A research paper from years ago

Sharing a research paper "RAROC-A Performance Measurement Tool". I wrote it in 2001 with a colleague from my team, when we worked together in ICICI Bank.

The paper is of great interest to anyone dealing with  Risk Based Performance Management for Banks and has been well referenced in many more publications.

The paper was originally published in http://www.iciciresearchcentre.org, but that site is now no longer valid and to ensure that this publication lives on, I am posting a link to it here in this blog.

Ethics and the Medical Profession in the Indian Context

The following is a response that I wrote on my high school Whatsapp group in response to some heated debate about the Medical Profession and stories about their sub-standard ethics.  Blogging it for others.

All professions providing some form of service have a lot of regulations around ‘ethicality’ and ‘morality’. This applies to financial professionals – people who give investment advice to their clients as well as the medical profession. I have worked in the finance profession all my life and have now moved into a regulator role. And I am applying some of the principles that we adopt for the financial advisory profession in this discussion.

No one will grudge a super-specialty doctor charging high fees because he has spent years and money in acquiring his skill and he does deliver results! They have spent lakhs and crores on that costly private medical education or on equipment and therefore they must now recover their cost. It is called ‘Return on Investment’. Yes I get that! But this argument immediately throws the ‘Hippocratic Oath’ out of the window and brings the doctor down from the heights of being in a ‘noble profession’ to being just another businessman.

One of the tests of ethicality is ‘Conflict of Interest’.  In any doctor-patient relationship, whose side is the doctor on? Is the doctor looking out for the best interest of the patient or is he/she acting in self-interest?  This I where all the talk of the ‘cut’ business comes into play. If as a financial advisor, I get a cut for every mutual fund I recommend and get the customer to invest in, then there are no marks for guessing that my interest would be to recommend the mutual fund which gives me the highest commission rather than the one that is best for the customer.  I have immediately compromised the financial health of the customer. Translate this to the medical profession and you have a large number of stories of over-prescribing, over-testing, and even advising surgery when not warranted. There is both anecdotal evidence of this as well as established case law.  Just do a google search.

How often do doctors sit with a patient and their relatives and go through the case, discuss the pros and cons of various optional routes of treatment and explain the doctor’s reasoning for the line of treatment that is being recommended? If the medical profession is prepared to be called just another business then business ethics demands that they be transparent.  

In my google search I came across a book authored by Pune-based Dr Abhay Shukla and Dr Arun Gadre. It is an English translation of the Marathi one — Kaifiyat pramanik doctoranchi (reflections by sincere doctors). It contains interviews of 78 practicing doctors from Mumbai, Pune, Delhi, Kolkata, Bangalore and Chennai. “These whistleblower doctors have mustered the ethical courage to expose facts for the first time on such a scale,” Dr Arun Gadre says. Several doctors spoke up including Dr Vijay Ajgaonkar, senior diabetologist from Mumbai, who says, “Now our greed has increased to the extent that when a patient of one consultant goes to another consultant, the second one prescribes the same medicine, but merely changes the brand to show that he is doing something different. And it is true that this profession has now become completely commercial.” The book describes every unethical practice from the horse’s mouth: cuts or referral fees for diagnostics as well as medical procedures; ‘Study tours’, also known as foreign trips funded by big labs and pharma companies for doctors; hospitals employing people who will rush to an accident scene and act as social workers to get the injured to the hospital that employs them. Etc. Etc.

There is one bold argument that is commonly made- that C is for choice. Whenever I hear this I am reminded of the time when my late father died way back in 1994. My brothers and I were doing the rituals of the kriya karma and were in a grieving state . The ‘priest’ (who smelled money as my brother was working in the UK and I came from Japan) would recommend to us one ritual after another emphasizing how not doing it would bring some pain or harm to our dad’s soul. He would always end his dire warnings with the words “it is your choice” Similarly, when relatives are worried about the health of their loved one, the doctor is in a position of trust. And at that time if he/she is going to be conflicted and concerned about making a commission then how different is he/she from this unethical priest?  

Long story short, the medical profession surely needs some soul searching as to where it all went south.

And finally there are some good apples and some bad apples in every basket.  The problem is that the bad apples give the whole basket a bad name.

On Acquiring Canadian Citizenship

Today (11^th Sept-2015) marks the final step in a 10-year journey for my family, as we complete our quest for acquiring Canadian Citizenship- a process we started in Sep-2005

I write this with mixed feelings. When I woke up today I was an Indian citizen and by the time the sun sets today I will have become a Canadian Citizen having taken the oath of citizenship at a Citizenship ceremony in the Art Gallery of Alberta, Edmonton after which I will receive the certificate of citizenship

The citizenship ceremony involves affirming to be faithful and bear true allegiance to Her Majesty Queen Elizabeth the Second, Queen of Canada (the symbol of the government in Canada) and to faithfully observe the laws of Canada and fulfil my duties as a Canadian Citizen. (Note: The Queen personifies the state and is the personal symbol of allegiance, unity and authority for all Canadians). My wife, Anita and Rohan will be by my side as we together embrace a new identity as citizens of the first world. (Note:  My daughter, Ankita acquired Canadian Citizenship earlier this year).

Today will also commence a process of renouncing Indian Citizenship, surrendering our passport and (optionally) acquiring Overseas Citizen of India (OCI) status and documentation. India does not recognize dual citizenship, hence they have devised this OCI status which equates us with NRIs in terms of financial transactions, property ownership and visa-free entry into India.

From a legal standpoint, this milestone for us means that henceforth we will travel on a Canadian passport and be eligible to vote in Canadian elections while losing the right to vote in Indian elections. The Canadian passport is decidedly more respected and accepted as it enables visa-free or visa-on-arrival entry to over 177 countries. Other than that very little changes. Canada encourages landed immigrants to bring with them their cultural heritage and value systems from their land of birth and upbringing. Canadians are rightfully proud of the multiculturalism that is visible everywhere you look. So we will continue to be Indian at heart while also being Canadian in our outlook and worldview.

As the saying goes, you can take a person out of India but you cannot take India out of a person!

Let he who is without sin cast the first stone!

There is a biblical story that goes like this.  When an adulteress was brought to the village square and was about to be meted out the traditional punishment of death by stoning, all the villagers gathered and took up a stone each. When the family of the woman appealed to Jesus who was in the village, he apparently said words to the effect that: “This woman must be punished. But Let he who is without sin cast the first stone”.

I am reminded of this story when I read all the posts in various whatsapp groups about recent cases wherein famous Politicians and Actors in India are able to hire top-notch lawyers or pay their way out of tough criminal cases and avoid going to jail. The common refrain is that the law should be applicable to everyone and just because someone has money-power he/she should not be spared. I wonder how many of us have always strictly adhered to various laws?

We need to do some soul searching and ask ourselves how many times we have paid a bribe – to the traffic cop after jumping a red light; to the TTE for a berth when there were others ahead of us in the waitlist; to the government clerk or ‘karmchaari’ for speeding up our case; to the IT officer to be lenient etc. etc.

My point is about the principle not the magnitude of the crime or the amount of the bribe.  If we value our work to be done and don’t mind paying a 1000 Rupees to escape the law we too will probably pay up.  If our child was involved – even unwittingly- in a crime, would we actually tell the cops, “he is a criminal, take him and punish him/her to the full extent of the law”? No. My bet is that our first thought will be to spend whatever it takes to ensure our child goes scot free.   We will probably consider a few thousand bucks well spent if our kid can avoid a night in jail.  In Sallu’s case a few lakhs/crores is the same as a few thousand bucks is to us. The amount is relative. What is not relative and common is that we all are willing to pay something and escape facing the law.

I am sharing this thought for us to reflect and self-introspect.

Canada's Health Care System: A personal story

Feeling confident (though still slightly apprehensive) before surgery for a total thyroidectomy on Monday Jan 26. This post is not about the 'why' and 'what for?' about my surgery. This is aimed at being a feel good story about the care and human elements in the health care delivery process in Canada!

Two months ago when the biopsy results came in, the surgeon’s office called me. The surgeon spent a good 30-minutes explaining to me the results, what they meant, the likely paths (with probabilities) that the cysts on my thyroid might take and my treatment options. This was indeed an illustrative talk with him drawing out the diagrams on his iPad! Given the odds and the prognosis I took his advice to go for a total thyroidectomy in one go, and was lucky to get a date within two months. (Alberta’s, like most of Canada, public health system is totally free for residents but is notorious for longish wait times for elective non-life threatening conditions!). 

A week before the surgery, I was pleasantly surprised to receive a call from the hospital (https://www.covenanthealth.ca/…/misericordia-community-hosp…) inviting me to attend a pre-surgical assessment clinic. During the more than 2 hour session I was seen by three different nurses and an anaesthetist, to assess my readiness, offer counselling and answer any questions that I may have. I was ushered into a regular examination room offered a seat at the table and a glass of water/coffee etc. After the routine physical check-up the 2nd nurse took an ECG and then the third nurse walked me through the entire process right from preparation at home and diet restrictions from the night before surgery, through to what the admission process will look like, time expected in the operating room followed by time in the recovery room, before I would be taken back to my room for an overnight stay. She concluded with the discharge and post-operative care that will normally be required. She told me that precise instructions for my condition would be given at time of discharge. This was not just her talking and my taking notes furiously. She told me to put away my note-pad and instead wrote the pertinent details in a pre-printed prepared booklet for me to carry back and not worry about missing some detail. By the end of her talk, my expectations were set and most of my routine questions – e.g.: what to wear, what to (and not to) eat and what to do with my glasses etc., were taken care of. Despite all the details that she provided, she assured me that on the day of surgery, the surgeon himself will be ready and willing to answer any further questions that I may have. The one thing that stuck with me long after the meeting was her mentioning not to get worried when I hear the surgical team talking at the time of surgery and asking me or each other what might look like routine questions. She assured me that this was because they are required to follow the WHO recommended ‘Safe Surgery Check List’ to ensure the best and safest possible outcome from the surgery. Part of this is to encourage me – and members of my family - to ask as many questions as I have and to keep talking to the surgical team. The time in the operating room is estimated at 1-hr & 40 minutes.

I was next seen by the Anaesthetist who put me completely at ease explaining how the General Anaesthesia will be administered, how the attending anaesthetist will be constantly monitoring me and how they will slowly revive me from deep slumber and ensure my condition is stable before moving me to the recovery room where another set of nurses will take over. She told me that I will probably need to be in the recovery room for an estimated 1-hour after which I will be moved to my room where I will be under observation overnight before being discharged the next day. The pre-assessment clinic then ended with a visit to the pathology lab within the hospital itself for getting a detailed blood analysis report. (More paper for my already thick binder!).
Sharing the story in some detail, as it made me realize the true meaning of what being a resident of a first world country meant. The medical profession at all levels is totally committed not just to treating me (admit – do procedure- discharge) but treating me like a human being all through the process, recognizing that (my family and) I would have emotional worries and taking the pains to address our concerns. And all this for an ordinary person. I am no VIP!

I recognize that while free at a transactional level, this is truly my tax dollars at work. But I would gladly pay any amount of tax so long as I have the assurance that those tax dollars will work for me, if and when I, or my family, need it. 

Blessed to be living (and paying taxes) in Canada!

Why do family and friends interfere in our marriages in India

The question of why friends and family interfere so much in our marriages, in the Indian context, has been vexing me for some time.  

And I believe, I've finally cracked it!

The answer is simple.  It is because we invite them into our marriages. Let me explain.

Take a random Indian wedding invitation. Yes I am talking about both the printed variety as well as the ones that are nowadays ubiquitous on social media (mainly Facebook & Twitter).  Up front and centre the invitation reads:

“Smt. and Shri (or the more modern Mrs. and Mr) So and So, Cordially invite you with family and friends…… “

- Ahaa!  The first mistake!  You might as well invite the whole town. We are all one big family and where the bloodline breaks, we have so many friends! Of the social media (Facebook) variety!

But the problem does not stop there! The next words are in my opinion the root cause of the whole problem.  Continuing with our example:

 “Smt. and Shri (or the more modern Mrs. and Mr) So and So, Cordially invite you with family and friends to the marriage of their daughter (or son)  XYZ  with ABC  etc etc…… “ .

Note that I have highlighted the word ‘marriage’. Now that means the whole period from the time the young couple tie the knot till ‘Death doth do them apart’!  That’s what is commonly meant by the term marriage. e.g., “my marriage is successful”, “She is in her third marriage”, or that famous line from Princess Diana, “I often felt there were three of us in this marriage”.  So if you invite someone (and worse still with their family and friends) to the “marriage”, you have invited them for a long, long time.

Now I don’t believe in just diagnosing the problem and not giving a remedy. The first simple remedy is to put the names of the persons you are inviting on the top of the invite and cut out the ‘with family and friends’ part.

But this is not so effective until you follow the second corrective step. Replace the word ‘marriage’ with  ‘wedding’ or ‘wedding ceremony’. This way you are sure that you are inviting certain specified individuals (& not their whole brood consisting of extended family & friends) to a certain specified ceremony/function called– yes you guessed it – the ‘wedding’. This is the brief 2-3 hours that it takes for the bride and the groom to exchange vows, accept the gifts from invitees and for all to enjoy the good food, music and dance and then depart.

So if you want peace and quiet from interfering friends and relatives in any marriage, amend your invitation to read:  

“Smt. and Shri (or the more modern Mrs. and Mr) So and So, cordially invite you to the wedding ceremony of their daughter (or son)  XYZ  with ABC  etc etc…… “.

Problem solved!

Now, Earn that Bharat Ratna, Sachin!

Dear Sachin,

There has been considerable hoopla about your retirement from test cricket. Your fans and the media have been involved in a keen tussle to out-awe each other with their praises for you, their wailing about what will happen to Indian Cricket and all the talk about this being the end of an era!

I do not share any of their angst – after all an era is longer than 24 years! Nor do I share Shashi Tharoor’s worries about how India will cope without you wielding the willow in Test Cricket. I think India has bigger problems than your retirement.  There’s the poverty, the hunger, the illiteracy not to speak of the communal hatred being spread by self seeking politicians. But that should not bother you!

What should bother you is: “What now?”If I were you, I would sit down in front of a mirror and look myself in the eye and ask myself, what it means to be the nation’s 43^rd Bharat Ratna. Who are the other 42? What is/was their claim to fame?  For the most part they were either Freedom activists or self- seeking politicians (people who you co-awardee Dr Rao referred to as ‘idiots’)! There are of course some who excelled in the fields of Music/ Entertainment, the Sciences, Educationists, and even a couple of non-citizens (Khan Abdul Ghaffar Khan and Nelson Mandela).  I would then wonder, what it is that made the powers that be think that I deserved this award. Is it just a political stunt on the part of the ruling party to cash in on my popularity and keep my myriad fans happy just when the elections are around the corner? Or is there finally recognition of the image building value that 'Brand Sachin Tendulkar' brings to India? Whatever, the reasoning, I would probably conclude that it is what it is; I might as well bask in the glory. This could probably explain your magnanimous gesture in dedicating your award to all mothers in India. What does this ‘dedicating’ mean?  Will it mean that you will take up the causes of mothers, instead of the inane ad promotions for various material goods that you get paid so fabulously for?  Or maybe you will use some of the wealth that fame has bestowed you with, to set up hospitals in remote locations with only one mission:  “No more mothers dying during child-birth!” Or maybe it is just a cliché and I am digressing in delusion!

Anyway, back to the “What now?” question. How can you silence all those critics who think that awarding you the Bharat Ratna was misplaced?  Here are just a couple of humble suggestions to actually ‘earn’ that Bharat Ratna: 

1. You could set up a 'Sachin Tendulkar Foundation' that will spot talent and train deserving children in every Olympic sport, setting your administrators and coaches the goal of 20 Gold Medals in the 2020 (Tokyo). That is 7-years from now! And Tokyo has just started building the facilities. So if they can plan and deliver the Olympics in 7-years, I guess  you can plan and get to the target of producing seven Gold medal winning athletes. Money should not be a problem for you. And judging by the harsh life that most children in rural India live neither should physical grit, endurance and will-power.  What is needed is good coaching, motivation, proper equipment and the right nutrition! This way you can be the catalyst for spawning many more Bharat Ratnas from the field of sports!  When you are 70, would you prefer to be known for all your cricketing records (some of which might be bettered by then) or would you want to be known for your service to Indian sport in all its shapes and forms. 
2. You could use Brand Sachin for promoting India as a tourism destination.  God knows we have more natural beauty that any other place in the world. And we need that foreign exchange to save the Rupee.

 So go for it Sachin.  You described your cricketing life as between 24 years and 22 yards.  But come on, Sachin! Life is more than years and yards.  It is also about how many lives one has tangibly touched and improved.

Eagerly looking forward to your second innings,

Sincerely,

Jammi