Interview with Dr. Rajiv Shah, India's first Foot and Ankle Surgeon

Mr. Sarfaraz Lakhani of Calibre Creators (CC) had the rare opportunity to interview Dr.Rajiv Shah, an accomplished Foot & Ankle Surgeon and the only one recognised in India for its treatment.  He has travelled around the world attending conferences as a guest speaker and doing podium presentations.   He is a Vice Chairman of Asia-Pacific   Foot and Ankle Council and also a Past President of Indian Foot and Ankle Society.  He has trained and mentored many young orthopaedic surgeons in the subject.


"It’s really very sad that in India, we have an epidemic of highly neglected foot and ankle diseases.Though Indian mythology has given the highest significance to touching feet of elderly, teachers and lords, sadly undergraduate medical curriculum in India has hardly touched Foot and Ankle as the area of the human body!"


Dr. Rajiv Shah is a practicing foot and ankle surgeon with over twenty years professional standing as an orthopaedist.  He obtained his fellowships in the subject from Columbus, OH, USA and Chicago, IL, USA.  He runs the first ever Foot and Ankle Centre of India at Vadodara and has a passion to develop this speciality in the Asian continent.  

He is a faculty member in various national & international level conferences and workshops with innovative techniques under his belt.  The ‘Foot School’ is a novel interactive educational model devised by him for spreading preventive care nationwide.  He also runs a project "Save the Foot" for diabetics and a project "We Walk" for leprosy victims.

He is the First foot and ankle surgeon of India.  He has been instrumental in establishing the first ever Foot and Ankle centre of India at Vadodara, Gujarat.  He has also launched the first ever foot and ankle website from India (www.footankle.in)

He did his advanced foot and ankle fellowships under world renowned foot and ankle surgeons like Dr. Thomas Lee, Dr. Greg Berlet and Dr. Weil at Columbus, USA and Chicago, USA. His book on the subject titled ‘Handbook of Foot and Ankle Orthopaedics’ was awarded with ‘Best Orthopaedic Book’ award for year 2015. This book is translated in to Chinese, Arabic and Portuguese.

To know more about him and some pictures of surgeries conducted by him, please scroll down to the bottom of this article.


Sir, It is an absolute delight to be meeting a very very accomplished surgeon of India who has achieved global iconic status and bringing pride and glory to India and at the same time relieving people from their foot and ankle ailments.You are a beacon of light and hope for those suffering from this ailment and itis a matter of honour and privilege for Calibre Creators to be having you with us sharing your views on the Foot and Ankle Diseases.


CC.1    Sir, despite advances in medical treatment and introduction of technology and doctors being able to treat almost any disease in India, (a) why has not much attention been paid to this condition of Foot and Ankle disease?  (b) Also, is this a medical condition related to some other health problem or is it a disease by itself?

Dr. RS: It’s really very sad that in India, we have an epidemic of highly neglected foot and ankle diseases.  Though Indian mythology has given the highest significance to touching feet of elderly, teachers and lords, sadly undergraduate medical curriculum in India has hardly touched Foot and Ankle as the area of the human body!  Today, if I ask a simple question pertaining to the anatomy and function of the human foot and ankle, the majority of medical students fail to answer.  Feeling of neglecting foot and ankle orthopaedics amongst the medical population is poured since the birth of a doctor.  On the side of patients, till the 19th century, our population hardly ever used footwear, because we never considered foot as an integral part of the human body.   Similar is the thought process of society towards problems of foot and ankle.    We never focused on our country’s performance at sports, hence we did never focus on augmenting the performance of sportsmen through diagnosing and fixing their foot and ankle problems.  In fact, foot and ankle problems are a large subset of problems in itself with its most vital secondary effects over every part of the body.


CC.2    If the awareness for this problem is so low in urban areas, what then would be the situation in rural India?  What are your plans to create awareness about this across the country?

Dr. RS:    Indeed awareness about foot and ankle problems is very low in urban areas of India.  Every city in the western world would have dedicated centres of excellence for foot and ankle care.  In the western world, foot and ankle diseases are being treated under one roof by a team of qualified medics and paramedics.  Every sports team has a foot and ankle specialist who periodically evaluates team members for the health of their feet.  Every possible effort is made to maintain the foot and ankle of sportsman in perfect shape, thereby to prevent injuries and to optimize performance.

The situation in urban India is just the opposite.  I fully agree about your worry. India lives in villages.  India is a world’s diabetic capital with our maximum diabetic population living in villages.  The situation is truly pathetic!  Many villagers are still not using footwear and are walking bare feet; working in farms; making themselves prone to foot and ankle problems.  A diabetic population with injuries in foot and ankle could be a waddle sign for salvage of feet!  Many of such cases end up in amputation of toes and foot.  The rate of amputation in diabetics in the western world is 2% to 4% while the matching rate in India is alarming at about 30%!

Prevention is always better than cure.  Creating awareness is the only way we can fight this issue out.  Since I started practicing foot and ankle orthopaedics, my only goal has remained ‘Education and Awareness’.  I have been doing ‘Foot Schools’.  Foot school is a novel interactive educational workshop that talks about the significance of foot and ankle, its common diseases and the prevention of these diseases.  For good foot and ankle health of society, large-scaled educational modules plus preventive foot and ankle check-ups are required.  I have already furnished a detailed concept paper to the health department of the government to set up various permanent health awareness programs.  They are as under:
•    Save the Foot for diabetics
•    We walk for the population at large
•    Let’s perform for sportsman
•    Catch them young for children

The details of these programs have already been passed with due remarks by Honorable Governor Sir to the Health Ministry of Gujarat State.


CC.3.     Sir, for the benefit of our readers, please explain the causes and consequences of the Foot and Ankle disease?

Dr. RS:    Foot and ankle is such an important ornament of the body that can get affected by trauma leading to sprains, strains, and fractures.  As the body’s 25% of total bones are located in the foot and ankle, every possible disease of bone can be seen to occur in the foot and ankle.  A wide spectrum of foot and ankle ailments range from congenital deformities, acquired deformities, Arthritis of joints, degenerative issues of tendons and ligaments, nerve problems, stress injuries and tumors.  The most important aspect of our understanding should be that problems in the foot and ankle could be the sole reason for problems in the spine, hip and knee!  In fact many of the diseases of the spine, hip and knee throw their first sign and symptom in the foot and ankle.  Today, the biggest health irony of developing countries like India is the steep rise in lifestyle diseases.  Such diseases include diabetes, obesity, hypertension and stress syndrome.  Control over these diseases is mostly by the way of maintaining the body’s fitness.  How can we control our diabetes and hypertension if our feet are not healthy?

CC.4.    Is it an age-related problem and what are the probable symptoms one should look out for and can early diagnosis help avoid surgery?

Dr. RS:    Age-related foot and ankle problems include arthritis, deformities, and stress injuries.  Development of pain, fatigue and deformation are the earliest symptoms.  After the age of 50, every individual must develop a habit of ‘Check-look’ at his/her feet after taking a bath.  This should be in a good light.  Any new symptom of pain or fatigue should never be taken casually.  Any deformation of feet should be consulted.  For a diabetic, I always advise having a complete foot examination with a magnifying mirror after a bath.  Sportspersons must periodically evaluate his footwear for wear and tear and deformation.  This would help in preventing sports injuries that can affect a sportsperson’s career from being cut short.

A watchful eye on any new symptom in the foot, regular exercises, and using correct footwear are the keys to control foot and ankle problems.  No question that these habits would only help in preventing surgeries.


CC.5.    How does corrective surgery help in treating the problem or can it be treated medically?

Dr. RS:    For foot and ankle problems surgery is not the only solution.  In fact, it is the last resort.  Most of the conditions can easily be treated with lifestyle modification, disciplined care of foot and ankle plus physiotherapy.  Orthotics which are the external devices or modifications made in footwear; helps a lot to support and balance the foot thereby reducing sufferings in most of the diseases.  Medical management in the form of drugs works well in many cases. Failing these conservative modalities only pushes a patient to option of surgery as the final answer. Surgery works in many ways like correcting the deformity, correcting the faulty axis, eliminating pain generating areas, removing offending focus, etc.


CC.6.    I read that you used 3-D printed titanium prosthetic /bone for one of the surgery?  Can such a treatment be made affordable for socially and economically challenged population and how?  Is this surgery covered under the PMJAY Ayushman Bharat Scheme, a pet scheme of our Honourable Prime Minister Shri Narendra Modi?

Dr. RS:    3=D printing technology has made a revolution in the world of foot and ankle orthopaedics.  By 3-D printing, one can make a body part similar to the original one!  The technology is used in foot and ankle trauma where a part or whole of a missing bone can be prepared with similar size and dimensions with the help of 3 D printing.  Even tailor-made jigs to put screws and plates for fixation of complex fractures can also be prepared.  It is also used extensively in correcting foot and ankle deformities.  A plastic bone model looking exactly like the original deformed foot can be made for a surgeon who plans and performs a virtual surgery on a bone model before the actual surgery.  You can imagine what wonders this technology can do.  Such a rehearsal of surgery would not only reduce the operating time of the surgeon but will also result in seamless execution and of surgery.

3-D printing technology is used extensively in the western world but the use in India is limited because of its high cost and a small number of service firms.  I wish special subsidies be given by the government to such 3-D printing firms to make this technology cheap and affordable.

I replaced lost talus bone of a tribal with 3-D printed titanium talus bone which saved a patient’s limb from being amputated.  This 3-D printed implant cost INR 1.5 lacs to the patient!  Obviously, this is the highly prohibitive cost.  The firm that prepared this implant took six weeks to supply this model!  Companies in the western world supply such models in a week's time, that too with three sizes (Plus two, zero and minus two) at a similar cost!

To make this technology available to every walk of population, coverage under government schemes would be worthwhile.  We need to work hard on this front very vigorously and I am striving hard to create an army of Foot and Ankle Doctors to handle this large scale pandemic situation.  We are running against time!


CC.7.    Sir, is this a simple or a very specialised surgery and what is the average length of this process?

Dr. RS:    3-D printed Talus replacement is a specialised surgery, more so whenever you are carrying it out for a case of trauma. After trauma, tissues are contracted and fibrosed. They do not ply as normal tissues. A surgeon should be able to accurately put new titanium bone into the place of the original bone. While implanting this artificial talus one has to be cautious of not injuring surrounding tissues as well as fracturing surrounding bones. The surgeon is supplied with only one size of such an artificial bone and he should be spot on to push this bone into the cavity where the original bone was lying. Failure to do so means the purpose of surgery is spoiled and all expenses and efforts are in vain. The surgery lasts for about two and a half hours. This is a replacement surgery and falls into major surgery.


CC.8.    For those who have never been in an OT in a conscious state (for procedure/ surgery/ delivery), what is a typical scene like in the OT?Are there any anxious moments?

Dr. RS: Operation theatre is a temple, mosque or a church and patient is God. The surgeon with his team has a unique opportunity to serve the Lord. No stones are left unturned to make prayers successful. There are multiple tenacious moments starting from the point of anaesthesia to the precise execution of surgery; as complications, can occur at every step. One has to be always thinking and anticipating in operation theatre. I always like to draw my plan for surgery beforehand which is communicated to the Surgical Team. “Plan B” should always be in mind for any surgery to take care of any complications or adverse situations. There is always peace and focused attention on the patient during the operation. No chatting, talking or unnecessary movements are permitted in the operation room. 


CC.9.    For a little while, let’s get on the lighter side of life. You must have come across many patients and some of them or situations must have been funny or provoked humour.  Can you recall any such incidents?

Dr. RS:    Yes, indeed. There are few moments in the operation theatre which generates humour. Let me site such an incident. Orthopaedic surgeons use equipment called “C-arm” or “Image Intensifier Television (IITV)”. This equipment gives live imaging of a part being operated and helps in speedy passage of nails and screws. In day to day language instead of calling it as C-arm or IITV, we call it ‘TV’! Once during surgery, I asked my resident ‘show me TV’. To our surprise, the patient who was little awake heard this and immediately said ‘Rajiv Sir, agar aapko TV hi dekhna hai to mera surgery khatam kareke dekhona’! (Sir if you indeed want to watch Television, please do so after completing my surgery!) We all laughed a lot and we still remember this incidence.


CC.10.     What was the turning point in your career when you decided that you want to focus on a specialty?

Dr. RS: I was a big-time spine specialist after starting off my orthopaedic private practice as a general orthopaedic surgeon. One fine day, one of my junior colleagues asked me, ‘Sir, who does good foot and ankle cases in India?’ I made a joke, ‘You!’ He immediately replied that there is a huge number of people suffering from it without any correct guidance and something needs to be done about it. The very same night I decided to carve my niche to become a foot and ankle specialist.


CC. 11    What career advice would you like to give to new medical graduates and those practicing as Orthopaedicians about specialising in the Foot & Ankle disease?

Dr. RS: Foot and ankle orthopaedics is a specialty where you have every sphere of orthopaedics under its umbrella. This covers trauma, deformity, replacement, arthroscopy, endoscopy, degenerative problems, tumors and paediatric orthopaedics. Why not shape a career in this young and emerging specialty? Least of competition, ease of learning and fun to practice! What one needs are focus and perseverance. If you really love the area of your specialisation, progress is deemed.


CC.12.    You recently had Dr.Amanda Fantry, Orthopaedic Surgeon of Brown University, US come to India to train under you for a month.  If Indian Doctors wants to do the same, how can they approach you?

Dr. RS: Training and mentoring US graduate was real fun. Western countries do not have exposure to kind of mangled and neglected cases we see day in and out. The western world always desires to learn about our methods based on our innovations with which we treat our cases in spite of limited resources and financial constraints. Mine is the first-ever centre in India, where a structured fellowship program for foot and ankle orthopaedics is being run from the last eight years. Young orthopaedic doctors apply well in time for the same. Every year, I train six such juniors in the subject. Looking to more than two years of waiting for such a fellowship program, I have now announced three days of capsule courses. Four such courses are planned per year. The doctor simply needs to write to me about this.


CC.13.     You juggle with multiple functions and social responsibilities and also have a family.  How do you maintain the balance between each of these?

Dr. RS:    Work-life balance is truly demanding. With my mission of establishing foot and ankle orthopaedics as the specialty of orthopaedics, I have to travel a lot. I make sure to take my better half with me during most of my trips. I start my day early by 4 am so that I can finish my academic work before my family members wake up. I try to make sure that I never carry the burden of my work at home. Frank discussions with family members before taking newer commitments has also resolved many of my issues. Fortunately, my family members being from medico background they have been truly accommodative.


CC.14.     Do you ever get restless or frustrated about not being able to accomplish enough and try to squeeze in maximum work activity in your working hours?

Dr. RS:    Like every other human being I do get frustrated when I am unable to finish my jobs in time. Though I plan way ahead of schedule and I also draw my plan B as a habit, still, things fall out of schedule. I do not try to squeeze work activity in limited hours but I like to delegate works to my team. I also love to finish all my work during travel.


CC.15.    Please list your top priorities to spread awareness about this health condition?

Dr. RS:    My top priority is to educate doctors. Doctors are primary touchpoints, if they are aware of early diagnosis and scientific management of foot and ankle ailments than my job is done. Doctors can only spread awareness amongst the population about preventive aspects. Trained doctors will also help in scrapping prevailing myths in society about foot and ankle disorders.


CC.16.    How you do relax?

Dr. RS:   Music, yoga and meditation are my buddies for relaxation.


CC.17.    Your Favourite Dish?

Dr. RS:   Sprouts


CC.18.    Your Favourite Song or Preference for Music?

Dr. RS:    “Hum Ko Man Ki Shakti Dena” (Oh Lord, bless us with the strength of spirit so that we emerge victorious”. I prefer live stage performances focused on old and classic Hindi movie songs.


CC.19.    A hobby you pursue in your spare time.

Dr. RS:   Dramatics and travelling.



Sir, I thank you for your time off from your hectic schedule and informing our readers about your work and the most neglected Foot and Ankle Diseases.  I pray that you succeed in your plans to help more and more people by treating them and training doctors across India and the world. 

Note: The views expressed by Dr.Rajiv Shah are his personal and do not represent the view of the organisation he is associated with.


About Dr. Rajiv Shah:

He is :
1.    Honorary Foot and Ankle Surgeon to Governor of Gujarat (2017-2019)
2.    The Managing Director of Sunshine Global Hospitals, Vadodara, Bharuch-Surat
3.    Member of the Executive Council, Global Foot & Ankle Community
4.    Vice Chairman, Asia Pacific Foot & Ankle Council (Chapter of APOA)
5.    Vice President, Asia-Pacific Society for Foot & Ankle Surgery (APSFAS), International Advisory Board Member & South-Asia coordinator, Foot Innovate, International webinars.
6.    Past President, Indian Foot and Ankle Society (2014-15)
7.    National Chairman, Indo-US foot and ankle courses (2009 onwards)
8.    Co-Chairman, Parekh African Foot and Ankle courses (2014 onwards)
9.    Member, editorial board, Journal of Asia-Pacific Foot and Ankle Society
10.  Reviewer for Foot and Ankle section for four indexed medical journals.
11.  Acclaimed radio, stage and television drama actor, radio announcer and a creative writer

He has successfully carried out more than 3500 Foot and Ankle surgeries on patients from India and from other countries like USA, UK, Gulf countries, African Countries and SAARC countries.
 

• Has authored chapters in ten international books in the subject of Foot & Ankle Orthopaedics
• Editor for Foot & ankle section for ‘Textbook of Orthopaedics & Traumatology’ published by Indian Orthopaedic Association
• Author of book titled ‘Handbook of Foot and Ankle Orthopaedics’ published by Thieme publications which was awarded the ‘Best Orthopaedic Book Award’ for year 2014-15.  The same has been translated in Portuguese, Chinese & Arabic languages.  The books is available on Amazon.in
• Delivered more than 350 podium presentations in International and National Foot and Ankle meetings
• Only Indian Foot and Ankle Surgeon, who as an invited guest speaker, has delivered many scientific presentations at international platforms in countries like USA, Canada, China, South Korea, Turkey and Mauritius.
• Has more than 20 publications and research paper presentations in reputed international journals to his credit.
• Has developed own classification ‘ADEINO classification’ for calcaneus malunion’ being recognized widely across the world.
• Trained and mentored many young and upcoming orthopaedic surgeons in the field of foot and ankle by fellowships, workshops and courses.

https://drrajiv.in
http://www.footankle.in/Dr.%20Rajiv%20Shah.pdf
http://www.ifas.in


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3-D Printed Bone

Talus Bone

One of the many press clippings

Electronic Media Coverage - Dr. Amanda Fantry's Visit to India

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Interview of Dr. Lakshmi Vaswani, Pathologist, Bhatia Hospital on Healthcare Quality

Dr. Lakshmi Vaswani, Pathologist

"The community that we are catering to needs to understand the significance of what we are doing and should see that reflected in our services provided; otherwise these stamps and logos are just going to look like letters on a board, with no tangible meaning."



Dr. Lakshmi Vaswani has been a Pathologist at Bhatia Hospital Laboratory, Tardeo, Mumbai, since 2013 She has been avidly interested in laboratory management, with an MBA in Healthcare Services, then venturing into quality assurance and service improvement in the laboratory, as well as in the hospital.  She is a Certified Internal Auditor for NABL ISO 15189:2012, with certifications in Laboratory Quality Management Systems (MIOT, Chennai & WHO) and Good Clinical Laboratory Practices (KEM Hospital, Mumbai). She has experience with the laboratory’s role in maintaining NABH standards in a tertiary care hospital, intra-departmental co-ordination in quality improvement projects and serves as the Junior Editor for the Bhatia Hospital Laboratory E-Newsletter.  She has national and international publications to her credit and has also done paper and poster presentations at various forums in her areas of interest.

Dr. Vaswani, it is a pleasure meeting and interacting with an advocate for Quality Assurance in Laboratories.  I thank you for your time and look forward to your interesting perspectives.  Let’s start.

CC.1    You seem to have committed yourself to spreading awareness about Quality.  What goals have you set for yourself?

Dr. LV:    When I started looking into quality aspects both in the lab and in the hospital set up, it was largely unchartered waters for me. These are concepts that are not taught in our medical curriculum, which means that we are learning about them on the job. With accreditation being the order of the day this can be challenging to implement, especially in organizations where staff is set in a predictable and comfortable working pattern.  In my opinion the sooner the authorities in all levels of healthcare education, from doctors, to nurses, paramedical and administrative staff, are introduced to quailty concepts in their curriculum, the  less resistance we will face to the introduction of these concepts, when we start working in the industry.  Quality and the efforts to track it, maintain it and improve upon it, will be considered as part of the job profile as opposed to additional tasks.
   
I realise that such an approach will take time and patience. So in the meantime, I hope to imbibe as much as I can and in turn share my experiences so everyone learns from each other along the way. There is so much to be learnt just by listening to another person’s view points or experiences, so much that resonates, rather than reading standards or guidelines from a book.
              
I also firmly believe in teaching these concepts from the grass roots especially to the technical staff, exposing them to a quality oriented organization, whether through lectures in colleges, or through internships, meeting them at their level where they are, will hopefully shape the way they work in the industry in the future.

Working in a hospital as opposed to a standalone lab, has also made me realise that the quality of our services depends upon so many other departments in our organization. For example, the accuracy of the reports will be dependent on the quality of sample collected for analysis. Therefore, it is in our best interest to cross departmental borders, break silos and reach out to the nurses, doctors and staff to encourage and train them to improve their processes so that we can in turn improve ours. 


CC.2    As per NABL, there are more than 1 Lakh Laboratories in India of which about only 1000 Labs have been Accredited or Certified.  Why is the coverage so less and how can it be improved?

Dr. LV:     Out of the large number of laboratories in India, very few of them are large scale, multi-city companies. Smaller labs may not be able to justify investment in time and labour to fulfil accreditation standards with the workload they currently have.  There are labs that are family owned small businesses that have earned the trust of the patients and the doctors in their own neighbourhoods.  They may not see the advantage of implementing standards at a cost, to obtain an accreditation that is largely unknown and not really a point of concern, to the patients who come to them.
              
The NABL board has already made a significant and welcomed effort to improve accreditation numbers by introducing the “Quality Assurance Scheme for Basic Composite Medical Laboratories (Entry Level)” which is aimed at smaller labs, maybe in Tier II and Tier III cities with a basic standard that is more cost effective as well.  Hopefully it will make accreditation more appealing and feasible to smaller labs.


CC3    There are misconceptions, even amongst medium and large sized labs, that implementing Quality process leads to increase in costs.  How can those myths and fears be allayed? 

Dr. LV:   The way that I would choose to explain the concept of implementing quality concepts in your organization is to think of the cost incurred as an investment that should be able to show returns in the future.
   
At the very least, the standards give a blue print for people who want to set up their own labs or who want to re-haul the current processes in their labs, just to improve efficiency and get organised. The steps you take may be small at first, but unless you map out and at least note down your processes, you could never figure out where your loopholes are and what you need to do to close them.  An organised lab may already be fulfilling most of what the standards says.  It’s a matter of compilation, consolidation and presentation of routine tasks, with a stress on complete documentation, which is always a good thing, as it helps with accountability.

For example, in our lab, we had to find a cost effective way to track the turnaround time for our tests, without upgrading our current software.  Our in-house IT team developed a middleware at no additional cost to track and calculate the average turnaround time of the tests so that we could begin to track and standardise them.

The decision to follow the standards without going for accreditation is also an option that many labs choose, simply because of the misconception of extreme costs involved.  However, in that case, we have to be completely motivated to follow them diligently without the apprehension of outside third party inspections for accreditation to inspire them.
   
Accreditation acts as the proverbial pot of gold at the end of the rainbow and can spur staff morale to get them through data collection and tough CAPA decisions!


CC 4:     Are there any studies that indicate that Quality leads to efficiency and reduced costs?

Dr. LV:  While the advantages of establishing a quality management system are many, it might help to better understand the implications of failure to implement one.
 
The challenge is, how do we as lab professionals convince our stakeholders to invest in quality maintenance, and demonstrate that it will fetch a return?  An exercise using “Cost of Poor Quality“ (COPQ) may help.  There have been many studies on COPQ in different industries since the 1950’s.  However, it entered into the clinical lab domain only in 2014.  The idea of calculating COPQ is to demonstrate that if a lab invests in prevention costs (like training or establishing quality management systems) and appraisal costs (like proficiency testing programs, inter lab comparisons, regular audits), it will not have to spend on Internal and External Failure costs (like money spent on re-runs or recalled reports, addressing repeated customer complaints and the blow to reputation and test numbers as a result). There are many studies available online. However a standardized COPQ worksheet, referred to as the COPQ Calculator, was developed and tested by seven leaders from multiple facilities across the USA, by an eminent lab professional, Ms Jennifer Dawson along with Roche. It is a free online tool and perfect for beginners and can be used to determine for each individual lab or organization if improved quality will lead to decreased costs for them in the long run.  Another tool in the quality arsenal, i.e. Risk Management, is beneficial in identifying and analysing potential lapses in a process helping lab personnel to add an element that will reduce the possibility of that failure, making residual risk acceptable.


CC.5    Small and standalone laboratories do not see much merit in implementing Quality Assurance Programmes (QAP).  What are they losing out on and how can it help their business?

Dr. LV:   There are laboratories which  are small but superbly organised, without using the standards but with a well honed system that works for them and is profitable as well.  I  would say, take a look at the standards anyways, just to see what the competition is up to and who knows, maybe you pick up something to make your processes even better, or catch some hitches in your set protocols that you could correct.  After all, there’s no finish line in good services.  Implementation of Quality Assurance Programs (QAPs) may lead you to applying for accreditation if one chooses to do so.  However, the benefits of quality awareness and following the standards have a long standing effect in the working culture of an organization and its staff.
 
Accreditation, while fulfilling its role as a standardization tool for services provided, as well as building confidence in a doctor and a patient about the accuracy of a lab’s reports and its services, also serves as a great motivational tool for the staff actually working towards quality improvement.

An accreditation logo may inspire doctors to refer patients to you and the community to use your services- it can get paying customers through the door. However, the onus of fulfilling their expectations and to maintain them as recurring loyal customers falls on the staff and the daily processes of the lab.


CC.6    Carelessness, negligence and ignorance are big factors and human being’s are prone to such behaviour.  How can even minor lapses on these counts affect performance and quality with detrimental consequences? 

Dr. LV:   In a clinical lab, we can face the effects of minor lapses in our processes in all three phases of our testing cycle, pre-analytical, analytical and post analytical.  With improved technology and automated systems, analytical and post-analytical errors have reduced.  70% of all errors are generally in the pre-analytical phase which largely has manual processes like phlebotomy.  Most common areas are wrong labelling, diluted and lysed samples, unsuitable for testing.

In my opinion, ignorance needs to be corrected as soon as possible through training and re-training.  Carelessness and negligence are tougher to combat.
              
Even though to err is human, in most instances the errors are not person driven, they are system driven.  Which means that there is a lacuna in a set process that is increasing the chances of errors.  For example, we had an increased incidence of reporting errors, typing errors for a particular test parameter.  After root cause analysis, we determined that the sequence of the parameters on the analyser did not match with the sequence on the printed reports.  So we changed the sequence on the report to match and this simple change drastically reduced the incidence of this typing error, without jumping to an interfacing solution, which would have been an expense.

The challenging part is actually catching the minor lapses in time to correct them before more harm is done. That can be improved with a robust, non -punitive incident reporting system, to avoid them being brushed under the carpet in fear.


CC.7    Poor and good quality of Lab impacts a Doctor’s line of treatment and care. Please comment. 

Dr. LV:      When we discuss labs which are good quality, we are really talking about labs who have imbibed the idea of maintaining quality as part of their daily work, churning out accurate and timely reports, consistently, irrespective of accreditation.  I think the key word here is consistency, because consistency builds trust.

A treating physician starts and edits his line of management based on laboratory reports.  So they have to have faith in the lab that has issued the report.  If the number of incidents of wrong reporting or proficiency testing failures have increased, it should be followed by adequate corrective actions, as the lab becomes accountable for any harm to the patient as a result of poor quality reporting.  This has a major impact on the diagnosis and clinical management of a patient’s illness.  For example, a wrongly labelled sample will lead to erroneous results for a patient’s actual condition and increases chances of a medication error if not caught in time.  Critical values and patient deterioration may be missed till it is too late.  A normal platelet count given to a patient with actually low platelets, could result in missing timely intervention with a platelet transfusion. 



CC.8    What are the minimum and basic things that Labs should do incrementally to enhance their quality of service being offered? 

Dr. LV:    From the multitude of quality indicators suggested in standards and commonly used in the lab, there are three that we have tracked in our department that I felt made the most impact:
1.    Pre-analytical errors and Phlebotomy techniques
2.    Turn Around Times (TAT)
3.    Invest in a third party proficiency testing program or inter-lab comparisons, track non- conformities and correct them.

If an organization can just track these factors and improve upon these Parameters, it will make a difference as these directly affect the patient or doctor using your service.


CC.9    Awareness being low, how can the general public be educated about the importance of seeking services at Quality Certified Labs? 

Dr. LV:   The challenge to spreading awareness about what an NABL or NABH accreditation means for the patients or their care takers is that they are largely laymen.

The community that we are catering to needs to understand the significance of what we are doing and should see that reflected in our services provided; otherwise these stamps and logos are just going to look like letters on a board, with no tangible meaning.  They have to be educated by experience.  That means, for example, if by following the standards and getting accredited, you have improved your turn around time to a point where the patients can get their reports earlier than before, the impact of it is felt in the service you provide.  Or if the technician you hired was credentialed and trained to check quality controls regularly, as per your schedule, the number of re-runs that you use reagents on due to faulty results caught later on, will decrease, and with that so will your costs. Phlebotomy is a skill based manual process and if the technician is well trained; number of repeat collections due to faulty collection of samples will also reduce, leading to improved patient satisfaction.

Spreading awareness to people in the healthcare industry may sometimes be like preaching to a choir.  However, treating physicians also need see the difference in accuracy and dependability of reports from a quality-oriented lab, as opposed to one that isn’t.  Doctors refer patients to laboratories, and they need to be confident about the quality of reports they are getting.  One approach taken in the United States of America, is the creation of “diagnostic management teams,” comprising of experts in specialty areas of medicine, primarily based in the clinical laboratory, who can advise physicians on the selection of necessary tests and the interpretation of complex test results, thereby building confidence and rapport between the physicians and lab professionals.  That may work in a hospital set up or in local physician organizations for standalone labs, where they are catering to patients in a common location.


CC.10    What will be your 5 key recommendations, especially to small Labs?

Dr. LV:  1.    Look into accreditation, with the basic standards now introduced by NABL, catering to small labs specifically, i.e. the Quality Assurance Scheme for Basic Composite Medical Laboratories (Entry Level);
2.    The standards of any program are a great starting point to organise and consolidate a lab. There are so many small changes, that if implemented, can radically improve your processes.  Start small, take 3 quality indicators at a time and consolidate those before choosing the next ones;
3.    Striving for quality cannot be a forced idea on your staff.   It has to be part of the work culture.  Building a quality oriented team, sending them for trainings and conferences will open them up to the concept of quality management.  Invest in your quality culture, even though it may be an uphill climb;
4.    Reach out to your stakeholders, whether it is other departments in an organization like a hospital, physicians and customers who patron your lab.  Customer feedback is great if taken positively and constructively;
5.    Be open to technology advancements and stepping up your systems.  There are a lot of free or minimally priced options available online. Get trained in basic programs that will make documentation easier and more efficient.



Dr. Vaswani, on behalf of Calibre Creators, I thank you for these deep insights and I am sure that this message reaches out to those hundreds of labs who are doing a wonderful job and will surely help them to further strengthen their processes.  You have shared some wonderful insights based on your own personal experience which is highly valued and I am confident people will take benefit of your knowledge.

With best wishes.

Sarfaraz Lakhani,
Calibre Creators

Disclaimer: The thoughts expressed by Dr. Lakshmi Vaswani here are her personal and do not represent or relate to any person or organization!

My Experience of Top 5 Ways to Acquire Clients

Looking to Build a career and a fortune in Sales, follow these 5 simple tricks

  
A business thrives on sales and customer acquisition.  Any doubts? Getting regular business is the key to an organisation’s sustainability.  It is not an easy function and requires a lot of effort, energy and planning.  It is a known fact that some strategies may not work on the ground and one has to continuously keep customising it to make an impact.

It is also important to understand if the product or the service you are offering is required by the prospect or not.  Nobody buys a product or service unless it meets some specific requirement unless it is a new product designed after tremendous amount of research and to meet the specific needs of the market.  Also your product has to have unique features and it can only sell if it has some very important unique selling propositions that is different from those already available in the market. 

Follow these tips to become a "rock star business developer" and garner sales to become a top ranking performer which your boss you would.

1.    Getting through the "gate keepers"

When you first visit the prospect, you encounter the staff at the security desk or the reception, who in common parlance are referred to as “Gatekeepers”.  These gatekeepers safeguard the employees inside the premises from “outsiders” and “intruders”.  This is a normal approach because a lot many “Jhola” type (“bag carrying” salesmen) call upon organisations on an everyday basis and offer products and services, some of which are local and unbranded, are commonly available, make them available at dirt cheap cheap rates, offer guarantees (wonder who will provide back-up guarantee and where do you catch hold of them?) and add no utility value to the user.   These are such cheap products that you wonder how they make any profit at all.  Well, that’s besides the point.  The point here is that because of such gate crashers, genuine persons get blocked and bombarded with questions like – why you want to meet, the person is busy or in a meeting, he will be or is available only at some very odd hours, just to keep you away.

So they key here is to do the following:

Make sure that you have a prior appointment.  If you don’t have one, make sure that your opening statements to the front desk is convincing enough for them to let them through to the person you are looking to meet.  Tell them why it is important for their manager to meet you.  Provide effective answers to their counter questions which you must anticipate and be prepared for them.

You must also be dressed to impress.  The reality of life is that people don’t value a person o his product or knowledge and the purpose but people do get impressed with one’s attire or how you carry your personality.  Not intending to demean anyone, but the reality is that people holding lower positions are far likely to get impressed with a person wearing a formal jacket or attractive sunglasses or carrying an impressive bag.  Yes, in the 21st century that still holds, at least in India.  If you have people accompanying you and if they address you as “Sir” or “Madam” that helps make a still bigger impression.  If they approach you on her/his behalf while s/he waits, also adds to the “impression communication”.  But in some cases, even this does not work.

I do not advise this but display of a bit of attitude and a slightly stern but not using curt language helps cast an impression.

I know of a real life instance where a short sized person arrived in a swanky car with security personnel in a car ahead of his and one behind.  The security personnel would cordon off people so that he could walk towards a store.  This created a kind of image of a very important person and people started wonder who he really was even though he may not be any celebrity or a rich corporate executive.  It just zapped people’s thinking and he had attained a superiority position over other lesser mortals.  He became the “upper crust” very easily.


2.    Building a good rapport with the prospect

Be thankful that you are finally got into the inner “sanctum sanctorium” where the “lord” sits and is an achievement in itself.  Now let’s get on to the most important part which is where we need to focus on our remaining energies on impressing the prospect.  A lot has been written and spoken about your opening lines, the firm handshake and so on so we will skip that part.

Now it is important to recall what you have observed and made mental notes, while you were waiting in the reception because that will help you raise discussion points and get into the prospects mindset. 

It is important that after initiating the discussion, you allow the prospect to talk or share as much as possible.   You do not want to put him off or tell you that you hardly know what s/he has been trying to convey or hardly understood the needs or requirements.  Once he has exhausted, you start giving him your replies point to point to ensure that you have covered every detail aspect of his “stated” requirements.  Don’t oversell your product or service but explain the key salient and uncommon features.  Make sure that you make constant eye contact, watch his facial expressions change with every statement. Facial expressions are a big giveaway and you would know that you have a strong or a poor chance of striking a deal.  Remember that some people have trained themselves not to reveal their mindsets through expressions or to have a straight face all through.  I have encountered such people who will smile all throughout the meeting and concur with you and yet mislead you into believing that you have “sealed the deal”.

How you resolve their queries is very important and explaining that the product or service has already taken care of their problem or pain points is crucial.  It might be important that highlighting such key features in the initial discussion itself will save her/him from embarrassment.
   
I have used praise and appreciation for something which I have found unique or special while I was waiting and convey my admiration and that it has impressed me.  I make it a point to convey my genuine appreciation or happiness at some client sites  and this has helped me build a good rapport with the prospect and also converted many of them as clients.


3.    Picking up cues about his pain points without the prospect even mentioning about it.

If you are smart enough and of course you should be, allow the Lord to speak as much as he can.  Ask her/him relevant questions that will do two things (a) he will understand that you are actually asking the right questions; (b) and that you can solve his problems and therefore he will open up by freely sharing information.  At this point, s/he will start blurting out her/his problems and that gives you an opportunity to get deeply into her/his mindset.  S/He will have almost fallen in your trap.  You have to be mentally alert to understand and recap whatever has been said so that s/he get the message that you have understood his pain points.


4.    Telling them how you’d be able to resolve this

Now this is like going for the kill.  Telling them that you have understood the problem, you can propose a couple of options of how it will be resolved, without giving much away.  Withhold some solutions and make sure that they ask you.  The moment they ask you about process, formalities, timelines or more details which you do not expect them to understand about your service, it is better to assume that the prospect is interested.  As soon as he starts asking technical questions, it is to be realised that the prospect has already been approached earlier and he is coming from there.  The question that is uppermost in their minds right from the initiation of the discussions is “how much will it cost me?” is the last but firmly asked.  Now there are two things to do: (a) tell him an estimate of the proposal if it is a product whose price is known; or (b) if it is too technical or involves both supply of products and technical service, then you can say that you will have to go back to your team, work out the various details and only then you will be able to give a final proposal.  Don’t forget to take an email id.  Give them a time-frame by which they should be able to receive your proposal.  Ask them if they have any other details to share or to ask which will be critical to the discussion.  If not, express your thanks and re-commit about the deadline for sending the proposal.


5.    Giving him a proposition s/he cannot refuse

Once you have understood that s/he already has a proposal, consider the costing and make it competitive but don’t undercut drastically.  This ends up spoiling the entire business opportunity, not only for yourself but for others too.  It is a buyer’s market and there are multiple competitors, then you might have to adjust your pricing accordingly.  But if your product is unique or exclusive, then you have the opportunity to demand a reasonable amount and even premium too.  

Follow-up your proposal by telephone calls to confirm if they have indeed received the proposal.  I have seen that prospects have not even checked to find out if they have received your correspondence.  At other times, they will simply tell you honestly that they have received but not have had the opportunity to go through it in detail and will ask for more time.  Such behaviour delays decision making for everybody.  You can follow-up but up to a point.  Telephonic calls may not be sufficient after a while and then you will have to make a personal visit for a face-to-face interaction to understand their body language and other non-verbal cues.

The personal visit may be an opportune time for the prospect to bargain and negotiate which is where you should open up.  It must be understood that s/he was waiting for this opportunity but was shying away.  Give him a final offer, get her/his verbal confirmation, offer to send a final proposal, if required or get his signature on the struck deal, send the contract papers later and get working!

Best Wishes!



Sarfaraz Lakhani
22nd January, 2020
#calibrecreators

Interview of Mr. Saurabh Kulkarni, a Bio-Medical Engineer turned Entrepreneur

Mr. Sarfaraz Lakhani of Calibre Creators had the opportunity to interview Mr. Saurabh Kulkarni of Thane, Mumbai who has tasted Entrepreneurship and seems to be basking in its glory.

Saurabh Kulkarni SK), the ever smiling and charming person, is a young eligible Bachelor, a Bio-Medical Engineer turned a healthcare professional.  He has done his Bio-Medical Engineering from a very reputed college in Mumbai and later pursued an MBA in Health & Hospital.  He worked with the Asian Heart Institute (AHI), Mumbai, AAA HealthCare Consultancy Services Pvt. Ltd., Mumbai and later with Hospro Consultancy, Thane, handling their sales and marketing function.  At AHI, he was responsible for its branding activities (internal & external) whereas at AAA HealthCare & Hospro Consultancy his role was to meet the hospital owners to promote consultancy services for various products and services.


At a very young age, he along with his friends-turned-partners, plunged into entrepreneurship, establishing two companies - starting a garment manufacturing company and also taking up the franchisee of an Indian fast food chain.


CC.1    Saurabh we worked together earlier and now its sheer pleasure to be interviewing you.  How does it feel?
SK:   Sir, its my honour that you considered me for an interview since my experience is not that much to be eligible for one.  I’m and always want to be a learner. I have learned many things from you e.g. time management, people management, idea generation, etc. and it has been a great learning experience which I will cherish for a long time to come.  These will be my guiding posts in my future life and career journey.


CC.2    Saurabh, tell us why you chose to be a Bio-Medical Engineer and what was your vision then?
SK:    I always wanted to be an engineer from childhood. I was good in Science, especially Biology, maths and engineering and had some interest in it too, so it was logical to get into Bio-Medical Engineering.  As for the vision part, I have for long dreamt of starting something of my own and do something creative.


CC.3    You then pursued a Masters degree in Hospital Administration.   What took you to that route?
SK:    In third year of Engineering, I realised that I needed to choose between working in the IT sector as a programmer or working in hospital as an Engineer.  However, I chose neither of these two and opted to pursue higher studies, clearly looking at the low compensation levels being offered and limited career options, in my opinion.  I wanted to pursue a Master’s Degree in later part of professional career but then I realised that rather than delaying the decision later, why not do it now  Also, we had been introduced to the subject of Hospital Management as part of our curriculum and it got me thinking and hence the decision.


CC.4    Why did you opt for Sales as against pursuing a career as a Bio-Medical Engineer or a Hospital Administrator, either with a Hospital or a Medical Equipment manufacturing company?
SK:   After getting into Hospital Management (MBA), I always got internships in Marketing & Sales function and I liked the part of meeting newer people and getting wider exposure about the functioning of the healthcare sector.  It was then that I decided to pursue this as a career choice since by this time, I had somewhat lost touch with the technical aspects of Bio-Medical Engineering.  I was now exposed to the larger aspects of healthcare and hospitals.  I could look at a much bigger opportunity rather than restricting it to just being a bio-medical engineer and it really helped.


CC.5    You seem to have suddenly caught the “entrepreneur” bug.  What was that turning point in your life when you decided to be an entrepreneur and was it a sudden event?
SK:      I wouldn’t say that it was a sudden event.  After my stint at AHI, me and my friend who are now my partners thought of starting something of our own.  During every outing, we would touch upon this and kept the discussion alive.  After a bit of market research, we narrowed down on the clothing segment.  We initially started on a small scale and at a very slow pace so that we learn the nuances of the business and not end up making major mistakes.  Till the point, I was in AAA HealthCare, my two partners were handling the pre-requisites and after exited from there, I got actively engaged in the venture.


CC.6    What challenges did you encounter and how did you strategise to overcome them?
SK:      The sector was completely new for the 3 of us.  We initially spent 6-8 months meeting people, knowing new things, exploring the market, understanding the market potential, specific requirements, etc.  Since we were completely new to the sector, we had little or no understanding of the supply side of clothes, manufacturing and sales.  People were not willing to entertain us but there were some people who valued the quality of our work and gave us the opportunity to do business with them.  People negotiated on rates, terms and duration of payments and they were important because we did not have much working capital to play around with.


CC.7    What is good and the flipside about being an Entrepreneur?
SK:      The good part of being an Entrepreneur is that you get to learn all the things that are required to run a company starting from market research, managing funds, your product, marketing promotion, sales, client relationship management, etc. The flipside is that your family should be supportive enough to understand the pressures.


CC.8    Most entrepreneurs would have started with one line of business and given it say 3 to 5 years but you seem to taken up two divergent industries and unchartered territories.  How do you manage this?
SK:    It is not tough if you ask me.  Every person is good at multitasking and it must be given a try.  We also faced many hiccups during this process but we persisted. An entrepreneur should be a leader who passes his strengths to his team, in turn, creating many more. Once you have learned to do that you can manage 2 or more businesses. It also depends on the scale of the business.  Also, we saw that these were opportunities that we could easily take up.  We shared the responsibility but were collectively involved.  The understanding between the partners was well laid down and all issues and problems are resolved through a healthy discussion.


CC.9    You are a Bio-Medical Engineer at core.  Any plans to venture in this sector too?
SK:      Definitely yes, I’m a Bio-Medical Engineer at core which is one thing that makes me restless and motivates me to do more and to do something in that field.


CC.10    Most young people believe it is easy being an entrepreneur.  Please comment.
SK:        Not at all!  It is a gross misconception.  There is nothing easy in life.  As they always say “the grass is always green on the other side” which is not the case.  It is way tougher than you think because your entire future is at stake.   There are times, when the anxiety levels are very high and can be an unnerving experience.  However, If it succeeds, nothing like it but if it does not meet the expectation, then it affects one very badly, not that one should take it personally.  There is always a 50% chance of success right from day one and therefore it requires perseverance, commitment, energy, enthusiasm to put all that behind and look ahead.  If one has the courage, then anyone can

What we learnt and realise is failure is not bad as it is made out to be.  It leaves us with lots of learning’s and there are so many things to imbibe before one rests, before age catches up and when you have to then go slow.  We are all roaring to go!


CC.11    What Risks and Benefits did you weigh before becoming an entrepreneur?
SK:        The major risks are that till the time your business isn’t set, you will have to be dependent on your family for sustenance and I have been fortunate on that count. You will not be having any stable income coming in every month and which pushes you harder. Benefits are that you will become an all rounder who knows everything from every department and that stays with you for life.


CC.13    Please list your learning’s and challenges and what did you learn from them?
SK:        My learning’s are:
1.   Always spend wisely. Think 10 times before spending as you might need that resource in future when needed the most. 
2.  You become self sufficient to encounter any problem.
3.  You get a whole new approach to look at life.

become an entrepreneur.
As far as challenges go, I can say that
1.    Be sure before quitting your job to become an entrepreneur. 
2.    In today’s age, always start a business in partnership.  Have partners that are always with you in your toughest times. 
3.    Most importantly, convince your family and take them into confidence if you want to be an entrepreneur, because if you have the support of your family then on emotional front your mind is stable. You can concentrate on your business.


CC.14    What are some of the key differences in being a professional corporate employee v/s being an entrepreneur?
SK:    A professional corporate employee is like wearing “horse blinkers” who always looks at only his assigned core responsibility while an entrepreneur is an all-rounder who has to know everything about his business from all departments.  The vision gets wider, the exposure to is unlimited, success gives your courage to still move forward to move higher and higher.  It gives him energy and the push to succeed and expand his business.


CC.15    Young entrepreneurs rise early and have a long stretched day.  What are your first thoughts in the morning about the day and what is your daily routine?
SK:    True. They rise early and have a long-stretched day and thinking about 1st thoughts in the morning is to plan your day, prioritise according to the need, attend to business demands and can be very hectic at most times.


Saurabh, Calibre Creators wishes you a successful entrepreneurial journey and that you may achieve your goals and aspirations to become an industry leader of the immediate future.