Value chain of healthcare delivery is intertwined among multiple stakeholders at every stage. Everyone has a role and responsibility too. The patient cannot be absolved of the responsibility under the pretext of wilful ignorance even if it is due to the subject matter being too technical or too clinical to comprehend. Moreover, there is a flurry of systemic gaps like missing or misaligned rules; compromised quality of care; sub-standard devices/drugs; or conflicted/improper choices to drive profiteering or other agendas. Far from being failproof, currently we are not even foolproof!
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Recent advances in the field of medicine especially in minimal invasive interventions in cardiac and neurosciences and in orthopedic practice — trauma, spine or joint reconstruction, have brought in increasing usage of implants and prosthesis. These implants, etc., are medical devices that help in treating several conditions that hitherto were left for palliative treatment, providing options for minimal invasive interventions, reduced the hospitalisation and restoration of functionality in shorter time such that individual is rehabilitated faster. However, the ultimate success of usage of implants is just not insertion or fixation to the body organ where it is needed but restoration of anatomical integrity and restoration of functionality to normal or at least near normal.
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Dr madhav surya read the e-mail from Abhed Govil, the son of one of his ex-patients Sunetra Govil. Connecting with the family again made Dr Surya, an orthopedic surgeon, happy. Sunetra’s had been a ‘repair’ case. She had suffered an arm fracture that was treated by several surgeons and finally come to Dr Surya for repair. And now Abhed wrote from Chennai: “It is unusual how life patterns present. I wish to consult you about my friend’s wrist, which he fractured during a rock climbing exercise. The local nursing home checked him and said it was a distal radius fracture. The doctor aligned the bones and put him in a plaster cast. It has been a month now and he has difficulty moving his fingers. I am in Delhi this weekend and would like to show you his X-rays....” That the friend was yet unable to move his fingers bothered Dr Surya. Usually it was expected that the fingers would be at ease within 24 hours of a surgery or cast. His mind began to raise questions already: Did the patient not go for check-ups or did the doctor not tell him to report within 24 hours and then again weekly for three weeks? Three weeks was a long time. It was usually one or the other... The X-rays that Abhed showed him, were taken immediately after the accident. It was an intra-articular, non displaced fracture, but the fact that Paritosh (Abhed’s friend) was not moving his fingers pointed to a displaced fracture. Likely the fracture worsened in the week after the accident? “I do think he must go back to the hospital and get examined,” said Dr Surya. “Frequent checkups are crucial to the recovery. Only then the rate of progress can be known. The hospital you mention is good, and did you tell doctor about the painful fingers?” Abhed: I stepped in only last week when I found him in pain. I did imagine hospitals were better today than they were 10 years ago when Ma’s fracture took place. Then again, what is good, what is better! The best hospitals have messed my mother’s arm, successfully ruining her life for eight years. So, why did the best hospitals go wrong? Dr surya did not hold this bitterness against Abhed. After all, the lives of everyone in the Govil family had been thrown off gear for those eight years. Not to mention, poorer by Rs 4 lakh. Abhed , a PhD student from IIT Madras had come with Paritosh’s X-rays and papers. Paritosh, also a research student, was in plaster cast but Abhed began to grow suspicious when his fingers remained painful three weeks hence. That was when Abhed recalled his own mother’s tryst with a fracture that was mismanaged. He was 17 then and in the throes of his 12th Boards and IIT entrance exams and the family had protected him and kept him out of all anxiety. It was much later, in fact at his IIT graduation lunch, that she shared with him all that had happened. Abhed who had gotten used to his mother in perpetual pain and frowns, was pleasantly surprised when he saw her, looking good, well dressed and back to being happy about life. She shared with him how she had chanced upon Dr Surya of Dhanwantri Care. “He repaired all my earlier faulty surgeries,” she explained. “Until then we had met, so many doctors; I sensed they were not getting it right. Each time they put a different nail or plate and it was such madness... eight years of trial and error....” It was this that had alerted him about Paritosh’s condition – that the doctors at Plus Care, were hinting at another surgery without even auditing what went wrong with the first. This was exactly what had happened with his mother too. He now told Dr Surya, “The patient will never know what the doctor does to his insides. He just submits himself, hands his body over to the doctor. Thereafter it is between doctor and your body! Long ago, the doctors at the City Hospital asked my mother what kind of plate she would like put into her arm, without telling her what she needed. How was she supposed to know?” Surya: Some doctors wonder if the patient can afford the cost of better quality implants.Abhed: Seriously? Is that how they deliver healthcare? According to affordability? Does my wealth give me a right to life? And my poor resources a duty to die with substandard treatment? Is there not a right to quality healthcare accorded to me under the Constitution? Dr surya then began to piece together the events surrounding the numerous surgeries that Abhed’s mother Sunetra had gone through, until she finally came to Dhanwantri for repair. Sunetra Govil had undergone four surgeries in all for her arms, three on her right arm and then a fourth and fifth on her left arm; she had had yet another fall a year after her right had been fully healed by Dr Surya. When Sunetra fractured her right humerus, she was first taken to a private nursing home by her family, where a 6 hole, locally made, DCP was used to fix the bones. Six months later, she continued to be in pain and it was found the fracture was not uniting. Her family then took her to the prestigious EFG Hospital, where she was operated upon yet again and another local 6 hole DCP was fitted and bone grafting done. Abhed: Did the EFG doctors say why the earlier surgery had gone wrong? Dr Surya: The investigating team saw that the plate had come loose, that her bone had not united; so they removed it and put another local made plate. Abhed: How did that help? Without an audit how can a hospital perform a second surgery?what could Dr Surya say! But as the story went, the second plate too came loose, the pain got worse and she was put back in plaster cast. And thus she remained in plaster cast for close to a year, yet unusually the fracture would not unite and all the screws and plate were almost out of the bone. Abhed: You said ‘local plate’ twice. Why do you say local? Are there other kinds? For example, if the surgery was done at a super speciality hospital, what is the kind of DCP they would have used? A patient is likely to think that using the best branded implant is the default for any hospital!Dr Surya: Local means either ‘source is unknown’ or unbranded. Save one or two global brands, no implants of any known quality or grade were available in India. It was mostly cottage sector models. Nor were there any filters operating in the implants market. Just about anyone could set up shop and fabricate these, sadly. Only in 2006, the law was enacted that every manufacturer of stents and implants must register the products. Hence it is not necessary that a patient gets fitted with the best, even today. Your mother came to Dhanwantri on the recommendation of good friends. But she was very cynical and unwilling to be guinea pig again. Her second surgery had failed too, and she was experiencing a lot of neural unrest. I must add, the implant was a fake and her body was rejecting it. Her blood tests recorded high numbers on some parameters, and it seemed to point to the implant. That was when I did a bone graft again but this time I used a titanium Kyosin implant. In two months she was recovering very well, and she was back at work. Abhed: And were you able to see why her earlier two surgeries had gone wrong?Dr Surya: A combination of events if we may say that. At 40, her age at the time of the first accident, she may have already been osteoporotic. (For, she was osteoporotic when she came to me the following year in 2005 after her left arm fractured; we had performed a bone density check then.) Now, see in the case of osteoporotic patients, the bones are very porous, hence the grip of implant is weaker. If the bone quality is strong, the screws and the plate will hold. Think of wood and think of hard foam. This is the difference between a healthy bone and an osteoporotic bone. In an osteoporotic bone, the screw will start to give way. What happens is that the overall construct that is meant to last for a certain period for the bone to unite, starts to become loose. That could be why her first implant came loose with her arm movements and caused her untold pain. I will also say that, that is why after the second surgery they also put her in plaster cast, to reinforce the implant. Usually with implant you don’t need plaster. Maybe there was a suspicion that her bone was osteoporotic and the doctors may have felt it best to add the plaster cast so that her movements will not cause the grip to come loose. Abhed: Suspicion? Can a doctor provide a course of treatment based on assumption? Is it not natural for a fracture doctor to first check bone density? If they did not, is it not negligence? The doctors at two big hospitals failed in not having audited why her surgery had failed twice! Nor had they done a bone density check! What is the point going to a big hospital then? Dr surya then mentioned Sunetra’s second fracture. Her right arm healed after I operated upon it. But a year later, on a family trip to Bharatpur, she fell and broke her left arm. Abhed: Yes, I remember, I got a call at IIT... Ma wanted to come to Dhanwantri to be treated, but they thought she was being hysteric and got her treated at some small clinic.Dr Surya: Very sad indeed. Often family members discount the feelings of the patient, which is wrong. It appears the doctors there convinced the family that if she was not operated upon she would lose her limb. In my opinion, patient families should not panic and seek to get informed. Anyway, the team of surgeons at Varsity Public Hospital, put a locally made intramedullary nail into her left humerus. But the nail-implant was not holding the bone in proper position and the limb was just rotating around the nail. This made shoulder movement very painful – the nail was practically sticking out of shoulder joint. Abhed: What? What does it mean? Dr Surya: See, the bone is like a pipe with a hollow centre. In the case of load bearing bones, sometimes the doctor may decide not to use a plate, but instead to put a steel rod called the intramedulary nail through the canal. This gives strength as it verily reinforces what the whole bone was doing. So, this is what was done on her. She remained in plaster for six months but the fracture could not unite and also the shoulder became frozen. She was back home and was enduring such a rotten fracture. Abhed: Is not a bone doctor supposed to check the patient several times in between? Did this doctor tell her what could be the reason for the failed union of the bones?Dr Surya: Ideally the damage should have been discovered far earlier. Things need not have come to this pass. See, patients too have very poor discipline. If families discount the pain of the patient, then at the other extreme, patients also discount the doctor’s recommendations for care. Even if I recommend an X-ray, I have seen patients saying ‘the bone will heal sooner or later, why do so many X-rays. Acchha nahi hota hai...’ And then the X-ray is not done. I think your mother was angry over her condition… . Abhed felt bad suddenly. He recalled one occasion when his mother complained of pain and the family had cajoled her saying, ‘See, it is winter, bones will pain, learn to be patient’; and they had fed her turmeric milk.. “What caused the damage this time round? asked Abhed. Dr Surya: What we saw was a poorly done surgery. I shared her X-ray with the technologists at the Kyosin implant manufacturing company. See, you don’t just put a rod and leave it there. You need to lock the nail into position at the top and the bottom so that the two pieces of the bone are no more rotating across the axis. This is the concept of LARD: length, angulations, rotation and displacement. In Sunetra’s case, the rotation was left loose. Actually we learn all this from the implant manufacturers too... they do train surgeons.Abhed: So, then, what did you do differently that mom was healed?Dr Surya: I looked at her bones and based on my work with implants, I felt she would heal perfectly if I fitted her with a titanium plate. It is suited to an osteoporotic bone, which is like sponge... hence any implant we use must grip the bone better. Dr surya opened a cupboard and brought out a titanium plate in its packaging for Abhed to see. “This is what a philos plate looks like,” he said handing it to him. Abhed examined it a trifle overwhelmed. One side of the pack showed the stages in which it is fixed on a humerus. Below, he read: This description alone does not provide sufficient background for direct use of the product. Instruction in handling this product in accordance with the corresponding technique guide and by a surgeon experienced in handling this product is essential. Abhed was reading it aloud. And Dr Surya commented, “This also means one needs to be informed, trained in what situations various plates and grips can be used. So, you see, it can never be based on affordability! Abhed’s mind was now a riot. Wow, he thought, four times mom was operated to put in and take out plates of these kinds. Dr Surya: There is a huge responsibility that doctors and surgeons have with regard to treatment and solutions. Technology keeps evolving. A doctor has to keep learning. And this occupies a huge part of my professional mind and this is why I spend more time learning than building a brand name. But I also wish to tell you that patients have a duty to know, a duty to ask, a duty to be informed. As in every domain, in medicine too, ignorance is not an option and cannot protect you!” To be continued... Meera Seth(This story was published in BW | Businessworld Issue Dated 29-12-2014)
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The narrative of Sunetra’s prolonged travails with impersonal doctors and mishandling hospitals, with a side story of Paritosh to reinforce that theme, profiles the ugly side of our healthcare system. Counterposed is the compassionate and professionally competent figure of Dr Madhav Surya who presents the reassuring face of empathetic and ethical healthcare. Such a conscientious and caring attitude should ideally be the norm but sadly is a rarity in recent times. The skewed relationship of doctors with their patients arises from the asymmetry of information that renders the latter helpless and concentrates the decision making power with the former. The exercise of this power is presumptuously paternalistic at its best and callously exploitative at its worst, in the warped world of commercial healthcare. The prohibitively high financial cost of healthcare, a burden even to the middle class, is bad enough but the biological costs of improper medical treatment compound the suffering. The kind, caring and trusted family physician of yore, who identified himself with the patient and considered her health and wellbeing to be his prime responsibility, has vanished into history. As technology advanced rapidly and large hospitals proliferated, medical care became increasingly impersonal and commodified. With organised private healthcare aiming for profit maximisation, the lexicon changed to label doctors as ‘providers’ who sell services to ‘consumers’ or ‘clients’. Even the public hospitals, which are expected to provide care that is untainted by profit-line concerns, become rude and inconsiderate under the pressure of mounting crowds and insufficient resources. It is widely recognised by economists all over the world that health is a classic case of ‘market failure’, where the relationship between the ‘supplier’ of services and those who ‘demand’ (need) care is imperfect. This is because doctors have the knowledge and skills that place them at a height well above their patients, when it comes to making decisions. Without even basic information about the nature of their illness and available treatment choices, patients have no option but to passively accept whatever is advised by their doctors. This asymmetry of information and power can be reduced by ethical conduct on part of the doctors who not only prioritise the patient’s interests but also willingly share information with them. With the doctor playing the role of an informed facilitator, the patient and her family too have an opportunity to participate in decision making. The outmoded paternalistic model will then yield place to a desirable partnership model. The education of health professionals, in their formative period, must impart medical ethics and infuse humane values to make such a transformation possible. A Patient Charter of Rights is also being adopted in many countries. The asymmetry is also reduced by patients and their families seeking out information on their own, from other doctors or the internet. This does not always assure accuracy or applicability to the specific case. However, it will at least enable an informed and intelligent conversation with the treating doctor. The doctor too must take the wishes and concerns of the patient on board while helping to choose among the treatment options. With rising costs of healthcare, the ‘affordability’ factor too distorts decisions. Ideally, this should not detract from the right treatment being provided. Of course, it does not mean that only imported, branded high-cost devices or drugs are the best. Indian made generic drugs and Aravind’s artificial eye lens (for post-cataract care) are inexpensive but reputed across the world for quality. Private health insurance is not affordable to many and is also very selective in the medical conditions it covers. A system of universal healthcare is the only way the world of medicine can provide appropriate care, relevant to patients’ needs and respectful of their rights. Even as many counties are moving towards this, the High Level Expert Group constituted by the Planning Commission developed a comprehensive framework for implementing it in India (www.uhc-india.org). That is the roadmap we need to adopt if the pain of Sunetra is not to be perpetuated across the lives of millions of other vulnerable Indians. The author, K. Srinath Reddy, is President, Public Health Foundation of India (PHFI). The views expressed are personal (This story was published in BW | Businessworld Issue Dated 29-12-2014)
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It is ironic that our nation has been unable to maintain the standards in patient’s health management. The case study begins from medical schooling, where no uniform standards of education are laid down. The corrupt administration has further weakened the education system in both government and private medical colleges. Admission to medical schools also happens through paying money and then you pass out paying some more money. And then you set up practice to reap returns on your ‘investment’. This vicious cycle prepares you for the greedy ploys of pharmaceutical and medical implant industry - for using sub-standard drugs and implants on patients, which leads to patients suffering, especially in fracture management. At our hospital, we receive patients with badly conducted fracture surgeries and when we analyse them we see how simple it was to avert that disaster. The reasons are classifiable as: Improper implants for a fracture, lack of understanding mechanics of fracture and implant, lack of proper instruments to apply them and poor quality of implants. Implant failure can occur in both branded and local implants. Failure in branded implants is because of ignorance of surgical techniques. In non-branded implants, it is due to poor quality metals, poorly polished surfaces, mismatch between screws and implants allergies – precipitating infection and loosening. Surgeon’s understanding of the mechanics and skill in applying the branded implants is the key to success. Many failed bone unions are among educated city dwellers who, like Sunetra, have not asked questions or discussed the treatment with their surgeon, but fearfully submitted themselves to bad fracture management. Good quality branded implants when understood perfectly, can only deliver success. Why did surgery No. 1 go wrong? Why did the surgeon have to re operate? Did Sunetra have a choice? Had her first surgery been done right, there would not have been a second or a third. Her second surgeon preferred to use a local made intramedulary SS nail. ‘Local’ only means not of accepted quality. This one fails too and Sunetra goes to a third surgeon, who repeats surgery…! It is very sad that for a simple fracture, she had to spend Rs 4 lakh. What she got in return was pain, loss of job and income, inability to perform routine activities, and disruption to the lives of all family members. That some surgeons advised her to leave the fracture as it was and not look for repair, saying now bone cannot unite, bone has inherent problem – is a function of the same inattention to what we bring into the medical profession that I alluded to in my opening paras. During both her fourth surgery on her right arm and her sixth on her left arm, we see her recovery because her body received what was compatible with the human system. This brings us to local and branded implants. Imported implants have stood the test of time and have been in use over decades all over the world. The metallurgy is significantly different and hence the quality is far superior. Their resistance to fatigue and strength are superior to locally made implants. Even the screws are different and made using precision tools which is critical for their matching with the plate. This is what helps implants perform. Sadly this is not obtained with the local plates. Could the problem have been identified sooner? There were enough signs that her fracture was not uniting. Had the first surgery ensured a strong fixation, the patient is asked to perform daily exercises, but in her case she was immobilised. When she was unable to do the exercises it should have rung warning bells. Fracture leads to immobilisation, stiffness, which makes movement painful. This requires intense rehabilitation and will power. There appears to be no follow up or audit. Healthcare in India begs honesty and ethical standards on the part of healthcare providers, and informed decision making and responsibility for one’s health, from the patients. Every healthcare centre has the responsibility, the duty to provide best quality care, employing experienced skilled surgeons, quality medical equipment, safe implants and accessories and no compromising health for profit. Profit is an automatic outcome of honest services. The doctor should remain “Next to God”. The author, Dr Mukesh Jain, is a leading orthopedic surgeon of Muzaffarnagar and has successfully operated over 25,000 patients during his 30-year career (This story was published in BW | Businessworld Issue Dated 29-12-2014)
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Arpita Dandavate nibbled through her food in the cafeteria of Bright & Thakur (B&T). At her table were Madhav and Soham — they were consultants at B&T. All three had grown silent as the voices at the next table grew audible. At the next table sat Vivek Sinha, Meghna Desai — both associate directors, along with two directors of the firm. Vivek and Meghna were agitatedly talking about their exchanges with the Principal of ABC school where their children studied. More than narrating, they were reiterating their arguments. Words flew around the trade off that schools did of quality over quantity, of how schools tried to create an aura of difficulty but, in fact, the learning that was happening was questionable, that the integration of knowledge between subjects was absent and the focus on fact-based evaluation at the exams did not aid strategic thinking and hence, Vivek was saying, “How do we even know what quality we are hiring? I might choose the student with 75-85 per cent marks over someone with a 98 per cent, for he may well have the strategic thinking we need, even if he does not know which joint secretary signed the Mandal Commission report!” Some explanation followed, some laughter, some argument and Soham and Arpita rolled their eyes as if to say, now, what do we do? As they picked up their trays and stood up to leave, Vivek caught the eye of Madhav and said, “Arre, get those executive trainees on board by end of November, the organisation structure study for the municipal corporation has come through, it is a mammoth task, so step on it!” B&T was hiring six executive trainees for this huge assignment and Arpita and Soham were sifting through CVs from candidates who had just graduated. Some were applying to grad schools overseas and would bide time till next fall. Vivek: We want candidates who will stay at least two years, Arpita. No short term jobs as the cost of retraining is very high for us. They stay 24 months and get a brilliant recommendation for their B-schools. If they quit sooner, they get nothing, make that clear. Ashok Vatsa (director): And you think this work experience (WE) at B&T matters?Megha: B-schools have begun to demand WE. If I was a student I would somehow get the WE, as the whole take-away from a B-school is significantly different if you have the WE.Vivek: When I taught a module on CRM for Aspen Business School. I did not use text books and such. I just stood there and taught. Now, the class had both kinds of students: those with WE and those without. Some students who had WE would ask ‘how do you’ questions, related to their experience with the subject. But those without WE, rated me real bad. They wanted work sheets, they wanted hand outs, they wanted something to learn and memorise, a book to study from. Then looking at our PPTs they wanted to know if they would be asked questions based on the PPT! When I said the questions will be very application based, you will be judged on the principles, they were sorely upset. They wanted a text book. There are no fixed answers — that was the message I was giving them, but they were brought up on set rules, and felt safe in format, in prescriptions, in scaffolds. They could not churn the lesson and draw a multiplicity of learning from it. This, I say is a function of education that tests memory and restricts thinking. And many get in through the crack... won’t these sorts contaminate the system and pull down students who have an unhindered mind? Ashok: But that is the kind of people you are going to get... The system today delivers students who are not assessed for strategic thinking. With what confidence then, do you hire a person who says he got a 98 per cent in his boards? (Looking at Arpita) What kind of candidates do you have in your shortlist? Arpita looked towards Vivek unsure if she should even reply. Then she said, “It is a mixed bunch. Many are top scorers at school level, but in their essays they do not all show adventure. I have been thinking about calling a fair mix and interviewing them individually. Meghna: Arpita had shown me the CV of an interesting young lad. No, no, not from one of the top colleges, no way. Arpita, just share what you told me about that boy Joseph?Arpita: ...yeah, about 80 per cent in his Boards; the cut offs were very high for the better colleges, so he joined some college in Umeed Nagar. But what I found admirable was that he has not been sapped by this; he has conducted a youth festival all on his own, he plays for his college, has his own band that performs at Khyber.... Vivek: There will always be hundreds such who are good in many things, but I am looking for a consultant. People have to be hardworking. It is a pre-requisite, not a qualification. Nuts and bolts, I would say poor marks at 12th grade is bad news. My ex-boss used to say when hiring look at just 2 things: 12th grade marks and family. Meghna: That’s absurd. How hard a person is willing to stretch, matters. People feel life owes them a favour. Many students demand things as a matter of right. My nephew was asked by a foreign university at the interview, ‘Tell us why should you be granted this admission. What is special about you? Right now, you only have shown ability to pay the fees because your father is rich and students like you form less than 5 per cent of India. But what have you done for India?’Ashok: So, Meghna is saying be not a cribber but a get-up-and-goer. So if the system doled out poor marks even though you worked very hard, are you sulking and moping or do you have the resilience to dust your back and bounce back, like whats-his-name Joseph? A distinctive ability to survive by working extra hard at their life.....Vivek: These are in the realms of subjectivity. I feel when it comes to hiring one must not apply subjective likes and dislikes. How can we assess if someone is resilient or not when we don’t know the person beyond what his CV says? Will I take that risk for the firm? I am not sure. Then again, can the duality of our minds be applied to hiring people? I feel firms should have templates for human resources and simply hire according to template.Ashok: Where is subjectivity here? To say people from good families are good is subjectivity. But this Joseph who scored 80 and not the fashionable 100 hence could not get admission, could have felt he deserved the 100 and carried that disappointment to self destructive levels. Instead what he did is celebratory! How is this subjective ‘like’ or ‘dislike’? Business needs survivors! He worked much harder to beat the rut he had been pushed into; much, much harder to remain relevant, because he would have figured that he needs to pole-vault to attain what he has lost owing to the whimsical methods of the colleges. And he did it. He seems to have not allowed judgement and society keep him down. I would watch out for this guy, he is definitely interesting... he is definitely worth short listing. (to Arpita) Ok, ok, I am not asking you to, but I am debating the arguments now. Meanwhile a confused Soham said to Madhav, “After so much talk, he is still not saying ‘hire Joseph’! So, what is the firm’s view on this?” Madhav: Tu pooch na? Ask, ask, it is your client...and just when it seemed like Meghna had an answer, Ashok stood up and pushed his chair noisily so that it was not clear what she said, but Vivek was shrugging and saying, “That is life, it is about risks...” which was neither here nor there. The party broke up and the men quickly got onto their phones and calls flew around as they all left the cafeteria leaving the younger consultants more confused than they were. Madhav: The approach that HR has depends on the kind of image building they do for the firm. Are they presenting B&T as the killer firm or the ‘we want good people’ or ‘if you have creamed the top, just walk in’...? Frankly we will tend to cover our backs and shortlist the good boy with the best marks, because it is the safest bet. How do you know this Joseph fellow is not a drug addict?Soham: You have something against good boys? If 5 guys feel he is a better bet, that he has the survivor instinct, and has worked the hardest... wouldn’t you run with that? Most sensible people would! I daresay the guys who got 100 per cent would not have that ability in them!Arpita: Ok, let’s run it with some serious HR types. I will call Subhash Bose in our Mumbai office and ask him his opinion.... Bose was my mentor at the last workshop, he is nice, he will guide us.Soham: Then, I will ask Ami Saldanha (Partner at B&T); she has worked at ITC — solid lineage... let’s see her attitude to this. Soham met Ami at the coffee machine. “Ami, I need direction. Would you place more credence on higher marks at CBSE and hence the kind of college the person has studied at? How much subjectivity is really there in hiring? Ami: A hiring manager’s reflections are finally his experiences and his perceptions. Maybe they are right and may be they are wrong. While hiring people, it is good to have consistency in what criteria you use and also a good shared understanding of the criteria among the panel members. Looks like in this situation both points seem to be absent, eh? Ha ha. Ok, my advice: HR has to define a criteria. Typically companies have started using competency based interviewing processes — candidates are assessed on a particular competency by posing ‘what would you do, if’ questions. For example, if you want hard working chaps, then ask the candidate — tell us a situation in which the task demanded you to work hard and what did you do. The replies will tell all. Obviously, interviewers need to be trained to catch when the candidate is spinning yarns. Similarly, probe the high marks candidate and establish that he has fire to match your Joseph and more hunger in his stomach. The interviewers, Soham, should manage their bias as well as their tendency for the Pygmalion effect. A lot of bosses end up hiring clones, which I find very annoying, but then... (she shrugged). So, it all depends on what are the demands of the client, the role, the culture — these play a big role in hiring. Marks, colleges, etc., can be filters to short list from a large pool, as these are entry level jobs. That is Recruitment. But Selection is dependent on clear cut pre agreed and shared criteria. So, please catch hold of your bosses and make them put their money where their mouth is! In every country, there would be a bias to particular pedigree — like India loves an IIT-IIM combo. In my own experience of hiring, I have seen people with great pedigrees not doing well in a particular role in a particular company. It is all about the fit. That same chap will likely do a very good job elsewhere. It is not the person, it is the context that is critical to be understood, and candidates evaluated accordingly. The problem compounds when you are hiring freshers because, at this level, everyone looks identical! Soham was captivated. Overwhelmed. He knew instantly he liked Ami Saldanha. He must quickly move into her accounts, he thought. Elsewhere Subhash Bose was telling Arpita on the phone, “This is an everlasting debate! We try not to be influenced by our own biases, but it cannot be helped I guess. But let’s start by understanding the work we are hiring for, and what is required for a person to be successful at it. The job you are profiling involves a lot of data collection, analysis and number crunching. I see two dimensions of this hiring: One, attributes needed to do the job well, and two, the kind of people who will enjoy this job, therefore ‘culture fit’ with the job. Or look for ‘disqualifiers’: What attributes will not work in this job! Mind you, these two dimensions are different, and, in most cases, we tend to ignore one for the other. “It seems to me this job needs candidates who are hard-working, systematic, and analytical. Now what role can grades play in our selection?" While it is not right to generalise, school grades in India are a primarily a function of focus, hard work and basic intelligence. They are also a function of which school you are from, as many schools work like a grade churning factory. People who consistently get good grades clearly demonstrate focus and commitment. That is all. High grades do not imply creativity or intelligence. One kind of intelligence is the ability to do logical analysis, and the ability to look at patterns and think conceptually. Definitely high grades don’t assure conceptual thinking, but can probably be an indicator of analytical thinking. So, grades can be a good proxy for shortlisting at this stage. But is a person committed and hard-working? For that, check if he has taken up one area of passion and strived to be excellent at it? These will cue for you best fitment. So Arpita, go with grades as a quick and dirty way to sift through the CVs; but if we have the resources, shortlist based on a set of clues from the CV that show commitment, and grades could be just one of the many factors there. This will give you the best fit for the job! I would do this! Later Soham said to Arpita: “Ashok said that there cannot be subjectivity while hiring. I don’t believe that. That everyone is dodging Joseph is subjectivity. Come, let’s grill Joseph...!” (This story was published in BW | Businessworld Issue Dated 15-12-2014)
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This year’s nobel peace prize announcement took Indians by surprise - Who was this Kailash Satyarthi? Soon enough, we all found out that he was the man from India who represented the Rights of children globally. To me, he is a transformational leader par none! Kailash is a true visionary and a strong leader, because he not only saw a problem but also worked hard at implementing solutions. Kailash is a product of our much-maligned Government municipal school system, which still follows the structured classroom instruction model that Meghna, Vivek and a majority of the middle class intelligentsia are condemning. I would argue that the same education system has produced many success stories here, and also abroad. India, as a country, has produced a significant number of world-class professionals with all the qualities needed to succeed — courage, conviction and confidence, backed by deep domain knowledge. Our IITs are ranked fourth (just ahead of Harvard) in a new ranking of the top 50 universities that have produced venture capital (VC)-backed founders. In such a scenario, it is hard to trash the prevalent education system. In fact the US, where the schooling system has focused more on the project/discussion model, is currently under siege as it is seen as failing kids, especially the poorer ones. One of the biggest criticism of the US system is that the kids are not pushed hard enough, and they are not taught enough material especially in the difficult to learn STEM (Science, Technology, Engineering & Math) subjects. They are questioning how a country like India, which spends very little per capita on education, has sent more engineers, researchers and managers their way. Vinod Khosla, Sathya Nadella, Sundar Pichai dominate the technology business while we have Indra Nooyi, Anshu Jain, Ajay Banga, Ivan Menezes heading consumer and financial services behemoths. Some credit for this must go to our existing educational infrastructure. The suitability of the approach to learning might depend on the child’s personality and is hard to generalise. Some children thrive in a structured academic environment, while others struggle in it. Perhaps, parents will have to do their bit in selecting one that works for their kid(s). Eventually, schools are only one part of the learning experience. Family, environment, role models, experiences go a long way in building personality of young adults. There is scope for tweaking, or even transforming what we have today to meet the changing needs of tomorrow. But it is a long drawn process which is not going to provide immediate results. Instead, it is more practical to work with the existing system, leveraging its strengths. Here we have Bright & Thakur wanting to hire entry level consultants who are hard working, analytical and strategic thinkers. Like Ami says, they need to figure out the right filters in this context. The uniqueness of its organisational DNA contributes significantly to its success in a competitive environment. Building this requires deliberate effort and conscious hiring. This is the model successful companies have followed worldwide. Tony Hsieh, the founder-CEO of Zappos, a company which built its reputation on high quality customer care, says his focus is on hiring “kind” people. They ascertain this by watching how the candidate behaves with different people, from the time they are picked up at the airport to when they leave post the interview. An engineering focused firm, like Google or Facebook, devises “problems” that test analytical skills. The hiring strategy also depends on where the company is in its lifecycle. Sometimes you might just not be known enough to attract the right pipeline of candidates, or rich enough to afford what they demand. In such cases, a well structured training program could do wonders. Sridhar Vembu, Founder & CEO of Zoho, a company that has successfully taken on Google and Microsoft in the highly competitive apps space, has perfected this technique. Zoho identifies poor kids in the 10th grade from interior of Tamil Nadu, India, trains them extensively in programming, and hires them as software engineers! Zoho has built world-class products with this workforce! In the ultimate analysis, there are no short cuts. Even the best school system is not going to deliver readymade students tailored to your unique needs. The writer, Anuradha Parthasarathy, is CEO of AnuPartha, a global executive search firm focussed on transformational leaders (This story was published in BW | Businessworld Issue Dated 15-12-2014)
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This is a very interesting, and a very different case. I see three broad issues that we can discuss here. First, we could deal with the question of ‘what is a good selection process’. As we read the case, it becomes clear why most companies struggle to perfect the selection process. This is one process where the skill and the biases of the hiring manager is a big determinant of the quality of the person hired and companies have tried to bring in various bits to make it more scientific, but with limited success. As you can see, our individual biases are very strong, and colour our decisions. One of us likes people with pedigree MBA from top institutes, some others don’t put that much emphasis, I may like good grades, others may not. The key is to define what is the job we are hiring for, and then identify the attributes that are needed for being successful in that job — both the technical skills and behavioural. There is also this debate on personality vs observed behaviour: do we look for examples of what a person has demonstrated or would an understanding of personality help us better extrapolate his behaviours. In my view, tools to assess both these can help if put together. To look for clues on a person’s demonstrated behaviour, we need to have a consistent method in the total selection process. This brings us to the question of what will you look for as clues before you shortlist, and then select a person. Again, this needs to be done against the backdrop of total clarity in what kind of person we are looking for. The CV provides great clues about what people have done, and along with a bit of personality assessment, can give us an hypothesis about an individual, which needs to be confirmed through a systematic interview. Most often, we don’t spend as much time on reading the clues from a CV — but great selection processes and interviewing techniques use this very constructively. So now, the school grades. First, given the huge volume of applications in most cases, the CV becomes an important shortlisting tool — and, therefore, we have to be careful in laying down the shortlisting criteria. Grades are a set of clues- in my opinion they predict the ability to work hard, be focussed and indicate a good level of IQ. If people have been consistent in their grades, it tells you clearly about their focus and commitment, and if people have been improving their grades it tells us their drive and quest to become better. It doesn’t tell you if a person is conceptually good, nor does it tell you if she has a strategic mind — these need to be checked subsequently. If I am hiring for a job that needs thoroughness and analysis, high grades could be a good indicator. But if I am looking for someone with a strategic and creative mind, grades may not have the answer. And grades don’t give any clue about a person’s leadership. Hence, my suggestion would be to put a set of shortlisting criteria based on what the role requires, get the clues from the CV, and along with other selection aids like personality/proficiency tests and interview, finalise the decision. Last, this question of our education system and grades. Our CBSE/ICSE system lays a premium on knowing things, ability to remember, rewards hard work and focus, and builds in some analytical skills. But we have to add other things in the school education to create the conceptual and critical thinking ability that is needed, especially if we want to develop thinkers, CEOs and leaders. Getting children to participate in multi-disciplinary activities and projects would help, and it would be good to encourage that. But, this is the system we have, and understanding it, and building in the right selection framework keeping the gaps in mind, will help organisations. Subjectivity in hiring is an undercurrent. Decisions on people are made based on very little ‘empirical’ data, and hence we have to use our experience and intuition a lot more, and that’s where our biases tend to creep in. This is also why a good selection framework and process helps — it puts available empirical data to good use, and keeps the focus of the interview on confirming or disconfirming the hypothesis we had put together. Being aware of the potential biases, and having a diverse interview panel establishes the necessary objectivity in what is often a largely subjective process. The writer, Krish Shankar, is the head of HR for South Asia for Philips. Earlier he was Executive Director of HR at Bharti Airtel, after over 20 years in Unilever (This story was published in BW | Businessworld Issue Dated 15-12-2014)
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