Successful Medical Practice - winning strategies for doctor

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Successful Medical Practice – Winning Strategies for Doctors

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Index
Preface 4
Chapter 1 - Planning your career – carve out a niche for yourself 6
Chapter 2 - Beginning practise – get off to a flying start ! 11
Chapter 3 - Designing your clinic - make it patient-friendly 20
Chapter 4 - Assessing your practice – take a critical look at what you are doing 25
Chapter 5 - Marketing your practice – how to get more patients 29
Chapter 6 - Business management 101 - basic business skills you need to know 35
Chapter 7 - Financial planning and management – boosting your bottomline 40
Chapter 8 - Making your money work for you 43
Chapter 9 - Hiring the right people – your most valuable investment 46
Chapter 10 - Creating superb employees by taking good care of them 50
Chapter 11 - How to keep good medical records - worth their weight in gold 54
Chapter 12 - Scheduling patients – how to manage appointments efficiently 58
Chapter 13 - The telephone – your clinic's lifeline 62
Chapter 14 - Buying medical equipment – getting value for money 65
Chapter 15 - Going digital - using computers to enhance your efficiency 68
Chapter 16 - www.doctor.com - setting up your virtual clinic on the internet 70
Chapter 17 - Information therapy - how to educate your patients 73
Chapter 18 - Communicating with your patients – polish your bedside manner 77
Chapter 19 - How to listen to your patients – so they will listen to you! 81
Chapter 20 - Treat your patients as valued customers – how to win their lifelong loyalty 83
Chapter 21 - Improving your emotional intelligence – honing your people-skills 89
Chapter 22 - Keeping upto date – learning how to learn 92
Chapter 23 - Time management – making the most of your day by working smarter 96

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Chapter 24 - Managing mistakes in medicine – what to do when you err 99
Chapter 25 - Steering clear of malpractise threats – how to avoid legal battles 103
Chapter 26 - Risk management – keeping problems at bay 105
Chapter 27 - Crisis management – how to cope when the chips are down 110
Chapter 28 - Health v/s Wealth - the danger of (mis)managed care 114
Chapter 29 - Making your marriage work – keeping your better half happy 118
Chapter 30 - Parenting – bringing up the next generation 122
Chapter 31 - Retiring – from medicine, but not from life 126
Chapter 32 - Medical ethics –how to do what is right 130
Chapter 33 - Preventing burnout – manage stress efficiently 134
Chapter 34 - The impaired physician – healing the wounded doctor 139
Chapter 35 - Professionalism in medicine –striving for excellence 142
Chapter 36 - Physicians as leaders – aim to be the best ! 146
Chapter 37 - Spirituality in patient care – looking at the bigger picture 153
Chapter 38 - The joy of practicing medicine – how to be a happy doctor 156

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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, and face more competition. 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 practicing 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 is the
difference between inputs, which is how busy you are, and outputs, which is how productive you are - and the

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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 a :
• 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 upto 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 caretaker, 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
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 Practise Management Consultants
Bombay. India.

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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 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 doctor’s 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?

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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 specialization, 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 .

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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 !
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

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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 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

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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.

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2-Beginning practise – 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 of fire 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
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 their 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

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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?
• Your 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 co-operative?
Since this may be one of the most important decisions you ever make, give it enough thought and attention,
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 Practise
When you commence private practise , you will need to decide which form your practice will take. There are
three main options:
1. Single-handed practice.
2. A partnership.
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.

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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.

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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 practise, 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 subspecialty 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 PRACTISE
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.

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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 PRACTISE
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 a Professor, 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 will need to help you start
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.

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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 for most doctors, 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

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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 their 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 -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
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.

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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
manifold !
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

19
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 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 everyone has to
struggle to establish themselves !

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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 doctor’s 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 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.
When you start your clinic, make sure you have all the required permissions. For example, not only will you

21
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 5-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,

22
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 décor 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 characterizes 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 !
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) .

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A telephone line should be available for the patient's 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 facilities’ 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

24
answering the telephone . It is useful to have “cheat 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 !

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4-Assessing your practice – take a critical look at what you are doing
"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?
b. Telephone System
Are their enough incoming lines?
Are phones answered promptly and politely?
Are fax, e-mail services 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?

26
How are the charts coded?
Is there a system to avoid mis-filing?
e. Medical Instruments and Equipment
Is the equipment modern and uptodate?
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 trouble shoot 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?

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Are educational and medical reference materials available for the
doctor? for the patients?
It’s 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 are 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 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
Yes No

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so on?
16
Do staff or physicians apologize for waits longer then 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’s 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 !

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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 their 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 every day – and giving away your time, services and expertise for free can be
very effective !

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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 look at things from the
reporter’s 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

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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’s 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

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singular identity through branding and create an edge over the competition.
Branding is the big picture view that a doctor presents. It's 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’s 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

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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

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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.

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6-Business management 101 - basic business skills you need to know
"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 practise 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,

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regulation, technology, and profession of medicine are quickly evolving. Your medical practice needs an
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 prioritized timeline for adding
specialists, equipment, and administrative support staff; a continually updated (every year) list identifying

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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 personalized, 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.

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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 practise in improving. Think of a bank loan as the equivalent of a blood
transfusion for your practise’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 practise’s profitability . One can
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

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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 !

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7-Financial planning and management – boosting your bottomline
"Money is a terrible master but an excellent servant. "
- P.T. 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.
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.
The 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 practices' 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?

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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 uptodate. 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 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-

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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’s 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 !

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8-Making your money work for you
While most doctors are usually financially well off, you need to remember that you are a daily wage earner ,
and earn only when you work ! While doctors do get paid well for their work, this means that their cash flow is
good as long as they are young and are working. However, this is not a comfortable situation to be in, and you
need to develop alternative sources of revenue generation, which will ensure you a source of passive income.
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 I 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.

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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, Accountants and Taxes
Most doctors will need an accountant, who will help you to prepare and file your tax returns. A good
accountant will analyze your previous three years' returns, look for ways to cut your tax bill in the coming
year, and help you plan for the future. Money spent on a good accountant is usually money well spent ! He
will check your accounting systems, and also present you with financial reports, such as profit and loss account
and balance sheets - the financial equivalent of the pulse and BP of your practise ! Never hesitate to ask about
items you don't understand - after all, it's your money !
Your accountant will ensure that your accounts are uptodate, 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.
While doctors don’t like patients who ask for free medical advise, 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

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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.
You also need to think about what will happen to the money you have earned after you are dead and gone.
This is why 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 will may be worse
than none at all. A will may be revised at any time to take account of changing circumstances.
Live Rich, Die Broke is the title of an excellent little book written by Polan.
Rich Dad, Poor Dad

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9-Hiring the right people – your most valuable investment
"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 doctor’s 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 practicing
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
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

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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.

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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.

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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 formalized, 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 ! .

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10-Creating superb employees by taking good care of them
"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 !
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

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• 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

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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.

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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!

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11-How to keep 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 DIMS) , 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

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Nursing care
Diet
IV fluids
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 EKG's, EEG's, 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 understands exactly what you have entered and
what it means.
It’s 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-

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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 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. Practice 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 organized 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 medical 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,

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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, computerized medical record handling does also carry certain downsides,
such as the issues of privacy and confidentiality, and these still need to be resolved.

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12-Scheduling patients – how to manage 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.

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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 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

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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 their 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 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 pm 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 am, 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

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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 !

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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 IV 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

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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 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 practises, 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.

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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 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 !

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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 maximize 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 realized
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

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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 you
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

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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 !

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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, 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.
Computerizing your clinic is not an easy task. If you run a disorganized clinic, the computer will multiply this
disorganization 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 done, 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

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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-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 !

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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-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 email. 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 athttp://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

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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
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 ezine, 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.

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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
emails! 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 !

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17-Information therapy - how to educate 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
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.

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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 sensationalized
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 realized 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.

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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
customized 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 personalized 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’s 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

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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.

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18-Communicating with your patients – polish 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 !
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

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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 2-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.

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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 nonverbal 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.

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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 nonverbal 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 !

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19- How to listen to your patients – so they will listen to you!
“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.”
- Albert 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
dehumanizing 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

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illness and how to cope. Since these books have been
written for patients, they are patient-centric, and 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 !

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20-Treat your patients as valued customers – how to win their lifelong 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 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 customer's
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.

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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 time frame.
• 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 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 !

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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 – followupto
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 their 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

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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, 6unbreakable 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 email .
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

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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 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

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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 !

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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 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.
Managing the emotions of others (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.

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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 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-

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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 learn 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
Your 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 !

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22-Keeping upto 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 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 need

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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 athttp://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);
• Establishment, when you have created a name for yourself;
• verbal ( by listening, for example, by attending lectures) ; or
• kinesthetic ( by doing , for example , by assisting an expert)

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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

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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 !

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23-Time management – making the most of your day by 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

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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 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 III-
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.

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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 .
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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24-Managing mistakes in medicine – what to do when you err
"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
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

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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

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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

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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 !
BOX – 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 upto us. The best way is by being more
honest about our mistakes to our patients, our colleagues, and ourselves.

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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. "
- Mario Puzo.
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 breed 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 their
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 the doctor. In order to get a damage award in a

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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 !

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26-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 minimize 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.
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:
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 recognize and treat them. The sequence of events leading
to poor patient outcomes and eventually to malpractice suits can usually be clearly visualized. 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 well!
It is important to realize your own limitations, and to ask for consultations and referrals to seniors when

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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.
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 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's 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 advise 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

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perceptions of what occurred. 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 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 caregivers, 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.
Organize a family meeting if several relatives are involved in the patient's care or if treatment decisions are
complicated. Empathize 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 criticize 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 criticize yourself or other caregivers
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. 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

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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 scrutinize 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’s 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

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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.

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27-Crisis management – how to cope when the chips are down
"One often learns more from ten days of agony than from ten years of contentment."
- Merle Shain
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 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

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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 .

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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

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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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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 organized, 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
standardizing it to maintain quality 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 (HMOs).
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 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?

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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 "authorizations", 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’s 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 naïve as businesspersons , and even 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’s 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 authorization 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

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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
HMO’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 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 commercialization, doctors are
forced to become businessmen – and learn all about new terms such as cost containment, authorization,
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 health care 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 organization) , 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 practise 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 Relman, 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

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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.

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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 – so that 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 “socialize” ,
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
façade 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.
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

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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 can 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

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superficial way, leading lives of quiet desperation; or they continue to fault-find and blame and may verbally
attack each other for decades.
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

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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 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.“

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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 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.
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
idealizes 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

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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 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
wellbeing 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

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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 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
father’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. Theirinspiration 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 realize 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 realize 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.

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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 years – they won’t come back again. Take good care of
your children now – 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 their bodies but not their souls, for their souls dwell in the house of tomorrow,
which you cannot visit, not even in your dreams.”

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31-Retiring – from medicine, but 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, practicing 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 burntout; 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.

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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

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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.

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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.

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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 & 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
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 XIIth Std 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

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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 their 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 practise, 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 practises 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 practises. However, if you have rational goals - I want shelter, food, education for my
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. 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

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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, 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 practise 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 practise, 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 practise,
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 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 malpractise 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

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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 behavior. 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 !

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33-Preventing burnout – manage stress efficiently
"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 practicing 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 practise 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 . Doctor’s 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 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

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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 characterize 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 recognizing 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

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he is 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 !) 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

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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 wellbeing.
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 practice 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.
DON'T'S:
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

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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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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 practice medicine with reasonable skill and safety to
patients because of physical or mental illness, 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 practice
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,
disheveled 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.

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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 realizes 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.

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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 organized 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://www.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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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
"deprofessionalization" of medicine, and doctors finds they are threatened today by many forces: technology,
corporatization, specialization, 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 depersonalize medicine and "de-professionalize" a physician.
Corporatization 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 Relman 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.
Specialization. Superspecialisation and subspecialisation 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 realization 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 MBBS examinations digs a deeper grave for all doctors’

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reputations. “ Ask not form whom the bell tolls – it tolls for thee”.
Physicians the world over are now realizing that their professional status is under threat, as a result of which
many are now organizing 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 specialized 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

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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 + I/ S, where
T = Trustworthiness
C= Credibility
R= Reliability
I = Intimacy
S= Self-orientation

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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 !

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36-Physicians as leaders – aim to be the best!
"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 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
subsidized 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,

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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;
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 specialized 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

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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 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 !

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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 galvanized them into organized
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 realized 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 realizes that our people are our most important

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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 capitalize 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 ( dated 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

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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

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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 !

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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 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 organized 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. (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 hard-headed rational scientists, so that many feel
that nebulous concepts such as spirituality are unimportant and irrelevant. After all, you can palpate an

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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 can play a complementary role to medical care,
especially in dealing with critically ill patients or the dying.
Physicians can easily incorporate spirituality into their 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?"
H: Sources of 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

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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 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 realize 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 !

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38-The joy of practicing 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 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

157
body , so that you appreciate the perfection of your own body every day. 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 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

158
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 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 every day – 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

159
living – be glad you are a doctor and make the most of your profession – for your sake, and for the sake of
your patients !

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