Summary : Currently medical education driven practice is a low level bloom game. Tech driven industry stakeholders show promising solutions
[8/26, 8:33 AM] Thanga Prabhu: Like in UK medschool admission criteria both Attitude and Aptitude are given weightage. Last 5 years how one spent time is used as a factor. If a student volunteered in clinic, palliative care, hospital, rehab, etc. they are given higher rating. One can't pretend for 5 years right?
[8/26, 8:50 AM] Rakesh Biswas: In Indian medical schools, the entire focus is on memory (bloom game level 1) little on understanding (bloom game level 2) almost nothing about application (bloom game level 3) in MBBS.
Post graduate Indian medical education is largely about learning application that was denied to them in MBBS and there is some backtracking to level 1 and 2 but almost no rising to level 4-6 which is about analysis (level 4), evaluation (level 5) and creating (level 6) because of the invisible rusty lock on their medical cognition that has gotten stuck as it lay unopened since their MBBS days!
Incidentally the role of health IT begins from level 4 and this may explain why we don't currently need it in India!
[8/26, 8:54 AM] Rahul healthcare 2.0: Very insightful
[8/26, 9:28 AM] Sundar IAMI: A very insightful method to stimulate reform of the medical curriculum, Doc! 🫡
We all could support an initiative to bring reforms in medical education in this direction. Without that we will be playing in the fringe areas of healthtech for decades to come. Lead us @Rakesh Biswas
[8/26, 9:35 AM] Thanga Prabhu: So we have whole mountain to climb now?
[8/26, 9:36 AM] Rakesh Biswas: Maybe circumvent or dig a tunnel! 🙂🙏
[8/26, 9:40 AM] Rakesh Biswas: The problem is just to do with current policies in the medical curricula focusing on level 1-2 and completely ignoring the primary beneficiary of medical education (the patient)!
We need to begin the curriculum at level 3, centred around the primary beneficiary and then move the game up and down the different levels!
This can tremendously improve make in India at level 6 of this game
[8/26, 9:42 AM] Thanga Prabhu: Let us pivot and see it as a patient. I come to you with fever. How does the system look to me? Starts with naam kya hai 😭
[8/26, 9:43 AM] Sundar IAMI: Please show the way. There could be a focus group formed and grown to influence the authorities
[8/26, 9:44 AM] Rakesh Biswas: Yes it needs to start with someone holding hands and gently applying a temperature monitoring device for continuous monitoring along with symptom relief
[8/26, 9:46 AM] Rahul healthcare 2.0: Would the standard treatment workflows change? Or that they would be implemented in a more human centric way?
[8/26, 9:52 AM] Rakesh Biswas: Have presented these in JIPMER where a focus group was created to change the curriculum in 2015 chaired by MK Bhan who was a director there at that time.
It wasn't looked upon well by many departments who would be most affected by patient centeredness as they are currently not encouraged to see patients.
The only fall out of that was when one of the JIPMER faculty became AIIMS director later, our student @Avinash Gupta Nepal was invited to present our work as archived here 👇
From then my focus has been to develop departments of patient centred anatomy, Physiology, biochemistry, pathology and essentially we need to make make medical college teachers all round physicians who can deal with patients everyday (in a blended manner offline and online) as well as their own specialty devices, be it the cadaver, microscope or spectroscope!
[8/26, 9:54 AM] Rakesh Biswas: Even they would change as we get more and more patient centred and realize that the standard workflow solutions are at best average in terms of outcomes and level 4-6 can do much better!
That is when we begin to move from standard static ontologies to dynamic rapidly evolving ontologies geared to deliver improved outcomes toward precision medicine led patient care
[8/26, 9:59 AM] Sundar IAMI: When I take a balcony view of all the discussions we are having, I see the following areas of reforms that we seem to be wanting:
a)Medicolegal - Dr Rajeev has already got started
b)Medical practice ethical guidelines embracing digital health
c)Affordable access to digital health, medtech and healthcare delivery technologies
d) Self-sustaining ecosystem of new age ecosystem in healthcare
e) Digital health standards and adoption - Digital Health India has been founded - @Pramod Jacob @Uma Nambiar Dean IISc Medical School
f) Preventive care
g) Medical curriculum to prepare future doctors
We seem to need reforms in many areas. That's why we are not able to acquire escape velocity.
If we want to be effective we need to fan out in groups along these 7 areas and start aggressively bringing in changes.
Views, perhaps, of a frustrated yet optimistic man
[8/26, 9:59 AM] Arnab Iami Iim: Does India have equivalent of nurse practioners?
[8/26, 10:06 AM] Rakesh Biswas: [8/24, 11:18 PM] Thanga Prabhu: can pharmacy serve as an interface?
[8/24, 11:30 PM] +91: It was difficult for us when we tried to transition pharmacists from a pure commerce-led mindset to a long term healthcare based model. That being said, couple of startups are trying to leverage the retail pharmacy network to setup e-clinics.
[8/25, 5:40 AM] Rakesh Biswas: Wow! What a find!
Have become a fan of the authors after reading this paper!
We have ourselves travelled from pillar (our tertiary care medical college centers) to post (even talked to post offices) to deliver comprehensive continuity of health care over the past few decades but never made much headway training pharmacists due to the barriers that @~Vibhor Agnihotri possibly hinted at.
Pharmacists have the selling retail mindset (even most doctors do) while comprehensive continuity of care requires a research mindset? Either way it's related to our field of medical cognition that we dabble in 24x7.
More about it later. 🙂🙏
[8/26, 10:18 AM] Rahul healthcare 2.0: Brilliant thought. The trust of patients with pharmacists is often more than that with the doctor.
Pharmacists are in neighbourhood, you say hi even when you are not buying anything, local language, casual setting, direct access.
Compare that to doctor's AC office, precise articulation needed (else doctor expresses impatience), condescending remarks on how you messed up your health, receptionist hop to meet doctor, you feel like you are being done a huge favour by being granted audience by the president, and of course you pay a bomb.
.
[8/26, 10:24 AM] Thanga Prabhu: Ahem...i object milord. You probably are seeing the wrong Dr.
[8/26, 10:43 AM] Bharat Gera: Quite true that the experience with doctors is not convenient..doesn't mean trust is lowered..some of the most crowded clinics are most preferred as people trust the doctor
[8/26, 10:53 AM] Bharat Gera: On the other hand, it does improve things vastly if clinics can provide a better experience..going through one right now with my wife at Proactive for Her..they have created an awesome ambience that appeals to the new generation woman..of course it costs a lot more to provide a Lux experience
[8/26, 10:54 AM] Rakesh Biswas: Like everyone throngs to most crowded hotel!
[8/26, 10:55 AM] Rakesh Biswas: Yes that's the reason corporate hospitals are such a big draw and government hospitals are a nightmare
[8/26, 11:01 AM] Bharat Gera: Combination of 4 Cs are needed by patient, Care, Convenience, Clinical Outcome and Cost..most important is always clinical outcome to gain trust..cost that patient is willing to pay is influenced by convenience and care as these are more directly measurable and observable..bit finally it is the clinical value that builds trust.. corporate hospitals or Lux clinics cannot sustain in long term without trust
[8/26, 11:02 AM] Vijayasimha Ajarananda: Absolutely. But I think the MCI was the bottleneck. The NMC is calling it task shifting. Wonder, if it's a word that implies 'give the boring and repetitive work out'.
[8/26, 11:24 AM] Thanga Prabhu: It means deskilling. A la Henry Ford the maverick who figured out if a task is broken up to its smallest possible component, it can be done by less skilled worker. Who can be paid a pittance. Model T was born. Healthcare is being equated to that production line...🤦🏽♂️
[8/26, 11:27 AM] Rakesh Biswas: Using a medical cognition lens :
All that demand for patients conciseness in information sharing making the doctor appear brusque and condescending is because of limited static ontology driven workflows where the doctor is trying to simplistically mental model and fit the patients information into a quick drug or device outcome as his medical education is heavily influenced by the two!
Pharmacy education needless to say is even more narrow and hence fraught with danger if it's standalone.
As hinted by @Sundar IAMI and others, we need to move away from the traditional dyadic and embrace the team driven information support systems approach where the individual competents of a deskilled workforce can be better regulated.
[8/26, 11:30 AM] Sundar IAMI: Unfortunate. Healthcare needs its own Henry Ford visionary. Healthcare should *not* get inspired by the reforms in industries based on man-made inventions. Yet we must find appropriate ways of delivering healthcare by decentralisation and dispersed collaboration.
[8/26, 11:30 AM] Thanga Prabhu: One can assist a Dr. Replacing him with lesser trained folks is criminal in my world.
[8/26, 11:51 AM] Rahul healthcare 2.0: Haan... I forgot the family doctor, who has highest trust of the patient. If family doctor can be the single point of contact and one shouldn't need to run to specialists, that would be ideal for trust.
@Sundar IAMI was sharing how patients nowadays want to directly go to specialists.
[8/26, 11:52 AM] Thanga Prabhu: Why the If? They exist
[8/26, 11:56 AM] Rahul healthcare 2.0: I meant the family physician refers patients to specialists (for a good reason) and the it's like passing the baton.
Just a thought - Can the physician only get opinion from specialists and convey that to patient? Does the patient have to talk to specialist?
[8/26, 11:58 AM] Sundar IAMI: In the world of complex chips and software, the system engineer is a revered role and the competence takes years to acquire. Any system problem first gets analysed by the system engineer and then referred to the subsystem experts. In medical practice why should the general physician (who understands the complete human body and determines the expert to refer to) be the person with the least valued qualification?
[8/26, 12:00 PM] Thanga Prabhu: I can handle basics + emergency. When a patient has brain tumour, i cant operate in him. There i request my neurosurgery colleague to help. He steps in, does his magic and hands patient back to me. I am the constant, others come when i invite
[8/26, 12:09 PM] Thanga Prabhu: You are asking the right question. In a world of value added services...pay 150 to talk. 50 more for gaana. 20 more for chat. 30 more for movies. That model crept into healthcare delivery. Hence if I charge x then I need to do y activity. Market forces mean, higher demand/ lesser supply = Higher mrp. Medical education and so called star Dr now can ask for moon and it is delivered.
[8/26, 12:14 PM] Sandeep Dighe CPS: Starting with this...
In the olden days (My Grandfather's days, who was a GP having all "good" qualities mentioned here - "trust" of patients, knowing when to treat himself vs when to refer, numerous informal hello walk ins during Clinic times - used to be handled between actual Patients quickly with Medical Representatives etc), "GPs" as Family Physicians would be _confident_. Over time, dare I say, it became mandatory for the MBBS ppl who could get PG Seats to do Post-graduation for better prospects and only the slightly less capable ppl remained at MBBS/as Family Physicians; Society also played their part in this. Thus, the best don't stop at MBBS hence Family Physicians no longer command that kind of trust in Society...
Sounds debatable? *There can be exceptions in everything* but can we say it became "fashionable" to get more degrees rather than remaining an All Rounder GP (My Grandfather would even do Minor Surgeries, something rarely done by GPs nowadays...?)
Discussion welcome...
So my point is similar to one already expressed... ⤵️
[8/26, 12:15 PM] Thanga Prabhu: Secondary care is his solution. Can't medical College do 3 things: 1. Treat 2. Educate and skills training 3. Research to publish
[8/26, 12:27 PM] Rahul healthcare 2.0: True.. but can the whole process be controlled by the family doctor? So today when a family doctor suggests going to specialist, the specialist takes over.. not just the medical advice part ..since they are associated with some big hospital, everything from the tests to the experience is now transferred to the specialist. I guess that is where a patient feels that they are out of control, out of their comfort zone.. even the GP isn't able to interfere.
[8/26, 12:35 PM] Aniruddha Nene: Why can the payer ( insurance cos ) offer an advocate to support the patient during the care journey, rather than turning to TPA and into claim rejection mode?
[8/26, 12:38 PM] Sundar IAMI: These models are being tried out .... check out "patient navigation". The problem here is that the patient navigator has no expertise nor credibility for his advice to override the suggestions from the Specialist
[8/26, 12:51 PM] Sundar IAMI: What if the district level medical colleges offer patient navigation? They have no mercenary incentive. They get rich set of cases for study. They have the expertise. If navigation is captured digitally on a platform, participating specialists and physicians and hospitals will be obliged to consider (even if they are permitted to modify) the recommended pathways.
[8/26, 12:56 PM] Sundar IAMI: Money spoils what would otherwise have been a great service of immense value to mankind. Some other models of rewarding the value created are missing.
[8/26, 12:56 PM] Rahul healthcare 2.0: Brilliant idea @Sundar IAMI !!
Would it be possible for a teaching hospital to take on more remote patients for navigating them and doing the analysis, evaluation and at times creativity @Rakesh Biswas ?
[8/26, 1:03 PM] Sundar IAMI: Medical Science education has to take responsibility for making medical science suitable for ethical, equitable and effective delivery. And in that direction I haven't seen much evidence. For example there are many "not clinically approved" techniques of detecting breathing issues. Can medical science be extended to include them in assessing the condition with some uncertainty?
[8/26, 1:15 PM] Aniruddha Nene: Some of the private teaching hospitals especially in Maharashtra, do face bed occupancy mandate as a challenge. They can become navigators. Navigation is a virtual clinic for the teaching institution / unit. NMC should relax the bed occupancy norms in favour of navigations performed for remote patients. I believe that learning is as strong an incentive as monetary benefits. 🙂
Now if a navigator discovers some services that are likely to be rejected in the claim settlement, the Navigator can question. Of course they cannot always control the outcome, but it will certainly deter blatant exploitation.
[8/26, 1:51 PM] Sundar IAMI: I was discussing with @Rahul healthcare 2.0 the other day. A GP gets 20 to 30 patients a day in OPD and gets to earn Rs 3000 to Rs 5000 per day. He cannot sustain at this level for long. He is aware that his advice opens up a value chain of Rs 1000 to Rs 10000 per patient. So he makes a measly 1% share of the wallet (SOW). This acute asymmetry needs to be addressed.
What does the GP do? He opens a pharmacy store in his spouse's name and lab in his uncle's name. So his SOW increases to 30%. How can he resist this? And probably his grandfather doctor used to have his own dispensary and biochemistry lab too in those days. All he has done is to adapt to the evolution of the players scaling their operations.
There is an unfair asymmetry of revenue that the prescribing doctor sees. And we want him to deny himself the share of the value he has unlocked. Are we not being unfair?
[8/26, 1:53 PM] Sundar IAMI: A CEO of a new age care provider put it brilliantly. Healthcare is a sum of parts. So the one who is able to bring together all the parts takes the major share of the wallet. That's why the hospitals are able to sustain and the individual doctor is not.
[8/26, 2:17 PM] Sundar IAMI: Yet, for quality healthcare to be equitably accessible, we need to grow the ecosystem outside the hospital. That is the conundrum
[8/26, 2:42 PM] Rakesh Biswas: @Rahul healthcare 2.0 @Avinash Gupta Nepal Best description of our current role 👏
[8/26, 2:45 PM] Rakesh Biswas: Yes we try to do that and could do it better if we could make the curriculum patient centered enough to support this. Currently we are swimming against the tide
[8/26, 2:47 PM] Rakesh Biswas: Also doing all this partly blended in an online platform with audit trails makes it transparent and accountable to all stakeholders who can be easily shown how to join the dots and learn how the learnings and earnings get utilized
[8/26, 2:51 PM] Rakesh Biswas: Here's is a very interesting write up in "national medical journal of India" from 2018 that appears even more relevant now :
"That year, as Head of Gastroenterology, I had organized a professional conference and had called three foreign speakers for the same. This was done on assurance of sponsorship by a multinational corporation (MNC) with a big presence in India. But just a month before the conference, the MNC had some legal trouble in India and started thinking of withdrawing operations from this part of the world and also withdrew the offer of sponsorship.'
‘That must have been terrible!' I said.
‘I was left with no option but to inform my foreign friends about this, cancel their talks and lose face. But then I was informed that tickets and stay had already been booked by my residents by paying an advance. Even if I was to cancel all arrangements, it would still lead to huge financial loss. I was extremely tense those days because I was not good at collecting sponsorships.'
‘What did you do?' I asked.
‘I discussed with my wife and she suggested that we pool in all our savings to get out of this situation.'
‘Did you do that?' I asked.
‘Thankfully no. It was during that time that Ruchir came to thank me again after a successful bariatric surgery. He had lost 40 kg. And during our two-minute talk he sensed my tension and asked me about the problem. I told him everything.'
‘What did he do?' I asked.
‘He laughed out very loudly and told me another joke. And ended his discourse with “What are friends for?”'
‘Did he agree to sponsor the speakers?' I asked.
Professor DS said, ‘He not only agreed to sponsor the speakers, he insisted that he will organize the banquet in a hotel. I remember that I had protested, because I was not buying anything from his company then. He just said, “Sir, you don’t have to. My company is doing well, and I am buying goodwill from some good people”. '
‘So, he bailed you out in difficulty,' I said.
‘I think he did more than that. In that banquet, he arranged a musical evening and sang himself. That’s when I learnt that he sings very well.'
Professor DS went on, ‘And my conference was remembered for a long time for that banquet. I was even invited by my friends to Europe and USA in reciprocation.' After a short pause he added, ‘Much later, when I retired and I was looking back at my career, I felt good about everything I did, except two occasions when I was helped by Ruchir. He somehow made me feel corrupt, where I accepted things that I did not deserve. He says he runs his business on goodwill, and I remember someone has said ‘“Never underestimate the allure of the Goodwill."
[8/26, 4:18 PM] Sundar IAMI: We will. But then we bear the consequence of a broken referral system that has no incentive to work. We are raising these matters here to find solutions to the root cause of the problem. Individuals are not bad. Every doctor who practices wants to do the best for the community. But the policies and structures force people to find unusual ways. The paper shared by Dr Rakesh is so insightful about how influences are exerted. The only way you can prevent such creative workarounds is to address the root cause - bring in fairness in remuneration. Then everything will settle down.
From creative commons licence accessed from and attributed to the blooms taxonomy wiki page
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