Paying the doctors as long as they keep you healthy

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Does this ancient Chinese system hold the secret to the future of managed care?

Modern medicine is going through somewhat of a crisis of identity in the modern world. As the population ages, the need for medicine changes and the budgets and margins for the profession look tighter all the time. So much of modern medicine, however is still reactive. In most areas of life the phrase ‘prevention is better than the cure’ is accepted wisdom.Why doesn’t it happen more often in medicine, where the phrase originated? A new way of thinking may be needed to take medicine into the future.

If we look back to Chinese History of Medicine, then this concept was actually embedded into medical practice, rather than being used as a doctrine for patients to carry around with them. The fact that the Chinese people over the millennia have written down what they did rather than rely on an oral tradition gives us a great insight into many facets of their life. And in terms of medicine, the Chinese doctors traveled extensively across Asia and spread their practices as they went. Doctors had a strong understanding of the body and dealt with a wide range of illnesses.

One such doctor was Li Shizhen. He was a proponent of Neo-Confucianism that helped people to live a healthy and happy life through Study, Self-awareness, Morality, Personal behavior, Meditation and Introspection

And as such, looking after your body, mind and soul were at the front and center of his way of thinking. So looking after your self was something that he thought about deeply and practiced during his time in the Imperial Medical Academy as a subordinate medical officer, in the Ming Dynasty. This was a high rank at the time and Shizhen looked at the role of the doctor in the overall health of the patient as something more important than a person to visit when things went wrong. His view was that the doctor should play a more integral role in the life of the people he or she was supposed to look after.

His belief was “To cure disease is like waiting until one is thirsty before digging a well”

In China during the 16th Century, medicine was something that was carried out in return for payment. The doctor used to help the patient in return for money. But things changed around the time of Shizhen and he, along with other deep thinkers saw a reversal in the way that a doctor functioned would lead to better results.

The doctor would be paid as long as the patient was healthy.

If they went about their normal daily life free of pain and protected from disease then the doctor would receive their money. Think of it along the lines of a monthly retainer for a modern professional to look after your finances, for example. But if the patient became ill then the payment would stop. The doctor would still be under a contract to look after the patient, but they would not be paid again until the patient was healthy. This changed the view of medicine at the time as something that kept people well rather than cured any problems. So using the modern example from above, if your financial investments were not performing then your adviser wouldn’t be paid again until they resumed a positive growth.

You can see how this might play out with managed care, as the medical professional would have to become more of an integral part of the life of their patients rather than have them drop in when they had an issue that needed to be resolved. It would change the focus from cure to prevention to general wellbeing.

Chinese medicine is given this kind of mythical status in the Western world as some strange alchemy that can cure everything but at the same time be something that they don’t trust 100%. But it is about far more than buying herbs, fungi and tea or the use of acupuncture. As you can see from the way that medicine developed in the time of Li Shizhen, the thought behind healthcare was as important as the practice. In many ways this is what we are lacking today. We develop new technologies and systems to help people in more diverse ways. The focus is often on the latest detection techniques or the most advanced treatment but all the time we are moving away from the core question – what is the mission of the doctor or a hospital or the field of medicine?

Chinese medicine was formed by a diverse range of influences that took it in the direction of caring about the whole being rather than the individual components of the body and the problems that they were facing at that point in time. It took lessons from Shamanism, Taoism and Buddhism. And as such looks to the practices that include the health of the patient in the body, the happiness of the patient in the mind and includes a religious aspect with the soul.

Modern Chinese medicine has taken some lessons from the way that techniques have developed in the rest of the world but have never let go of their founding tenets of acupuncture, herbal medicine, meditation, the diet and massage. The rest of the world has a lot to learn from this way of treating someone. Perhaps a return to doctors that are only paid when the patient is healthy is a way to realign the focus and produce a healthier, happier society.

Hospitals – A historical perspective and relevance for the future

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Most modern institutions have been optimised for efficiency, leading to increasing specialisation and focus on repetition. But institutions of the future are at risk of obsolescence if they rely on repetition and increasing the silo-ed approach to improve efficiency. One such institution is a “Hospital”. How did we end up with this notion of specialised centres of care specialised by organs and lost track of the person as a whole. It might be interesting to trace the evolution of hospitals via this lens.

Hospitals have evolved over the centuries rather than being buildings that have appeared near towns and cities over the last hundred years or so. So as we look back through the ages we can see how the modern day hospital evolved from humble beginnings.

The earliest hospitals can be traced back as far as the 5th Century BC. The ancient Sinhalese are responsible for introducing the concept of hospitals to the world. According to the Mahavamsa, written in the 4th century B.C. King Pandukabhaya had lying in homes and hospitals (Sivikasotthi Sala) built in various parts of the country. This is the earliest literary evidence we have of the concept of hospitals. Sri Lanka as well as Mesopotamia had hospitals – we know this from the artefacts we have found but we don’t know too many details about the hospitals of this time. Interestingly, Baghdad had the most advanced hospital system of its time and it was called Bimaristan. “Bimaristan” is a compound of “bimar” (sick or ill) and “stan” (place). In the medieval Islamic world, the word “bimaristan” referred to a hospital establishment where the ill were welcomed, cared for and treated by qualified staff.

Before this the Ancient Romans and Greeks had doctors of sorts in their communities but they paid house calls rather than have a set place to deliver their care. Some sites in these communities had places where the military would be tended en masse but these were mobile and would follow them to the battlefield. The way that their belief systems worked was that it was fitting and noble to die on the battlefield so the mobile units were designed to keep people comfortable until death rather than cure them of their injuries. This was more of a transition into the afterlife than anything that resembles a modern-day hospital.

The rise of the Middle Ages is when what we might consider to be a modern hospital arose. In Europe the Christian church ruled over the people as much as the monarchs. As churches raised taxes and collected money they started to do some good for the local community with the money raised. Church infirmaries spring up in many parts of the continent across the 7th Century and beyond. Women were not considered a part of the parish in these times as both religion and church were dominated by men. To engage women better, many churches involved women to set up the infirmaries and look after the young, the elderly and the sick alongside the church. People were encouraged to embrace religion and have access to the basic medical care that these infirmaries were able to offer.

The newly built and operated infirmaries were a way for women to become a part of the church community and have acceptance. This is actually the birth of nursing. The women worked around the clock to set standards of care for their patients in their time of need. In return they were recognised and accepted by the church for the good that they did in the community. Nursing was as noble a calling then as it is now. Of course all nurses in these church infirmaries were working there on a voluntary basis.

It was during this time that the concept of philanthropy became more prominent and churches raised money to build special homes to care for lepers or plague sufferers and as such specialist hospitals were born. The nurses that attended these developed relevant skills and techniques to tend to the particular needs of their patients. Even royalty got in on the act with Emperor Charlemagne making a decree that all infirmaries in France that had fallen into decay should be restored to their former glory. Nursing was still a predominantly female (and voluntary) occupation but it was receiving more recognition from the church and the rulers of Europe.

In England the link between the monasteries and nunneries were leading providers of care for the sick and elderly. But when Henry VII dissolves the monasteries in 1540 the church stopped to support the hospitals that it had built and it became the state that took up the running, staffing and finance of these buildings. The modern hospital that we know today was starting to take shape. Many of the institutions that were effectively passed from church to state at this time in London are still operating as hospitals in the modern day. Across the rest of Europe rich families and feudal lords funded the hospitals that kept their workforce and armies (as well as their families) fit and well enough to work or fight. As a consequence the standards of care were directly related to the funds made available.

During the Age of Enlightenment of the 18th Century the progress of science and medicine made great strides and as a consequence doctors and surgeons entered hospitals to perform operations and raise the standards of care. Surgeons were joined by new group of specialists who administered an anesthetic – anaesthesiologists, so that operations could be carried out in more safety. This meant that one single institution could care for many people in one place. A range of doctors could all carry out all manner of procedures in one place, sharing expertise as they went. The times were typified by a vast increase in knowledge of all areas of life. The pioneers of the day looked at innovation and experimentation to cure their patients of the diseases that made them unwell. Hospitals were separated into wards with specialities founded to look after people that suffered from the same symptoms. This meant that doctors were able to spend all day dealing with similar cases and develop a greater understanding of a particular area of medicine. But over a period of time, this led to patients being looked at as individual organs or body parts rather than whole human beings. There were however two systems of medicines which were deeply rooted in treating the whole person, which continued to grow over the years – the Chinese medical system and the Indian version – Ayurveda.

Modern Medicine (Allopathic) started to become more focused on dealing with the issue of only one part of the body when the best cures may have been to look at the individual as a full human system. Often the cure for one ailment in modern medicine brings about issues in other parts of the body that end further attention. Patients often end up seeing several specialists in the same hospital as a cause of only one initial admission.

What started off a home visit based system, slowly evolved through the passage of time to being a highly specialised institution based system. As we enter the new world where repetition and specialization is going to go out of favour, our hypothesis is that in 50 years from now, Hospitals will case to be the institutions that we see now, and we will revert back to the home based care of ancient times, and only highly specialized or rare cases would need a visit to an institution.

What are we celebrating today?

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                         WE, THE PEOPLE OF INDIA, having solemnly
                             resolved to constitute India into a 
                   SOVEREIGN SOCIALIST SECULAR DEMOCRATIC REPUBLIC and
                             to secure to all its citizens:
                        JUSTICE, social, economic and political;
                    LIBERTY of thought, expression, belief, faith and
                                         worship;
                          EQUALITY of status and of opportunity;
                               and to promote among them all
                    FRATERNITY assuring the dignity of the individual
                      and the unity and integrity of the Nation;
     IN OUR CONSTITUENT ASSEMBLY this twenty sixth day of November, 1949, do HEREBY ADOPT,
                      ENACT AND GIVE TO OURSELVES THIS CONSTITUTION.

Time to read and reflect, what of this is true? Not for some, but for everyone. If not, what are we celebrating?

Happy New Year 2017!

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Where the mind is without fear and the head is held high
Where knowledge is free
Where the world has not been broken up into fragments
By narrow domestic walls
Where words come out from the depth of truth
Where tireless striving stretches its arms towards perfection
Where the clear stream of reason has not lost its way
Into the dreary desert sand of dead habit
Where the mind is led forward by thee
Into ever-widening thought and action
Into that heaven of freedom, my Father, let my country awake

Takeaways from Tokyo

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In a world where every city looks more of the same, Tokyo takes you by surprise.

And this happened without fail to almost 600 of us as we traveled to Tokyo for the World Economic Forum Young Global Leaders Annual Summit last month. Even though we knew that this is going to be a special place, none of us were prepared to be blown away by what we saw in the city and the experiences that we had with the locals.

ZEN IN THE CITY

shibuyaThere are 13.62 million people in Tokyo and that makes it one of the largest cities in the entire world. One of the things that I noticed though is that even though there are that many people, there was a Zen like feeling when I was out walking along the streets. My experience was nothing like the times when I was in New York City or Mumbai, where you naturally pick up pace to keep up with everyone. In Tokyo, it was much different than that. I was able to walk at a slower pace while enjoying the views of the city. It was a very calming and serene experience for me as I realized that the city was always going to be there to enjoy and that there was no rush to see everything at once.

BUILD FOR EVERYONEaccess

I also discovered that Tokyo was built with people of all abilities in mind. All of the subways, hotels, parks and streets were designed and filled with yellow lines so that they were accessible for everyone. I was amazed at the time and thoughtfulness that went into creating a city that everyone could love and enjoy.

IT IS OK NOT TO HAVE ALL THE ANSWERS

Many of us took a little trip and visited Yahoo Japan to listen to a panel of speakers as they discussed the future of media. Most of the time when I am listening to panel discussions, I am trying to distinguish who is speaking because everyone is talking over everyone else as they are sharing data, insights ad viewpoints. In Tokyo, though, there was none of that. Every single panelist was deliberate in their answers and let another person finish speaking before they started. At one point, a question was raised and the room was silent as all of the panelists looked at each other to see if one of them actually knew the answer. Finally, a panelist looked at us and simply said “sorry, none of us know the answer to that question”. No beating around the bush and then saying – I don’t know whether than answers your question.

LIFE AND AMBITION WILL NOT BE DEFINED BY WHERE WE ARE

japan-skylineThere are so many skyscrapers in the city, which I find puzzling, because they have had more than 300 earthquake tremors that have measured more than a 5.0 on the Richter scale. And that too in this calendar year. The city knows that they are located on the epicenter, but they are not going to let that stop them from having any type of building that they want.

 

SIMPLE IS BEAUTIFULtoto-toilet1
Everything in Tokyo focused on simplicity. Every presentation that we attended was presented in a simple fashion whether they were discussing drawing an electronic circuit with pen and paper or finding a way to choose individual cancer cells from blood. Even our hotels rooms were simple as well, but very functional. But when it’s the toilet seat. Then, all bets are off! There is even an instruction manual stuck to it.

YOU CAN NEVER BE TOO POLITE

The people in Tokyo (and japan in general) are so very polite, almost to a fault. No one ever points to give out directions in Tokyo. Whenever I asked someone where something was, they would simply walk with me topoliteaircraft my destination. It did not matter if it was 2 minutes down the road or 20 minutes, they simply did it to be nice. By the time it neared the end of my trip, I was basically expecting people to walk me to places that I didn’t know how to get to.

One of the other Young Global Leaders, Esteban Bullrich, so eloquently highlighted this during the closing hour. He said they truly recognize the other and respect the other fully. They see each other as a person who has a dream like everyone else does and they all acknowledge and respect that dream. He urged all of us to respect our dreams and recognize the other.

The Japanese have a word for it “Omoiyari” in simple terms means “having a thoughtful and sympathetic regard for others”

YOU DON’T HAVE TO IGNORE YOUR PAST TO BUILD YOUR FUTURE

kazuo-quoteTokyo is very modern, but that does not mean that they have ignored their past. We were able to visit many different ancient temples in between trips to the Mori Towers, Imperial gardens and Hitech scientific Labs. The city has managed to merge the newer buildings in spaces that are surrounded by the older ones, so that none of the history of the city is ever forgotten. Truly amazing.

 

AND FINALLY, ITS OK TO SLURP YOUR NOODLES

ramentokyoMany of us have been taught that it is not nice to make sound while eating but I found out that there are some traditions which are contrary to this norm in japan. E.g It is okay to slurp your noodles in Tokyo. Actually, people expect you to slurp your noodles as it is part of the Japanese food etiquette. It does make the noodle feast much more enjoyable at many of the quaint little ramen noodle shops.

 

My takeaways: Go ahead – slurp your noodles, soak in the zen of the lovely city, recognise the other and respect your dreams!

And oh be careful of the toilet buttons!