not taught in Indian medical colleges, unlike in the West. Also, I feel that the government should provide much more support and funding for new research in hospitals, an aspect that is often neglected in this country.
Why do we not see a robust patient-reference culture among Indian doctors or hospitals as it exists in developed markets, especially in the private healthcare set-up?
The main issue here is that the individual doctors often do not want to lose patients. There are two key reasons for this. One is the financial loss, and the other is the ego that doesn’t allow them to admit that someone else is a better expert or is better equipped. References to other doctors or hospitals is not a big issue in a government funded set-up as the doctors are not concerned about revenue. In fact, they can leave the risk to someone else by referring high-risk cases to another doctor. There are also issues with the receiving doctors or hospitals in the referral context. They do not often report back to the referring doctor with case progress or additional details on the investigation. So the referring doctor loses confidence as well as the patient. Referring complicated or improperly diagnosed cases to an expert doctor or a hospital is a well-appreciated and appropriate culture in the healthcare system and good for the doctor. I am sure this culture will gradually emerge in India too as the system gets evolved with better awareness. For example, we at Aster have, from the beginning, implemented a policy to reach back to the referring doctor with the feedback on additional investigation, case progress with our expertise etc., and also referring
the patient back to the original doctor for follow-ups. That’s how it should be as
it is a long-term relationship which will ultimately prove beneficial for the patient as well.
Do you think Indian patients are, in some way, deprived of better medical treatment because of less updated doctors and slow adaptation of better technologies by hospitals? Does the existing revenue level at Indian hospitals create a constraint?
This could be true in the rural and semi-urban areas, because the doctors don’t get much opportunity for re-skilling themselves. There is the need for a more structured CME programme that covers a majority of doctors. Technology upgradation in Indian hospitals is quite fast and advanced. In our own hospitals, for example, we have PET, Robotic Surgery, facilities for
Molecular Diagnosis, etc. In fact, the Gulf countries are a little behind in this respect. On the revenue front, the hospitals in metro cities do not face much of problem. However, the situation is very different in the Tier-II and Tier-III towns. In the latter, the investors are not quite willing to allocate funds for new technology. But things can improve if the government is able to provide some financial incentives to people who want to set up hospitals in non-metro locations.
As a doctor-entrepreneur, what are the other key challenges that you see in the Indian healthcare system? Do you think the big proposals like Ayushman Bharat can find some solution to resolve them?
The main challenge or lacunae in the Indian healthcare system is the low spending by the government. It does not even match the 5-6 % of the GDP which we see in the emerging markets. In developed countries, it is close to 10%; the highest being in the US where it is almost 16%. The other issue is the low penetration of medical insurance. As a result, the Indian masses are not able to avail of good healthcare facilities. However, we hope these issues will get resolved to a great extent if the government could successfully implement the health coverage as proposed in Ayushman Bharat, and things could change for the better.