Business of medicine
Department of Biomedical Imaging, University of Malaya, Kuala Lumpur, Malaysia
Keywords: Business, medicine, perspectives
As has often been said, people get set in their ways of
thinking, living and believing until they are unable to see situations in ways
other than what they are used to. Their brains just refuse to change its
paradigm of thinking.
For me, I have always thought of business in a certain
way. Firstly, I was never really exposed to the concept of business, going as
far back as I can remember. My father always reminded me that you should devote
yourself to helping others for the overall good of society. So it should not
come as a surprise that all my siblings work in the public service. When I
started to work in the public sector serving a tertiary university hospital,
the concept of pushing oneself for money or profit was considered �dirty�, even
to the point of viewing such individuals as lower life forms!
But over the last several years, while managing a
department and pursuing an MBA, one question has been popping up in my mind:
�What business are doctors in?� Is it about treating patients to help them
recover from whatever ails them, no matter the cost to the society at large? Or
is it about providing a patient a limb prosthesis even though he or she cannot
afford to pay for it? What about keeping the public healthy first so they do not
get sick, and saving all that money and technology? Are we not supposed to
provide parking bays for our patients so they will not be driving around in
circles while we literally drive into our offices?
Is it about protecting one's discipline against the
onslaught of the invaders? Is it about living in our little silos which,
incidentally, were artificially created for an era long gone by? Is it about
the need to ensure the maximum amount of resources no matter how it is used? Is
it about being the first to get all the fancy high-tech gadgets and equipment?
Is it about meeting all the performance targets set by the hospital or health
authority? Should the insurance industry set guidelines for patients who need
treatment? Should the vendors of imaging equipment and drugs be allowed to
promote their products only with limited indications? Are they also acting
ethically when they lobby the governments to pay for some of these new choices?
If all these questions have not given you a headache yet,
here's more: should money be spent on a 3T MRI or on treating patients with
expensive chemotherapies where the survival prognosis is only 3- 6 months?
Instead, might it be better to purchase ventilators for the paediatric ICU, or
a new image-guided or robotic surgical system for the surgeon? Would the money
be better invested in implementing a wellness programme run by the primary care
doctors? Perhaps the money should be spent on none of the above, but instead on
upgrading the car park, the lift system or refurbishing the outpatient clinics.
Choices! Decisions! Discussions, lobbying, politicking,
and invariably gridlock, lead to lots of heartache, anger, confusion,
disappointment and, eventually, withdrawal and resignation. Unfortunately,
throughout our entire training as healthcare professionals, we have never been
exposed to this reality of limited resources, competing needs and, more
importantly, different value systems. We find that those who shout the loudest,
are the most unreasonable and play �politics� are usually the ones who get
their way . This then becomes a way of life and the unwritten rule for
getting things done.
To answer the question �What business are we in?�, it
depends on which view you coming from.
The patients� perspective of the medical services depends
on their view of medicine. If they hold to a paternalistic view of the doctor,
then they will be subservient to their doctors, putting up little or no fuss.
On the other hand, those who view themselves as customers feel that doctors are
at their beck and call to sort out their problems immediately even if it means
that their expectations are unrealistic. These patients are not to blame since
the hospitals themselves are increasingly behaving like any other commercial
service provider, with key performance indicators, visions, missions, etc. The
problem may be that even though medicine has a lot of science behind it, is
still very much an art. Unfortunately, in the medical management of patients,
their care is not similar to having your car serviced or getting your food in
four minutes. Despite all the challenges, both groups of patients expect to be
told the truth of their conditions and prefer medications that they only have
to take once a day to get rapid action, good effect, and few adverse events
(common or rare).
Above all else, what most patients and citizens want is
the security of knowing that these health services will be there
when they need them, that their views and preferences will be taken
into account by health professionals, that they will be given the
support they need to help themselves, that they can access reliable
information about their condition and the treatment options, and
that they won't have to worry about the financial consequences of
being ill. They also want to be sure that these benefits are
equitably delivered and that public resources are being used
efficiently for the good of all. Social solidarity and trust will
continue to be the essential underpinnings of a sustainable health
When we look at students who enter the medical discipline,
we get a different perspective. Many students who are determined to pursue
medicine do so partly because they see a future in which they will work for
themselves and control their professional lives in a way unlike their peers in
other careers. Even though that vision was a reality generations ago, today it
is a seldom-realised fantasy but one that I have to confess is still a
widely-held view. In reality, doctors who work in solo practice are
increasingly becoming part of a larger network of healthcare plans or some
consortium of sorts. The vast majority are either in private groups or
employees of medical schools or large networks. Despite all these changes,
doctors adamantly protect independence in their relationships with patients and
in their other day-to-day activities. Interestingly, most do not enter the
profession with the interest in, or equipped with the skills for,
administrative responsibilities. It would probably be true to say that we have
pre-programmed ourselves with the desire not to run an organisation. I guess
there is an inherent rebellious steak that will go against any loss of control
or any desire for uniformity or the regimentation that comes as a part of the
corporate culture .
If you are a practising clinician in the public service,
your perspective is probably that ALL resources must be made available for your
needs; be they expensive antibiotics which are currently not in the formulary,
or more ICU beds to cater for the sick patients, so that they can provide the
best for their patients. However, money should not be wasted on making the
place comfortable, for example repainting the premises, or upgrading the
cafeteria. Public health clinicians have repeatedly re-enforced in their
practice that everything that an institution does should be in the patients�
This raises the question: is there a potential conflict of
interest when doctors make decisions in the interests of the organisation as
well as that of their patient? The biggest conflict lies in rationing the
finite available resources, especially when the parties in the scramble cannot
see the needs of others. For example, should USD 2 million be spent on
preventing or treating TB cases, versus buying a 3T MRI? What about needs
outside the healthcare industry, such as social needs including the need to
educate children or invest in road safety and transportation? In reality,
medical specialties, as well as technological and procedural services are often
For those in academia, the challenges are even more
dramatic. There is a vital need for freedom of expression and free scientific
exchange among the faculty, trainees, and students. They need to have their
research and lectures on patho-physiology of health and disease, new diagnostic
tools and treatments published widely, while striving to continually upgrade
the practice and delivery of health care itself, which for most, is the core of
their professional lives. These core values often require challenging the leaders
in universities who wish to push a different agenda with the use of key
performance indicators, 3600 appraisal, grantsmanship and turf
battles. However, there are academics for whom these challenges are not
entirely relevant, as they feel that academia should not only be about
lecturing and publishing. They believe that members of the academia should get
out of their ivory towers and become advocates for scientists, engineers, or
health care workers who have been unjustly imprisoned or threatened with
imprisonment . The responsibility of academics should not be merely be
generating and exchanging new knowledge, but applying that knowledge to make a
difference in the world so that they fulfil their work�s true potential. One
such example is the Duke Global Health Institute which brings together
interdisciplinary teams from schools and departments throughout the University
to work with partners to solve highly complex health problems and train the
next generation of global health scholars .
For the managers, their challenges are different. As a
consequence of the Reagan and Thatcher eras, as well as the �globalists�, the
last several decades has seen a distinct trend where even public institutions
are being encouraged to deliver on their objectives. Hospitals, medical
institutions and universities also have not been spared. In the United Kingdom there are now direct or indirect financial incentives for medical
practitioners who have been given the responsibility of managing funds. Even
though the link between practitioners' income and services delivered currently
remains weak, financial rewards are based on performance at the level of the
individual practice or trust . The increased accountability for the
resources used, combined with measurable performance indicators, has added a
complexity to the managers' responsibility.
Then there are those who are in the business of generating
revenue for their investments. They speak of the need for a good business model
with concepts like value proposition (a description of the customer�s problem,
the product that addresses the problem, and the value of the product from the
customer's perspective), market segment (the group of customers to target,
recognising that different market segments have different needs), value chain
structure (the firm's position and activities in the value chain and how the
firm will capture part of the value that it creates in the chain), revenue
generation and margins (how revenue is generated, the cost structure, and
target profit margins), position in value network (identification of
competitors, complementors, and any network effects that can be used to deliver
more value to the customer) and the competitive strategy (how the company will
attempt to develop a sustainable competitive advantage, for example, by means
of a cost, differentiation, or niche strategy). These �investors� see the
provision of healthcare based on business principles as being different from
any other commercial business. Therefore, it is now very common to find jargon
like mission, vision, customers, key performance indicators, and return on
investments being thrown around.
"Customers, not patients� is now the common cry
everywhere! So what is a customer? In business-speak, a customer is someone who
makes or influences the decision to buy services, regulate business, or affect
brand perception. In health care, customers are not just your patients but also
include referring medical professionals, families, hospitals, the government,
disease and patient advocacy groups, and joint-venture partners. The services
we provide must meet their expectations about healthcare, which have changed
dramatically in recent decades. People now refer to a rise of
"concierge" medical services, in an attempt to beat the competition.
While patients are now given designated car parks, free refreshments, and a
comfortable environment akin to that of a posh hotel, they also have increased
expectations of the care provided to them. Patients who are looking for
one-stop shopping (they would rather have their MRI performed and interpreted
on the same day as their neurologic/mammographic/cardiologic consultation,
rather than having to leave the consulting doctor�s office, schedule an
appointment, have the scan, and wait a few more days for results) create a
business environment that seriously challenges the traditional territory of
What usually gets lost in the discussion comparing
medicine with other services is the fact that you cannot take your body back if
the treatment or surgery did not produce the results you asked for; something
that you can do with your car or your refrigerator. The difference between the
medical trade and other commercial trades is that healthcare deals with acute
life-threatening issues, while the mechanic's endeavours do not affect your
The increase in global trade raises important new
challenges for health and the provision of health-related goods and services.
Multinational corporations in the new millennium are increasingly becoming
fluid, borderless entities that ultimately answer to no one. Globalisation will
affect key components of public health, from public hospitals and community
health centres to government agencies, occupational and environmental health
standards, as well as the availability and regulation of drugs and equipment.
This is occurring as multinational insurance companies and managed-care
organisations (MCOs) cross international borders. Since the early 1990s,
institutions such as the World Bank and the International Monetary Fund have
required state-owned hospitals and clinics in Third World countries to be
privatised before loans are considered. Not infrequently, those formerly
state-owned and -run hospitals were purchased by U.S. and European insurance companies
which then introduced U.S. models of managed care, despite the vastly different
history of healthcare in those countries.
Other challenges arising from the internationalisation of
medicine include health tourism, and the increasing need for standardisation of
medical practice. To what extent can or should the work of doctors in the
various hospitals be standardised? It is dangerous to try to herd doctors into
a corral made of the latest computer technology. One can understand how
difficult it would be to persuade them to follow regimented patterns in their
work. For instance, the transition to a computerised system for charting
clinical information presents a problem to those charged with establishing a
workable IT strategy. Younger doctors who are well versed in computer
technology will have less difficulty accepting such a system, compared to older
doctors who are not particularly computer-literate. Making the work of doctors
more computer-compatible is only one factor that management has to consider.
They must also accept that many doctors will resist applying sophisticated
technology to their day-to-day activities. Management should not attempt to
change the essential features of how doctors work in its community hospitals.
That spark of independence still glows in the psyche of many doctors, and
trying to regiment them will only increase its intensity .
There is no single correct answer to the question of �what
business are we in�; instead, it will depend on our individual perspectives.
Invariably one will have to manage a limited amount of resources to achieve
one's aims. This is basic economics, which is a social science that studies the
allocation of scarce resources used to produce goods and services that satisfy
consumers' unlimited wants and needs. The perspectives change with shifts in
government policies, social factors as well as commercial interests. We are
always having to choose between all the different alternatives, but what is
alarming is that the basis on which these decisions are made is often arbitrary
and tied to whom you know in the �old boys/girls� network.
Maybe it is time to adopt a different way of thinking,
namely integrative thinking which generates options and new solutions, and
creates a sense of limitless possibilities. Conventional thinking wears us away
with every apparent reinforcement of the lesson that life is about accepting
unattractive trade-offs. Fundamentally, the conventional thinker prefers to
accept the world as it is, whereas the integrative thinker welcomes the
challenge of shaping the world for the better .
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|Received 26 April 2009; accepted 11 January 2010
Correspondence: Department of Biomedical Imaging, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia. Tel.: +603-79492069; Fax: +603-79581973; E-mail: firstname.lastname@example.org (Basri J.J. Abdullah).
Please cite as: Abdullah BJJ,
Business of medicine, Biomed Imaging Interv J 2010; 6(2):e14